QP Acute Suppurative Mesenteric Lymphadenitis Complicated with Intraperitoneal Abscess: A Case Report Chun-Yu Chen 1, Wen-Chieh Yang 1, Han-Ping Wu 2,3,4 1 Department of pediatrics, Changhua Christian Hospital, Changhua, Taiwan 2 Department of Pediatrics, Buddhist Tzu-Chi General Hospital, Taichung Branch, Taichung, Taiwan 3 Institute of Clinical Medicine, ational Yang-Ming University, Taipei, Taiwan 4 Department of Medicine, Tzu Chi University, Hualien, Taiwan ABSTRACT Acute mesenteric lymphadenitis is usually a self-limiting clinical condition but intra-peritoneal abscesses are critical in children. It has been reported but was so rarely that mesenteric lymphadenitis could be an underlying etiology of intra-peritoneal abscess in children. We report a 10 year-old boy that presented with acute mesenteric lymphadenitis initially, but complicated with acute abdomen. Keywords: Mesenteric adenitis; intraperitoneal abscess; children J Taiwan Emerg Med 2011;13:43-47 ITRODUCTIO Abdominal pain is one of the most common presenting symptoms of children brought to the pediatric emergency department (PED). Etiologies of abdominal pain in children range from simple causes such as acute mesenteric lymphadenitis to potentially catastrophic causes such as intra-peritoneal abscesses. Acute mesenteric lymphadenitis is usually a self-limiting clinical condition characterized by fever, nausea, vomiting, diarrhea, diffuse or right lower quadrant abdominal pain and tenderness, and frequent leukocytosis. Due to the clinical presentation of the abdomen, it could be difficult to discriminate this condition from other acute abdominal diseases such as acute appendicitis. 1,2 To our knowledge, early diagnosis of intra-peritoneal abscesses is the best way to prevent poor prognosis. However, it has been reported but was so rarely that acute mesenteric lymphadenitis could be an underlying etiology of intra-peritoneal abscess in children. Here, we report the case of a 10-year-old boy that visited the PED because of severe acute abdominal pain, with the initial impression of acute mesenteric lymphadenitis, but complicated with intra-peritoneal abscesses within ten days. CASE REPORT A 10-year-old previously healthy boy without any history of surgery or blunt abdominal traumatic injury presented to our PED with sudden onset of acute abdominal pain and vomiting. On physical examination, the patient appeared acutely ill, with diffused abdominal tenderness especially over right lower quadrant and decreased bowel sound. Laboratory analyses including a complete blood count (CBC) and white blood cell differential count (DC) were performed and revealed a white blood cell (WBC) count of 14.7 10 3 /mm 3 with 76.5% neutrophils, 19.9% lymphocytes, 2.3% monocytes and 1.3% eosinophils. Serum C-reactive protein (CRP) level was less than 0.7 mg/l. Plain abdominal Received: December 5, 2010 Accepted: February 16, 2011 Address for requests and correspondence to: Han-Ping Wu, Department of Pediatrics, Buddhist Tzu Chi General Hospital, Taichung Branch, Taichung, 66, Sec. 1, Fong Sing Rd., Tanzih Township, Taichung County, Taiwan TEL: +886-4-36060666 ext. 2798 E-mail: arthur1226@gmail.com
QQ C. Y. Chen et al radiography was performed and did not show specific abnormal finding (Figure 1A). Due to persistent abdominal pain, further abdominal computer tomography (CT) scan was performed in the ED. The CT scan was performed by a senior radiologist and the report revealed mesenteric lymphadenitis only but without any finding for acute abdomen (Figure 1B). Therefore, this patient was discharged home later due to gradual improvement of clinical condition after a short period of observation in the ED. After being discharged, the patient was regularly followed up at the outpatient clinic. However, 10 days later, the child visited to our ED again due to severe abdominal pain. After his last ED visit, he still suffered from mild intermittent abdominal pain and also had diarrhea with small-volume mucous stools during the recent 1 week. In addition, the child suffered from fever of up to 39 C 2 days prior to admission to the PED. In the PED, physical examinations showed acutely illappearance, tenderness over lower abdomen, rebounded abdominal pain, muscle guarding of the abdomen, and decreased bowel sound. Also, the CBC/DC showed a WBC count of 26.9 10 3 /mm 3 with 85.2% neutrophils, 7.7% lymphocytes, 6.9% monocytes and 0.2% basophils. Serum CRP level increased to 7.46 mg/l. Plain abdominal radiography showed ileus without pneumoperitoneum (Figure 2A). Ultrasonogram of the abdomen showed diffused bowel wall thickness with hypokenetic bowel movement and an irregular hypo-echogenicity mass lesion over pelvis (Figure 2B). Moreover, the CT scan of the abdomen was undergone and showed multiloculated intra-abdominal abscess of pelvis (Figure 2C and D). Emergency surgical consultation was indicated for the impression of acute abdomen. Immediate operation was undertaken by senior pediatric surgeons for this surgical emergency. Laparotomy explored with surgical drainage and appendectomy was performed. Enlarged mesenteric lymph nodes with severe adhesion of pelvis and terminal ileum were found. However, no hallow organ perforation could be determined. After operation, the results of culture of abscess showed bacteroides fragilis and peptostreptococcus spp. evertheless, the results of the cultures for blood and stool revealed no growth of bacteria. The pathology of the appendix revealed neither perforation nor acutely inflamed change. We administrated Ertapenem to this patient for 12 days and then the patient recovered completely. He was discharged smoothly without any sequel. DISCUSSIO In 1926, Wilensky and Hahn classified mesenteric lymphadenitis into four groups: group I: simple mesenteric lymphadenitis; group II: suppurative mesenteric lymphadentis; group III: tuberculous mesenteric lymphadenitis; and group IV: terminal stage of mesenteric lymphadenitis (calcification). 3 However, suppurative mesenteric lymphadenitis is so rarely encountered that it is always not included in the differential diagnosis of a child with acute abdomen. 4 Viral, bacterial and mycobacterial causes have been reported as the common etiologies causing mesenteric lymphadenitis. The etiology of mesenteric lymphadenitis of eastern countries seems to be different from that of western countries. 2,5,6 It is questionable that routinely antibiotics used in patients with mesenteric lymphadenitis. Mesenteric lymphadenitis which is a usually self-limiting and non-surgical clini- A B Fig.ure 1. (A) Plain abdominal radiography showing non-specific findings (B) CT of the abdomen showing clustering of mesenteric lymph nodes with largest diameter of about 11.2 mm (black arrow) and thickening of the bowel wall of terminal ileum.
QR A B D C Figure 2. (A) Plain abdominal radiography reveals increased gas accumulation of the bowel loops and no definite pneumoperitoneum. (B) Ultrasonogram of the abdomen reveals irregular mass like lesion with hypo-echogenicity center over supra-pubic area (white arrow). (C) and (D) CT of the abdomen reveals multiloculated abscesses in the pelvic cavity (black arrow). cal condition could present symptoms and signs mimicking acute abdomen. Imaging examination, such as abdominal CT scan, can be a valuable tool in accurately diagnosing mesenteric lymphadenitis and can help to avoid normal appendectomy due to the clinical misdiagnosis of appendicitis. 1 Intra-peritoneal abscesses are relatively rare in infants and children as compared to adults, but may still lead to severe consequences or even mortality. 7 Clinically, intra-peritoneal abscesses generally form following the entry of enteric microorganisms into the peritoneal cavity through a defect in the intestine wall or other viscus as a result of infarction, obstruction, or direct trauma. 8,9 In children, intra-peritoneal abscesses often occur as a complication of local or generalized peritonitis, secondary to perforated appendicitis, necrotizing enterocolitis, pelvic inflammatory disease, ulcerative colitis, surgery or trauma. 7,8 The clinical presentations of intra-peritoneal abscesses may be non-specific and variable, including persisted abdominal symptoms, localized peritonitis, systemic toxicity and palpable mass. 7 The use of ultrasonography is more accurate than plain X-ray in diagnosing intra-peritoneal abscesses. However, abdominopelvic CT scan is considered to be the best diagnostic tool. 10 The management of intra-peritoneal abscesses may involve a combination of percutaneous/surgical drainage and antibiotics. 11,12 However, once vital conditions are unstable or once hallow organ perforation with septic peritonitis occurs, an emergent surgical approach is indicated and appropriate fluid resuscitation is required. In our case report, the initial diagnosis was acute mesenteric lymphadenitis with normal appendix based on the interpretation of abdominal CT. However, the repeat CT scan performed 10 days later showed multiloculated abscesses in pelvis. Although no definite bowel perforation, trauma, bacteremia, appendicitis, or bowel infarction was found in this patient. In addition, acute mesenteric lymphadenitis may be an early sign of abdominal infection. Therefore, it is reasonable to con-
QS C. Y. Chen et al sider that acute suppurative mesenteric lymphadenitis may play an important role in the pathogenesis of intraperitoneal abscess. In conclusion, acute mesenteric lymphadenitis, that may be a possible etiology causing intra-peritoneal abscesses, is not always a self-limiting clinical condition. Suppurative mesenteric lymphadenitis should be considered in patients suffering from persistent abdominal pain, localized peritonitis, systemic toxicity and palpable mass. REFERECES 1. Rao PM, Rhea JT, ovelline RA. CT diagnosis of mesenteric adenitis. Radiolog 1997;202:145-9. 2. Prince RL. Evidence for an aetiological role for adenovirus type 7 in the mesenteric adenitis syndrome. Med J Aust 1979;2:56-7. 3. Wilenski AO, Hahn LJ. Mesenteric Lymphadenitis. Ann Surg 1926; 83:812. 4. Constantinides CG., Davies MR., Cywes S. Suppurative mesenteric lymphadenitis in children. Case reports. S. Afr. med. j. 1981;60:629-31. 5. Lee JH, Rhea PL, Lee JK, et al. The etiology and clinical characteristics of mesenteric adenitis in Korean adults. J Korean Med Sci 1997;12:105-10. 6. Lee CC, Su CP, Chen SY, et al. Mesenteric adenitis caused by Salmonella enterica serovar Enteritidis. J Formos Med Assoc 2004;103:463-6. 7. Brook I. Intra-abdominal, retroperitoneal, and visceral abscesses in children. Eur J Pediatr Surg 2004;14:265-73. 8. Brook I. Microbiology and management of intra-abdominal infections in children. Pediatr Int, 2003:45:123-9. 9. Gibson FC 3rd, Onderdonk AB, Kasper DL, et al. Cellular mechanism of intraabdominal abscess formation by Bacteroides fragilis. J Immunol 1998;160:5000-6. 10. Saini S, Kellum JM, O Leary MP, et al. Improved localization and survival in patients with intraabdominal abscesses. Am J Surg 1983;145:136-42. 11. Gervais DA, Brown SD, Connolly SA, et al. Percutaneous imaging-fuided abdominal and pelvic abscess drainage in children. RadioGraphics 2004;24:737-54. 12. Gervais DA, Hahn PF, O eill MJ, et al. CT-guided transgluteal drainage of deep pelvic abscesses in children: selective use as an alternative to transrectal drainage. AJR Am J Roentgenol, 2000;175:1393-6.
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