Prolonged atraumatic back pain in an adolescent female: Emergency department presentation of Ewing's Sarcoma

Back pain and syncope are two common complaints encountered in the emergency department. However, prolonged atraumatic back pain in a pediatric patient should always be considered a "red flag" symptom. We describe a case of a 14-year-old female who presented to the emergency department with syncope and hypotension due to low back pain who was ultimately diagnosed with Primary Ewing's Sarcoma (ES) of the lumbar spine with extensive pulmonary metastasis. The diagnosis was expedited by the use of a bedside RUSH exam that identified an otherwise asymptomatic, unilateral pleural effusion. ES is the second most common primary bone malignancy in adolescents and young adults and unfortunately has a delayed diagnosis due to vague and non-specific symptoms. Survival rates of metastatic ES are still quite poor despite advances in therapies and treatments. This case emphasizes the importance of obtaining a focused history and physical exam, and how targeted point-of-care ultrasonography can aid in the diagnosis of rare and life-threatening conditions.