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A school-girl with constipation
THE LANCET
Case report
A school-girl with constipation Tamar Stricker, Ulrich V Willi, Gaby E Pfyffer, David Nadal A 7-year-old girl from former Yugoslavia was referred to the University Children’s Hospital in Zurich (TS, DN) in August, 1995, because of constipation for 2 months and left-sided abdominal pain. She had one bowel movement every 2–3 days and fever up to 39°C for a week. The sicklooking girl weighed 17·8 kg (3rd to 10th centile) and was 116 cm tall (10th centile). She had an axillary temperature of 39°C, a diffusely tender abdomen, especially its left lower quadrant, and hard stool in her rectum. Abdominal radiograph showed a moderately distended transverse colon and right-sided thoracolumbar scoliosis (figure, top). Ultrasonography of the abdomen was normal. Her haemoglobin was 12 g/dL, platelet count 511⫻109/L and white cell count 18·2⫻109/L with 14% band forms and 53% segmented neutrophils. The erythrocyte sedimentation rate (ESR) was 92 mm/h and the C-reactive protein (CRP) 63 mg/L. 3 days later she developed left-sided paravertebral pain and tenderness at T11–L1 with a local swelling 6 cm in diameter. The overlying skin was purple. She had not received any local injections. Ultrasonography and computed tomography (CT) revealed an abscess in the musculus erector spinae with involvement of the musculus quadratus lumborum from T 10/11 to L 1/2 (figure, bottom). Skeletal scintigraphy showed no bone involvement. An intradermal tuberculin test was negative and a radiograph of the chest was normal. Blood cultures were sterile and the girl was seronegative for HIV-1. The abscess was incised and drained. Staining of pus showed gram-positive cocci in clusters, subsequently identified as Staphylococcus aureus. Ziehl-Neelsen stain revealed acid-fast bacilli (AFB) in one of four slides. Amplified Mycobacterium tuberculosis Direct Test (MTD; Gen-Probe, San Diego, USA) on a specimen of pus was positive. Cultures for mycobacteria remained negative. Treatment with flucloxacillin, for 2 weeks, and isoniazid, rifampicin, and pyrazinamide was started. The patient became afebrile 1 day after surgical drainage. Her abdominal pain and constipation resolved and the wound healed without complications. 2 weeks later the ESR was 12 mm/h and the CRP 15 mg/L and after 2 more months 5 mm/h and 8 mg/L, respectively, while an intradermal tuberculin test was reactive with an induration 20 mm in diameter. When last seen in June, 1996, she was well. A tuberculous intramuscular abscess is a rare extrapulmonary manifestation of tuberculosis.1 The diagnosis can be established by microscopic detection of AFB and by culture of M tuberculosis. In this case the diagnosis was substantiated by the MTD test, which provides an immediate result.2 Concomitant tuberculous Lancet 1996; 348: 306 Infectious Diseases Unit (T Stricker MD, D Nadal MD) and Division of Radiology (U V Willi MD), University Children’s Hospital of Zurich, CH-8032 Zurich, and Swiss National Centre for Mycobacteria (G E Pfyffer MD), Department of Medical Microbiology, University of Zurich, Zurich, Switzerland Correspondence to: Dr David Nadal
306
Figure: Abdominal plain radiograph and CT scan Top: moderate distension of transverse colon and hepatic flexure with mild to moderate right-sided thoraco-lumbar scoliosis. Bottom: postcontrast axial CT scan of upper abdomen shows left paraspinal abscess involving the erector spinae and quadratus lumborum muscles.
and staphylococcal osteomyelitis has been reported,3 as well as a case of multiple staphylococcal abscesses simulating cold tuberculous abscesses in a 3-year-old child.4 This case and a series of 32 patients with superficial tuberculous abscesses reported 25 years ago5 suggest that tuberculosis should be considered in patients from endemic regions, even in the absence of pulmonary signs and symptoms. References 1 Bonomo RA, Graham R, Makle JT, Petersil CA. Tuberculous pyomyositis: an unusual presentation of disseminated Mycobacterium tuberculosis infection. Clin Infect Dis 1995; 20: 1576–77. 2 Pfyffer GE, Kissling P, Jahn EMI, Welscher HM, Salfinger M, Weber R. Diagnostic performance of Amplified Mycobacterium tuberculosis Direct Test with cerebrospinal fluid, other nonrespiratory, and respiratory specimens. J Clin Microbiol 1996; 34: 834–41. 3 Quereda C, Guerrero A, Navas E, Pérez-Elías MJ. Concomitant tuberculous and staphylococcal osteomyelitis. Arch Intern Med 1991; 151: 2314. 4 Coles HMT. Staphylococcal pyaemia with pulmonary and cold subcutaneous abscesses. Arch Dis Child 1950; 25: 280–81. 5 Ward AS. Superficial abscess formation: an unusual presenting feature of tuberculosis. Br J Surg 1971; 58: 540–43.
Vol 348 • August 3, 1996
Case report
A school-girl with constipation Tamar Stricker, Ulrich V Willi, Gaby E Pfyffer, David Nadal A 7-year-old girl from former Yugoslavia was referred to the University Children’s Hospital in Zurich (TS, DN) in August, 1995, because of constipation for 2 months and left-sided abdominal pain. She had one bowel movement every 2–3 days and fever up to 39°C for a week. The sicklooking girl weighed 17·8 kg (3rd to 10th centile) and was 116 cm tall (10th centile). She had an axillary temperature of 39°C, a diffusely tender abdomen, especially its left lower quadrant, and hard stool in her rectum. Abdominal radiograph showed a moderately distended transverse colon and right-sided thoracolumbar scoliosis (figure, top). Ultrasonography of the abdomen was normal. Her haemoglobin was 12 g/dL, platelet count 511⫻109/L and white cell count 18·2⫻109/L with 14% band forms and 53% segmented neutrophils. The erythrocyte sedimentation rate (ESR) was 92 mm/h and the C-reactive protein (CRP) 63 mg/L. 3 days later she developed left-sided paravertebral pain and tenderness at T11–L1 with a local swelling 6 cm in diameter. The overlying skin was purple. She had not received any local injections. Ultrasonography and computed tomography (CT) revealed an abscess in the musculus erector spinae with involvement of the musculus quadratus lumborum from T 10/11 to L 1/2 (figure, bottom). Skeletal scintigraphy showed no bone involvement. An intradermal tuberculin test was negative and a radiograph of the chest was normal. Blood cultures were sterile and the girl was seronegative for HIV-1. The abscess was incised and drained. Staining of pus showed gram-positive cocci in clusters, subsequently identified as Staphylococcus aureus. Ziehl-Neelsen stain revealed acid-fast bacilli (AFB) in one of four slides. Amplified Mycobacterium tuberculosis Direct Test (MTD; Gen-Probe, San Diego, USA) on a specimen of pus was positive. Cultures for mycobacteria remained negative. Treatment with flucloxacillin, for 2 weeks, and isoniazid, rifampicin, and pyrazinamide was started. The patient became afebrile 1 day after surgical drainage. Her abdominal pain and constipation resolved and the wound healed without complications. 2 weeks later the ESR was 12 mm/h and the CRP 15 mg/L and after 2 more months 5 mm/h and 8 mg/L, respectively, while an intradermal tuberculin test was reactive with an induration 20 mm in diameter. When last seen in June, 1996, she was well. A tuberculous intramuscular abscess is a rare extrapulmonary manifestation of tuberculosis.1 The diagnosis can be established by microscopic detection of AFB and by culture of M tuberculosis. In this case the diagnosis was substantiated by the MTD test, which provides an immediate result.2 Concomitant tuberculous Lancet 1996; 348: 306 Infectious Diseases Unit (T Stricker MD, D Nadal MD) and Division of Radiology (U V Willi MD), University Children’s Hospital of Zurich, CH-8032 Zurich, and Swiss National Centre for Mycobacteria (G E Pfyffer MD), Department of Medical Microbiology, University of Zurich, Zurich, Switzerland Correspondence to: Dr David Nadal
306
Figure: Abdominal plain radiograph and CT scan Top: moderate distension of transverse colon and hepatic flexure with mild to moderate right-sided thoraco-lumbar scoliosis. Bottom: postcontrast axial CT scan of upper abdomen shows left paraspinal abscess involving the erector spinae and quadratus lumborum muscles.
and staphylococcal osteomyelitis has been reported,3 as well as a case of multiple staphylococcal abscesses simulating cold tuberculous abscesses in a 3-year-old child.4 This case and a series of 32 patients with superficial tuberculous abscesses reported 25 years ago5 suggest that tuberculosis should be considered in patients from endemic regions, even in the absence of pulmonary signs and symptoms. References 1 Bonomo RA, Graham R, Makle JT, Petersil CA. Tuberculous pyomyositis: an unusual presentation of disseminated Mycobacterium tuberculosis infection. Clin Infect Dis 1995; 20: 1576–77. 2 Pfyffer GE, Kissling P, Jahn EMI, Welscher HM, Salfinger M, Weber R. Diagnostic performance of Amplified Mycobacterium tuberculosis Direct Test with cerebrospinal fluid, other nonrespiratory, and respiratory specimens. J Clin Microbiol 1996; 34: 834–41. 3 Quereda C, Guerrero A, Navas E, Pérez-Elías MJ. Concomitant tuberculous and staphylococcal osteomyelitis. Arch Intern Med 1991; 151: 2314. 4 Coles HMT. Staphylococcal pyaemia with pulmonary and cold subcutaneous abscesses. Arch Dis Child 1950; 25: 280–81. 5 Ward AS. Superficial abscess formation: an unusual presenting feature of tuberculosis. Br J Surg 1971; 58: 540–43.
Vol 348 • August 3, 1996