Image Quiz
Abdominal Pain in a Nine-Year-Old Boy
Alexandre Arkader, MD, Jorge Fabregas, MD, Jared E. Friedman, BA, and John P. Dormans, MD*
Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
A previously healthy nine-year-old boy was seen at the emergency department of a community hospital because of lower abdominal pain, nausea, and vomiting of a few hours' duration. At the time of physical examination, the patient had a low-grade fever and pain on palpation of the right lower quadrant of the abdomen. Bowel sounds were present. There were no other symptoms or findings. The neurologic evaluation showed 5 of 5 strength in all major muscle groups of the upper and lower extremities and no spasticity, hyperreflexia, or increased tonus or clonus. The remainder of the neurovascular examination was normal. After the initial evaluation, intravenous fluids were begun and, with symptomatic treatment, the symptoms resolved. A provisional diagnosis of acute appendicitis was deferred.
A plain anteroposterior radiograph of the lower abdomen was made (Fig. 1).
After evaluating the radiograph and noting an osseous abnormality (arrow), further imaging studies were requested to more fully evaluate the spine, including computed tomographic and magnetic resonance images (Figs. 2, 3, and 4). Ultimately, an incisional biopsy was performed (Figs. 5 and 6).
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| For larger view, click on image |
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