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Think about the ‘C’ (in custard and crackers)
  1. Jane Metz1,
  2. Izidora Holjar-Erlic2,
  3. Alison Kelly3,
  4. Athimalaipet, V Ramanan3
  1. 1Department of Paediatric Infectious Diseases and Immunology, Bristol Royal Hospital for Children, Bristol, UK
  2. 2Department of Radiology, Bristol Royal Hospital for Children, Bristol, UK
  3. 3Department of Rheumatology, Bristol Royal Hospital for Children, Bristol & Royal National Hospital for Rheumatic Diseases, Bath, UK
  1. Correspondence to Prof Athimalaipet and V Ramanan, Department of Rheumatology, Bristol Royal Hospital for Children & Royal National Hospital for Rheumatic Diseases, Bath, UK; avramanan{at}hotmail.com

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Case history

A 9-year-old girl with autistic spectrum disorder (ASD) was admitted for a flare-up of chronic recurrent multi-osteomyelitis (CRMO). She complained of leg pain over 3 months, was unable to weight-bear and had a petechial rash for 10 days. She had bleeding gums and a long history of only eating custard and crackers.

CRMO was diagnosed at age 3. She’d had shoulder, knee, and ankle involvement, two courses of pamidronate (2011 and 2015) and was currently taking simple analgesia.

On examination, she was afebrile, with a widespread petechial rash, most pronounced over her ankles/shins. Her knees and ankles were tender; her ankles had small medial effusions.

Investigations

Mild hypochromic anaemia, …

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