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Dysplasia Epiphysealis Hemimelica (DEH) or Trevor's disease is a rare skeletal condition that forms osteochondroma like lesions in the epiphysis of long bones. This occurs mainly in pediatric patients with a predilection for the lower extremities. The knee and the ankle joint are most commonly affected in a hemimelic distribution meaning that either the medial or the lateral part of the center of ossification is affected. We report a rare case of Dysplasia Epiphysealis Hemimelica in an active pediatric patient involving multiple tarsal bones around the left ankle that was surgically excised after using a medial malleolar osteotomy for exposure. At over four years of follow up, our patient is pain free, has no growth arrest and continues to engage in normal activities.

Background Rocky Mountain spotted fever (RMSF) is a well-described, potentially lethal, tick-borne zoonotic infection and has very effective therapy. However, the diagnosis might not be made early enough, often leading to worse outcomes. Objective Our aim was to discuss the diagnostic dilemmas facing the physician when evaluating patients with suspected RMSF. Methods We report a case of RMSF in a 6-year-old girl who presented to our hospital with a 7-day history of fever, headache, and a petechial rash. After blood cultures were obtained, the patient was treated empirically with doxycycline, vancomycin, and ceftriaxone. During the next 24 h, her clinical status worsened, with acute onset of altered mental status, posturing, and fixed and dilated pupils. A computed tomography scan of the brain demonstrated diffuse cerebral edema with evidence of tonsillar herniation. She died 24 h after admission. A serum specimen tested positive for immunoglobulin G to Rickettsia rickettsii at a titer of 128 dilutions, confirming recent infection. Conclusions We present this case to raise awareness of RMSF in patients who present with a nonspecific febrile illness in tick-endemic areas in the United States. Early diagnosis and treatment with doxycycline before day 5 of illness is essential and can prevent morbidity and mortality.