Back, Joint, and Extremity Pain - Case 5-1: 2-Year-Old Boy
I. History of Present Illness
A 2-year-old boy presented to the emergency department for evaluation of back
pain. Three days before admission, he began to complain of abdominal pain,
refused to eat lunch that day, and spent most of the afternoon watching
television rather than playing outside with his siblings. At that time, he was
taken to a nearby hospital for evaluation. On examination, he had mild, diffuse
abdominal tenderness but no rebound tenderness or involuntary guarding.
Abdominal radiographs showed significant stool in the rectum and distal colon.
He was diagnosed with constipation, was given a glycerin suppository, and was
discharged home after producing a moderate amount of stool.
On the day of admission, he returned to the hospital with persistent abdominal
pain and new complaints of low back pain. His oral intake had been poor over
the past few days. There had been minimal response to a glycerin suppository
earlier that day. He also seemed particularly uncomfortable while his diaper
was being changed. There was no fever, cough, hematemesis, hematochezia,
dysuria, or urinary frequency. There were no ill contacts and no known trauma.
The only pet was an elderly dog that had been euthanized earlier in the week.
II. Past Medical History
Tympanostomy tubes had been placed at 15 months of age for recurrent otitis
media. He had only one episode of otitis media after the tubes were placed. He
did not have a previous history of constipation. He does not take any
medications. The family history was remarkable for a paternal uncle who had a
myocardial infarction at 55 years of age.
III. Physical Examination
T, 38.9°C; RR, 36/min; HR, 130 bpm; BP, 115/55 mm Hg; SpO2, 99% in room air
Weight, 18.0 kg (greater than the 95th percentile)
The child appeared uncomfortable and refused to stand. The eyes, nose, and
oropharynx were clear. The neck was supple. The abdomen was mildly distended
and diffusely tender, particularly in the right lower quadrant. However, there
was no rebound tenderness or involuntary guarding. There was no costovertebral
angle tenderness. There was discomfort with passive flexion of the right hip.
There was mild edema and tenderness to percussion along the right paraspinous
muscle at the level of the L1 vertebra. There was no kyphosis, scoliosis, or
abnormal lordosis. There were no apparent sensory or motor neurologic deficits,
although the degree of back and abdominal pain made assessment of muscle
strength in the lower extremities difficult. There was no muscle atrophy.
Rectal tone was normal. The deep tendon reflexes were symmetric and
appropriately brisk. The remainder of the examination was normal.
IV. Diagnostic Studies
Complete blood count revealed the following: 19,700 white blood cells (WBCs)/mm3, with 67% segmented neutrophils, 29% lymphocytes, and 3% monocytes; hemoglobin,
11.4 g/dL; and platelets, 390,000/mm
3. Serum electrolytes were remarkable for a bicarbonate level of 19 mEq/L, a
blood urea nitrogen level of 7 mg/dL, and a creatinine level of 0.3 mg/dL.
Urinanalysis revealed a specific gravity of 1.020 and 3+ ketones but the
microscopic examination was normal. Serum albumin and transaminases were
normal. C-reactive protein (CRP) and the erythrocyte sedimentation rate (ESR)
were elevated at 7.9 mg/dL and 65 mm/hour, respectively. Abdominal obstruction
series revealed scattered air
–fluid levels and a small amount of stool in the rectum.
V. Course of Illness
Magnetic resonance imaging (MRI) of the spine localized the abnormality (Fig.
5-1), and the definitive diagnosis was made by an interventional study.
Discussion: Case 5-1
I. Differential Diagnosis
Back pain is a relatively common complaint among children, although fewer than
2% of older children with back pain require specific medical evaluation. In a
young child, neoplastic, infectious, and inflammatory disorders should be
considered. Malignant causes may be primary or metastatic and include osteoid
osteoma, neuroblastoma, Wilms tumor, and leukemia. Infectious or inflammatory
causes include pyelonephritis, vertebral osteomyelitis, spinal epidural
abscess, and pyomyositis. Diskitis in children usually involves the lower
thoracic or lumbar spine. The presence of fever, if related to the back pain,
makes diskitis less likely. Local tenderness and elevated CRP and ESR can be
seen with many infectious and neoplastic causes. MRI of the spine readily
differentiates diskitis, vertebral osteomyelitis, and spinal epidural abscess.
Rheumatologic conditions include systemic juvenile rheumatoid arthritis.
Mechanical disorders such as muscle strains and intervertebral disk herniation
are less likely in this age group. The absence of neurologic findings, although
reassuring, does not permit exclusion of any of these entities.
II. Diagnosis
MRI of the spine revealed an abnormal heterogeneous enhancing mass (7 × 4 cm) involving the right psoas muscle and extending to the epidural space at
the L1
–L3 vertebral level (see Fig. 5-1). There was associated compression of the
thecal sac. Urine homovanillic acid and vanillylmandelic acid levels were
normal, making neuroblastoma less likely. Gram staining of purulent material
drained during biopsy of the mass revealed many WBCs and gram-positive cocci.
Group A
Streptococcus subsequently grew from culture. The diagnosis is spinal epidural abscess due to group A
Streptococcus. The demise of the pet dog did not appear to be related to this patient's diagnosis.
III. Epidemiology and Incidence of Spinal Epidural Abscess
Spinal epidural abscesses occur rarely in children. Auletta and John reported an
incidence of 0.6 per 10,000 hospital admissions. Most patients are boys that
were previously healthy, but predisposing factors include sickle cell disease
(SCD), hematologic malignancy, and spinal surgery. Spinal epidural abscess
occasionally complicates serial lumbar puncture and varicella infection.
Staphylococcus aureus causes more than two-thirds of cases but infections due to group A Streptococcus, group B Streptococcus, Salmonella species, Escherichia coli, and Pseudomonas aeruginosa have also been reported. Rare fungal causes include Candida species and Aspergillus flavus. Mycobacterium tuberculosis may be seen more commonly in areas with a high prevalence of tuberculosis.
The infection is usually acquired by hematogenous spread and occasionally by
direct extension from an adjacent site of infection. Associated osteomyelitis
is present in approximately 50% of patients. In the study by Auletta and John,
seven of eight children with spinal epidural abscess had an associated psoas or
paraspinal abscess.
IV. Clinical Presentation
Most children develop fever early during the course of infection. Common
presenting complaints include back pain, limp, and refusal to walk. Hip pain is
an unusual presenting complaint, although it may be difficult to differentiate
back from hip pain in an ill and irritable child. Depending on the level of
involvement, progression of infection can cause spinal cord compression, muscle
weakness, and bowel and bladder incontinence followed by paralysis. On
examination, there may be tenderness over the vertebrae or paraspinal tissues.
Some children develop protective paraspinal muscle spasm. There may also be
loss of normal curvature of the spine (usually decreased lumbar lordosis) and
limited lumbosacral mobility. Abdominal pain is relatively common and can
indicate radicular pain or associated psoas abscess.
V. Diagnostic Approach
Spinal epidural abscesses can result in a range of clinical and laboratory
findings, and a high level of suspicion is required to make the diagnosis early
in the course of infection. Surgical aspiration should always be performed,
because identification of a specific pathogen permits optimal antibiotic
selection. Other studies may increase the level of suspicion for spinal
epidural abscess.
Complete blood count. The peripheral WBC count is elevated in approximately 50% of cases.
Thrombocytosis may be present.
C-reactive protein and erythrocyte sedimentation rate. These markers of inflammation are usually elevated, especially when there is an
associated vertebral osteomyelitis. They may be elevated also in noninfectious
conditions such as malignancy.
Blood culture. Organisms are isolated from blood culture in approximately 10% of cases. If
positive, the blood culture is invaluable in guiding specific antibiotic
therapy.
Tuberculin skin testing. Tuberculin skin testing should be performed if no bacterial organism is
isolated from blood or abscess culture, because
M. tuberculosis can cause spinal epidural abscesses.
Spine radiographs. Radiographs of the spine exclude other causes of back pain. Associated vertebral
osteomyelitis may be evident in children with a prolonged duration of symptoms.
Magnetic resonance imaging of the spine. MRI of the spine demonstrates the abscess, although definitive diagnosis
requires biopsy. MRI reveals concomitant vertebral osteomyelitis in 20% to 50%
of cases.
Other studies. At the time of diagnostic biopsy, specimens should be sent for stains and
cultures of aerobic and anaerobic bacteria, fungi, and mycobacteria.
Radionuclide bone scans to detect osteomyelitis at sites distant from the
abscess should be considered in cases in which the abscess occurred as a
consequence of hematogenous seeding. Cerebrospinal fluid (CSF) abnormalities
are common with spinal epidural abscesses. In a review by Rubin et al., 33
(78%) of 42 children with spinal epidural abscess had findings consistent with
meningeal infection (mild to moderate pleocytosis or hypoglycorrachia). In 12%,
elevated CSF protein was the only CSF abnormality. Examination of the CSF was
completely normal in 10% of children with spinal epidural abscess. Lumbar
puncture should not be performed if the abscess is located in the lumbar
region.
VI. Treatment
Standard management of epidural abscesses includes antibiotic therapy and
surgical drainage. Sporadic cases reported in the literature have been treated
with antibiotics alone. Candidates for antibiotic therapy without surgical
drainage may include patients without neurologic deficits and those with
numerous abscesses that would be technically difficult to drain. In those
children who are treated with antibiotics without surgical drainage, diagnostic
surgical aspiration to identify the infecting organism should be strongly
considered. This decision usually is made in consultation with infectious
disease and neurosurgical specialists. The empiric antibiotic regimen should
include agents with activity against
S. aureus, such as oxacillin or vancomycin. Vancomycin should be the initial antibiotic if
(a) methicillin-resistant
Staphylococcus aureus (MRSA) accounts for more than 10% to 15% of local S. aureus isolates, (b) a household member works in a nursing home or other facility with
high rates of MRSA colonization, and (c) the patient lives with someone known
to be colonized with MRSA. Cefotaxime and metronidazole should be added if
gram-negative or anaerobic organisms are suspected. Ultimate antibiotic
selection depends on the results of blood and abscess culture. The duration of
antibiotic treatment usually is determined by improvements in clinical findings
(e.g., improved pain and function), laboratory results (e.g., normalization of
ESR and CRP levels), and radiologic imaging studies (e.g., resolved epidural
fluid collection on MRI). Most children require approximately 6 weeks of
parenteral antibiotic therapy.
Mortality rates for adults with spinal epidural abscesses range from 5% to 25%.
Mortality rates in children are substantially lower. There were no deaths among
the 34 children reviewed in one series. Approximately 75% to 85% of children
treated for spinal epidural abscess have normal neurologic function at the
completion of therapy. Risk factors for persistent deficits include multiple
medical problems, previous spinal surgery, and severe neurologic deficit at
presentation.
VII. References
1. Auletta JJ, John CC. Spinal epidural abscesses in children: a 15-year
experience and review of the literature.
Clin Infect Dis 2001;32:9–16.
2. Bair-Merritt MH, Chung C, Collier A. Spinal epidural abscess in a young
child.
Pediatrics 2000;106:e39. Available at: http://www.pediatrics.org/cgi/content/full/106/3/e39 (accessed July 20, 2003).
3. Herold BC, Immergluck LC, Maranan MC, et al. Community-acquired
methicillin-resistant
Staphylococcus aureus in children with no identified predisposing risk. JAMA 1998;279:593–598.
4. Mason DE. Back pain in children. Pediatr Ann 1999;28:727–738.
5. Rubin G, Michowiz DS, Ashkenasi A, et al. Spinal epidural abscess in the
pediatric age group: case report and review of the literature.
Pediatr Infect Dis J 1993;12:1007–1011.
6. Yogev R. Focal suppurative infections of the central nervous system. In: Long
SS, Pickering LK, Prober CG, eds.
Principles and practice of pediatric infectious diseases, 2nd ed. New York: Churchill Livingstone, 2003:302–312.
Pictures
Book Source Details
- Book Title: Pediatric Complaints and Diagnostic Dilemmas
- Author(s): Samir S Shah MD; Stephen Ludwig MD
- Year of Publication: 2003
- Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2008 Williams & Wilkins.
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