(Radiographics. 1999;19:552-554.)
© RSNA, 1999
Pediatric Case of the Day
Janice W. Allison, MD1,
Rosalind S. Abernathy, MD2,
Maria S. Figarola, MD3 and
Ina L. Tonkin, MD4
1 Department of Radiology, University of Arkansas for Medical Sciences and the Arkansas Children's Hospital, 800 Marshall St, Slot 105, Little Rock, AR 72202 (J.W.A.)
2 Division of Pulmonary Medicine, University of Arkansas for Medical Sciences, Little Rock (R.S.A.)
3 Department of Radiology, University of South Alabama Medical Center, Mobile (M.S.F.)
4 Department of Radiology, LeBonheur Children's Medical Center and University of Tennessee, Memphis (I.L.T.)
Index Terms: Bones, infection, 10.21, 30.21 • Children, infections, 10.21, 10.23, 30.21, 30.23 • Skull, diseases, 10.21, 10.23 • Tuberculosis, musculoskeletal, 10.23, 30.23
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HISTORY
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An 11-year girl presented to the county health department with complaints of anorexia, fatigue, a fever of 1 month's duration, a weight loss of 14 pounds over the past 2 months, and a bruised left shoulder. Findings at physical examination included a temperature of 101.8° F, a weight at the 35th percentile, and a height at the 60th percentile. The patient's left upper arm was swollen and reddish purple with taut, shiny skin. She had swelling of the right sacrum and walked with a limp. Laboratory values included a hematocrit of 29.5%, a serum iron level of 13 µg/dl, an erythrocyte sedimentation rate of 40, and a serum albumin level of 2.8 g/dl. Radiography of the chest and left shoulder were performed, along with bone scintigraphy. The left shoulder was aspirated, and magnetic resonance (MR) imaging of the spine and head was subsequently performed.
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FINDINGS
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Results of chest radiography and bone scintigraphy were normal. However, an anteroposterior radiograph of the left shoulder revealed lytic destruction in the acromial process (Fig 1). A coronal fast multiplanar inversion-recovery MR image of the spine revealed abnormal signal intensity in the L1 vertebral body and left psoas muscle (Fig 2). The left kidney was displaced laterally by the mass effect from the psoas process. A coronal T1-weighted MR image of the spine obtained after administration of gadopentetate dimeglumine (Magnevist; Berlex, Wayne, NJ) revealed a rim-enhancing lesion in the left paraspinal muscles (Fig 3). A coronal contrast-enhanced T1-weighted MR image of the brain revealed skull involvement with epidural rim enhancement (Fig 4).
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Figure 2. Figures 2–4. (2) Coronal fast multiplanar inversion-recovery (repetition time msec/echo time msec/inversion time msec = 3,000/18/150) MR image of the spine reveals abnormal signal intensity in the L1 vertebral body (arrow) and left psoas muscle (arrowheads). The psoas process is seen displacing the lower pole of the left kidney laterally. The disk spaces are well maintained. (3) Coronal contrast material–enhanced T1-weighted (450/11) MR image of the spine reveals a rim-enhancing abscess in the left paraspinal muscles (arrows). (4) Coronal contrast-enhanced T1-weighted (450/10) MR image of the brain reveals a focal area of skull destruction with a rim-enhancing epidural abscess (arrows).
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Figure 3. Figures 2–4. (2) Coronal fast multiplanar inversion-recovery (repetition time msec/echo time msec/inversion time msec = 3,000/18/150) MR image of the spine reveals abnormal signal intensity in the L1 vertebral body (arrow) and left psoas muscle (arrowheads). The psoas process is seen displacing the lower pole of the left kidney laterally. The disk spaces are well maintained. (3) Coronal contrast material–enhanced T1-weighted (450/11) MR image of the spine reveals a rim-enhancing abscess in the left paraspinal muscles (arrows). (4) Coronal contrast-enhanced T1-weighted (450/10) MR image of the brain reveals a focal area of skull destruction with a rim-enhancing epidural abscess (arrows).
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Figure 4. Figures 2–4. (2) Coronal fast multiplanar inversion-recovery (repetition time msec/echo time msec/inversion time msec = 3,000/18/150) MR image of the spine reveals abnormal signal intensity in the L1 vertebral body (arrow) and left psoas muscle (arrowheads). The psoas process is seen displacing the lower pole of the left kidney laterally. The disk spaces are well maintained. (3) Coronal contrast material–enhanced T1-weighted (450/11) MR image of the spine reveals a rim-enhancing abscess in the left paraspinal muscles (arrows). (4) Coronal contrast-enhanced T1-weighted (450/10) MR image of the brain reveals a focal area of skull destruction with a rim-enhancing epidural abscess (arrows).
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DIAGNOSIS: Tuberculous osteomyelitis with skull involvement and epidural abscess.
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DISCUSSION
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Tuberculosis (TB) is reemerging as a major public health threat in industrialized countries due to increased immigration, acquired immunodeficiency syndrome, and new drug-resistant strains (1). TB is the classic mimicker and can simulate many other diseases.
TB osteomyelitis in children is the result of hematogenous spread of primary TB. The spine is the most frequent site of involvement with the paravertebral venous plexus of Batson playing an important role in dissemination (2). The most common locations are the lower thoracic and upper lumbar spine. The infection begins in the anterior aspect of the vertebral body end plate (3). Computed tomography is useful in showing bone destruction and fragmentation. Multiple levels of involvement are the rule, although single vertebral bodies can be involved with normal adjacent disks. Disk involvement can occur in children due to the persistent fetal blood supply to the disk (4). Paravertebral abscesses occur in over half of cases of spinal TB. For optimal imaging of the paravertebral areas, MR imaging with gadopentetate dimeglumine and fat suppression are needed. Calcifications within the paravertebral abscess are pathognomonic of TB (5). Brucellosis is a disease process that can mimic spinal TB with involvement of the anterior aspect of the vertebral body end plate and paraspinal soft tissues (6).
TB rarely involves the upper extremities and nonweight-bearing bones. Skull involvement is exceptionally rare and is seen mainly in children. Lesions may be solitary or multiple. Both tables of the skull may be involved, with scalp swelling and cutaneous sinus formation associated with outer table destruction and epidural and subdural abscess formation noted with inner table destruction. The skull lesions may mimic histiocytosis and neuroblastoma in children (7,8). Basilar meningitis is much more common than skull lesions and associated abscesses.
The diagnosis in this case was made on the basis of a positive tuberculin reaction with 22 mm of induration and growth of mycobacterium TB from the paraspinal abscess. Acid-fast bacteria smears from the acromion and paraspinal abscess were negative. None of the patient's family had positive tuberculin reactions. The patient had visited an uncle 31/2 years earlier who was diagnosed with smear-positive TB 2 months later.
This case demonstrates unusual skull and intracranial involvement by TB as well as typical spinal and paraspinal infection. The patient was started on isoniazid, rifampin, and pyrazinamide. She was afebrile and gaining weight after 1 week of treatment. After 1 month, all hematologic and chemistry findings had normalized and the patient had regained the weight she had lost.
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Footnotes
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Address reprint requests to J.W.A.
From the 1998 RSNA scientific assembly.
Received for publication October 2, 1998.
Revision received October 23, 1998. November 16, 1998.
Accepted for publication November 18, 1998.
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References
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Buckner CB, Leithiser RE, Walker CW, Allison JW. The changing epidemiology of tuberculosis and other mycobacterial infections in the United States: implications for the radiologist. AJR 1991; 156:255-264.[Abstract/Free Full Text]
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Resnick D, Niwayama G. Osteomyelitis, septic arthritis, and soft tissue infection: organisms. In: Resnick D, Niwayama G, eds. Diagnosis of bone and joint disorders. 3rd ed. Vol 4. Philadelphia, Pa: Saunders, 1995; 2448-2558.
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Sharif HS, Morgan JL, al Shahed MS, al Thagafi MY. The role of CT and MR imaging in the management of tuberculous spondylitis. Radiol Clin North Am 1995; 33:787-804.[Medline]
-
Smith AS, Blaser SI. Infectious and inflammatory processes of the spine. Radiol Clin North Am 1991; 29:809-827.[Medline]
-
Jain R, Sawhney S, Berry M. Computed tomography of vertebral tuberculosis: patterns of bone destruction. Clin Radiol 1993; 47:196-199.[Medline]
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Marom EM, Porter A, Gornish M, Cohen M, Russo I. Atypical skeletal tuberculosis. Skeletal Radiol 1995; 24:620-622.[Medline]
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Schuster JD, Rakusan TA, Chonmaitree T, Box QT. Tuberculous osteitis of the skull mimicking histiocytosis X. J Pediatr 1984; 105:269-271.[Medline]
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Wessels G, Hesseling PB, Beyers N. Skeletal tuberculosis: dactylitis and involvement of the skull. Pediatr Radiol 1998; 28:234-236.[Medline]
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HISTORY
FINDINGS
