Looking Deeper: 14 Year Old with a Chronic Draining Chest Wound

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Submission ID :
ESPR425
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Abstract: :

Initial History/Presentation:

14 year old male presented with a six month history of non-healing chest wall wound. He first presented to the emergency department (ED) with a boil on his right chest wall. Incision and drainage yielded methicillin resistant Staphylococcus aureus and he completed a 10 day course of clindamycin. Lost to follow up for five months, after which a one cm cutaneous ulcer with seropurulence remained. Computed Tomography (CT) of chest showed an osteocutaneous fistula to fused 5th and 6th ribs. Past history: Complicated right sided MRSA pneumonia with partial thoracotomy and chest tube placement at 7 weeks old. Recurrent yearly pneumonia. Family history of chronic skin infections in father and maternal uncle.

Relevant Physical Exam:

GENERAL - no acute distress, obese, well appearing

SKIN - open draining purulent 2 cm cutaneous fistula at right anterior axillary line with surrounding erythema. Tenderness to palpation of ribs deep to fistula. Acanthosis nigricans of neck, bilateral axilla; striae on abdomen.

Diagnostic Evaluation: 

Initial CT Chest: Chronic osteomyelitis in the right fifth rib with extension to lateral chest wall, focal pneumonia right upper lobe. 

ESR 9 mm/Hr, CRP 0.9 mg/dL 

Wound culture - light growth MRSA 

Repeat CT Chest: Redemonstrated right chest wall soft tissue infiltration compatible with osteomyelitis.

Diagnosis: Chronic MRSA osteomyelitis of the fused right 5th-6th ribs secondary to a 14 year old retained Ethibond suture.

Discussion/Conclusion: 

Ten days after removal of osteocutaneous fistula, the wound dehisced. A recurrent sinus tract through the right anterolateral chest wall was seen on CT. Repeat surgical exploration revealed a retained Ethibond suture buried in the fused 5th-6th ribs, thought to be retained from initial insertion of chest tube as an infant. Since removal of the retained foreign body, patient completed a course of anti-MRSA antibiotics for chronic rib osteomyelitis without incident. History of infections at the same location as prior surgery including the cutaneous abscess, chronic fistula, and the recurrent pneumonias raises the concern for a structurally related infection. In this case, the details of his past medical history were very important to his current presentation. Review of his records from his first pneumonia at 7 weeks old shows he had undergone a partial thoracotomy for chest tube placement and had radiograph imaging showing fracture of the 5th and 6th ribs on the right. The inflammatory response from the rib fractures, the MRSA pneumonia, and the retained foreign body likely allowed for a pocket of infection to remain present but indolent over the last 14 years. Additionally, his retained suture culture MRSA susceptibilities are identical to those of his initial pneumonia.

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INOVA Children's Hospital
Inova Childrens Hospital
Inova Childrens Hospital

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