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Case Report
Persistent fever and focal tibial swelling after laboratory-confirmed dengue revealing acute hematogenous tibial osteomyelitis in a toddler: A diagnostic challenge in a resource-limited setting
1 MBChB, MMed Paediatrics, Department of Pediatrics, Gargaar Multispecialty Hospital, Hargeisa, Somaliland
2 MBChB, MCS Tropical Pediatrics, Department of Pediatrics, Gargaar Multispecialty Hospital, Hargeisa, Somaliland
Address correspondence to:
Noradin Garad Egeh Elmi
MBChB, MMed Paediatrics, Department of Pediatrics, Gargaar Multispecialty Hospital, Hargeisa,
Somaliland
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Article ID: 100023Z16NE2026
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Elmi NGE, Ali MM. Persistent fever and focal tibial swelling after laboratory-confirmed dengue revealing acute hematogenous tibial osteomyelitis in a toddler: A diagnostic challenge in a resource-limited setting. J Case Rep Images Infect Dis 2026;9(2):1–9.ABSTRACT
Introduction: Dengue fever is common in tropical and subtropical regions and may present with fever, rash, lethargy, and generalized musculoskeletal symptoms. However, persistent fever accompanied by progressive focal musculoskeletal findings should prompt reassessment for an additional invasive bacterial process.
Case Report: A 19-month-old boy with laboratory-confirmed dengue initially received supportive outpatient management. Approximately 10 days later, he developed persistent high-grade fever, progressive swelling, and tenderness over the right tibia, limping, and refusal to bear weight. Laboratory investigations demonstrated marked leukocytosis with granulocytic predominance, C-reactive protein (CRP) of 111 mg/L, and erythrocyte sedimentation rate of 70 mm/hour. Plain radiography showed subtle anterior tibial soft-tissue changes, while targeted ultrasonography reportedly demonstrated periosteal thickening. Acute hematogenous tibial osteomyelitis was considered the most likely clinical diagnosis. Empirical intravenous ceftriaxone-sulbactam produced no clear clinical improvement after 48 hours, and therapy was changed to intravenous vancomycin. The child subsequently became afebrile, local inflammatory findings resolved, limb function returned, and CRP decreased to <5 mg/L. He was discharged on oral cephalexin to complete therapy. Microbiological confirmation and magnetic resonance imaging (MRI) were unavailable.
Conclusion: Laboratory-confirmed dengue should not preclude diagnostic reassessment when persistent fever is accompanied by new focal musculoskeletal findings. In resource-limited settings, repeated clinical examination, serial inflammatory markers, and available imaging may support timely recognition and management of probable bacterial osteomyelitis when microbiological confirmation and advanced imaging are unavailable.
Keywords: Acute hematogenous osteomyelitis, Bacterial infection, Dengue, Resource-limited setting
SUPPORTING INFORMATION
Author Contributions
Noradin Garad Egeh Elmi - Substantial contributions to conception and design, Acquisition of data, Interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Mohamed Muse Ali - Substantial contributions to conception and design, Acquisition of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Guaranter of SubmissionThe corresponding author is the guarantor of submission.
Source of SupportNone
Consent StatementWritten informed consent was obtained from the patient for publication of this article.
Data AvailabilityAll relevant data are within the paper and its Supporting Information files.
Conflict of InterestAuthors declare no conflict of interest.
Copyright© 2026 Noradin Garad Egeh Elmi et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.
