Salmonella Typhi Rib Osteomyelitis with Abscess Mimicking a ‘Cold Abscess’
A 39-year-old Indian woman presented with swelling and pain in the left side of the back since one month associated with low grade fever on and off for the last two weeks. She also complained of minimal weight loss. There were no significant co-morbid illnesses except for mild hypertension for few years. The patient did not appear toxic and was hemodynamically stable. There was a 6 × 8 cm sized globular swelling in the left infra-scapular region with no signs of inflammation. There was minimal tenderness over the adjoining sixth rib. Her white blood cell count was 17,500/mm3 (neutrophils 74%, lymphocytes 18%, monocytes 7%, eosinophils 1%); bilirubin - total 0.8 mg/dl and direct 0.2 mg/dl; aspartate aminotransferase 50 U/L; alanine aminotransferase 44 U/L; alkaline phosphatase, 175 U/L; erythrocyte sedimentation rate of 96 mm/h and glycosylated hemoglobin (HbA1C) of 6.8%. Computed tomography (CT) of the thoracic region revealed a lytic lesion involving the posterior aspect of the left sixth rib with a collection measuring twelve by seven by two cm in the left paraspinal muscles []. Percutaneous aspiration and culture of the abscess grew Salmonella typhi which was susceptible to ampicillin, chloramphenicol, ciprofloxacin, cotrimoxazole and ceftriaxone but resistant to nalidixic acid. Mycobacterial cultures subsequently did not yield any growth. The left sixth rib was surgically excised with drainage of the abscess. The patient was treated successfully with gatifloxacin at a dose of 10 mg/kg/day for six weeks. The patient did well and continued to be asymptomatic one year later on follow-up.