56 Acquired torticollis in a toddler- a rare diagnosis

Abstract

Introduction Inflammation of the intervertebral disc and vertebral bodies is uncommon in children. The diagnosis can be challenging due to non-specific signs and symptoms. Case Report A 12 month-old previously healthy female child presented with pain in the right hip, refusal to walk, and fever (up to 38.6°C) for five days. There was no history of trauma. On admission, the infant was febrile and had a limping gait. The remainder of the physical examination was normal. She was hospitalized for further investigation. A complete blood count revealed 10880 white blood cells/mL (52% neutrophils, 34% lymphocytes, 2% eosinophils and 10% monocytes), a haemoglobin level of 10,2g/dL, and a platelet count of 452000/mL. The erythrocyte sedimentation rate (ESR) was 73mm/hour and the C-reactive protein was 2,74 mg/dL. Radiography of the lower limbs and pelvis was normal. The following day, the child was unable to sit. Magnetic resonance imaging (MRI) of the spine showed an abnormal signal in the vertebral bodies and intervertebral disc at L4-L5, with a high signal on the STIR image, compatible with spondylodiscitis. Bed rest and empirical treatment with intravenous ceftriaxone and flucloxacillin was started.Diagnostic tests performed to detect an infectious cause were negative, including blood and stool cultures, Wright's and Widal's tests, a Mantoux test, an Interferon-Gamma Release Assays blood test, a Polymerase Chain Reaction test for Mycobacterium tuberculosis from gastric washings, staining for acid-fast bacilli, and cultures for mycobacteria.One week later, the levels of inflammatory markers decreased and the child improved clinically. An additional MRI study performed in the second week showed a reduction in signal alterations. After four weeks, the infant was siting and walking again without difficulty or pain. The inflammatory markers returned to normal. Intravenous therapy was switched to oral treatment with cefuroxime and flucloxacillin for another four weeks.At a follow-up visit, an MRI study showed complete resolution of spondylodiscitis. There were residual abnormalities of the disc space and L4/L5 vertebrae, with no functional significance. The child was asymptomatic and behaving normally. Conclusion Suspicion of spondylodiscitis is important when a child presents with walking difficulties. The vascular nature of the intervertebral disc in children explains the predisposition to this rare condition. Magnetic resonance imaging of the spine is the gold standard for diagnosis. Early diagnosis is important to ensure a favourable outcome.