Case Presentation: A previously healthy 4 year-old male presented with bilateral leg pains and abnormal gait for 3 days. One week prior to admission, the patient had viral upper respiratory symptoms consisting of dry cough, congestion and rhinorrhea without abdominal pain or diarrhea, which resolved prior to presentation. Three days prior to presentation he began to complain of intermittent bilateral shin pain. The pain increased with ambulation causing him to revert to crawling. Parents reported diminished balance, with concern for safety on stairs. There were no medications in the home and no known ingestions, seizures or preceding trauma. On admission he was afebrile, tachycardic and tachypneic but normotensive. His exam was remarkable for a wide-based shuffling, unsteady gait, with an otherwise normal neuro exam. His bilateral lower extremities were non-tender to palpation, with no joint swelling, range of motion limitation, rash or lesions. Initial workup included a head CT (normal), and CBC, BMP, CK and urine drug screen (normal except platelets of 557,000). MRI of the brain and spine were normal. Myasthenia Gravis workup (acetylcholine receptor antibodies) was obtained. Symptoms waxed and waned, but did not worsen; he was discharged to continue workup as outpatient.
Neurology saw patient 2 weeks post-hospitalization (PH); EMG normal, myasthenia gravis workup negative. Patient saw his PCP 3 weeks PH for continued leg pains, refusal to walk and new onset hematochezia and night sweats. He was readmitted 4 weeks PH. Workup included a CBC, ESR, CRP, CK and an XR of the bilateral legs. The XR was normal, but the labs showed a significant leukocytosis (22,900), normocytic anemia (hematocrit 31, MCV 82), thrombocytosis (platelets 619,000), ESR (73mm) and CRP (6.7mg/dL). CK was normal. Enteric pathogens were negative. Stool occult was positive.
A 2.5kg weight loss was noted since initial presentation. GI was consulted to evaluate for colitis, and he underwent EGD and colonoscopy that revealed the diagnosis of very early onset IBD. He was started on high dose steroids for induction, and methotrexate for maintenance therapy. At time of discharge, hematochezia had resolved, and his leg pains and refusal to walk had improved.
Discussion: Very-early onset inflammatory bowel disorder (VEOIBD) is a rare form of IBD that occurs in children less than 6 years of age. VEOIBD is often more severe, resistant to standard medical therapy and associated with an underlying immunodeficiency in up to 25% of patients.
Conclusions: A broad differential of ataxia and refusal to walk should include neurologic, infectious, inflammatory/autoimmune and developmental etiologies. The hospitalist should recognize common intestinal and extra-intestinal symptoms of IBD and know how to initiate diagnostic workup.