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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 greater5 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.
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Elmi et al. (2026) studied this question.