DISSEMINATED DEEP TISSUE INFECTION WITH DRAINING SINUS TRACTS IN A HEALTHY SEVEN-YEAR-OLD

Abstract

An apparently healthy 7-year-old Haitian boy with purulent draining sinuses of the left thoracic paravertebral area was admitted to the hospital for evaluation. Three days before admission a small nodule was noticed on the left side of his back which progressed to a larger tender red mass which drained pus on the day of admission. There was no fever, cough, arthralgia, weight loss or back pain. There was no history of insect bite, trauma or travel. The patient had had a minor fall on his back 3 months earlier, but no serious injury was reported. The child had dental work done 4 to 5 months before presentation, details of which could not be obtained. Physical examination revealed an active thin, pale appearing 7-year-old with no fever. Three distinct erythematous fluctuant tender masses each measuring approximately 3 by 4, 4 by 3 and 2 by 3 cm were present along the left paravertebral area at T7 to T8 which extended to intercostal spaces. Moderate tenderness was elicited on palpation of this area. The thoracic and lumbar spine did not have any bony deformity. Thoracic bony structures were normal. There were several palpable axillary lymph nodes about 1 to 2 cm in size bilaterally. The remainder of the physical examination was normal. Laboratory studies revealed a white blood cell count of 13 600/mm3 with 84% neutrophils, 10% lymphocytes, 5% monocytes and 1% eosinophils. Hemoglobin was 7 g/dl with a hematocrit of 22% and mean corpuscular volume of 65 fl. Platelets were 554 000/mm3. Serum iron was less than 5 μg/ml with total iron-binding capacity of 155 μg/ml and ferritin concentration of 135 mg/ml. The erythrocyte sedimentation rate was 136 mm/h. The serum electrolytes were as follows: sodium, 133 mmol/l; potassium, 5.2 mmol/l; chlorine, 95 mmol/l; CO2, 3 mmol/l; blood urea nitrogen, 11 mg/dl; creatinine, 0.4 mg/dl. Serum albumin was 2.7 g/dl with total protein of 10.2 g/dl. Serum glucose was 71 mg/dl with aspartate aminotransferase of 19 units/l. Urinalysis was normal. The immunologic workup included a nonreactive HIV antibody test by enzyme-linked immunosorbent assay. Absolute CD4 cell count was 632/mm3 with CD4% of 29 and absolute CD8 of 670/mm3 with CD8% of 30. IgG was 5379 mg/dl, IgA was 514 mg/dl, IgM was 173 mg/dl and IgE was 196 mg/dl. Nitroblue tetrazolium test for chronic granulomatous disease was normal. Leukocyte adhesion deficiency was ruled out because monoclonal antibodies against leukocyte function antigen of the CD18 integrin family showed presence of these adhesion markers. A purified protein derivative skin test was negative. Echocardiogram revealed no abnormalities. A chest roentgenogram was normal. Roentgenogram examination of the spine and ribs showed no bony involvement. Computerized tomographic scan of the chest and abdomen with and without contrast revealed prominence of the left paraspinal soft tissue, extending from the lower thoracic spine to the level of L2 vertebra. A discrete fluid collection with associated air bubble was seen in the left paraspinal region, suggesting a paraspinal abscess (Fig. 1). Multiple defects were noted within the spleen; five to six were ring-enhanced measuring 0.5 to 1 cm, suggesting the presence of multiple microabscesses. In addition the patient had a wedge-shaped low attenuation area within the left kidney and nonspecific thickening of the left psoas muscle and posterior pararenal fascia. Multiple tiny nodules were noted within the right upper lobe of the lung, with two prominent nodules measuring 0.4 to 0.75 cm, respectively. Computerized tomography of the head was normal. Dental evaluation during hospitalization showed normal gums.Fig. 1: Computerized tomography scan of the patient.Incision and drainage of the abscesses was performed, and the specimens were sent for Gram stain, bacterial, fungal and acid-fast bacillus cultures. Histopathology of the abscess cavities revealed necrotic inflamed granulating tissue. The results of the culture revealed the etiologic agent.