Tibial osteomyelitis with cold abscess in a toddler: BMJ cas
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A 2-year-old male child was referred to the paediatric rheumatology clinic with history of limping, swelling of right knee and low-grade fevers for 6 weeks. About 2 months prior to this presentation, he had an episode of upper respiratory infection which was followed by swelling of the right knee.

He was initially treated with oral analgesics by his primary physician. After 6 weeks when there was no improvement, he was referred for evaluation of possible juvenile idiopathic arthritis.

On examination, there was visible swelling of his right knee compared with his left and he was refusing to bear weight on his right lower limb. On closer observation, a diffuse swelling was noted over the right calf region with fullness of the popliteal fossa. The swelling was not warm or tender. There was no contact history with tuberculosis.

An ultrasound scan revealed an abscess within the calf muscles. An MRI also revealed marrow oedema in tibial diaphysis with periosteal reaction and extension of abscess into the intermuscular plane.

Incision and drainage of the cold abscess was performed and Mycobacterium tuberculosis was detected by staining for acid-fast bacilli and by genexpert method.

A diagnosis of tubercular osteomyelitis of the tibia with cold abscess was confirmed. The patient was commenced on four-drug antitubercular therapy with rifampicin, isoniazid, ethambutol and pyrazinamide for 2 months followed by rifampicin, isoniazid and ethambutol for 8 months.

Read more here: http://casereports.bmj.com/content/2018/bcr-2018-227092.full