hWe describe a case of paravertebral abscess caused by a Phellinus sp. in a boy with chronic granulomatous disease. Sequencebased identification of this mold, a new agent of disease, suggests a close relation to Phellinus umbrinellus.
CASE REPORTA 10-year-old white male with X-linked gp91 PHOX -deficient chronic granulomatous disease (CGD) presented for a scheduled clinic visit without any acute complaints. He was diagnosed with CGD (cytochrome b 245 beta-polypeptide [CYBB] gene) at 17 months of age following presentation with cervical lymphadenopathy. Despite standard prophylactic medications, his course had been complicated by recurrent pneumonias, granulomatous gastric outlet obstruction, and CGD-related inflammatory bowel disease with chronic constipation, perianal fissures and fistula, recurrent abdominal pain, and failure to thrive. His CGD-related prophylaxis medications included cefprozil, itraconazole, and gamma interferon. He also received medications for his gastrointestinal (GI) complications, including cyproheptadine, mesalamine, and topical treatment for perianal disease. Management of his GI disease had periodically included prolonged courses of prednisone (0.1 to 1 mg/kg of body weight/day) prescribed for relapses of perianal disease and gastric outlet obstructive symptoms. His recent history was significant for right hip pain that was not associated with fever, back pain, or focal neurological symptoms. A hip magnetic resonance image (MRI) revealed a small fluid collection in his hip without any specific abnormality.The discomfort in the hip lasted about 6 weeks and resolved spontaneously without any treatment or analgesics.On examination, he was afebrile and his height and weight were below the 3rd centile for his age. His physical exam was completely unremarkable. In particular, his cranial nerves and gait were normal, as was the remainder of his peripheral neuromuscular system. His laboratory investigations revealed a white cell count of 138,000/l, a platelet count of 335,000/l, a C-reactive protein (CRP) level of 7.4 mg/liter, and an erythrocyte sedimentation rate (ESR) of 21.0 mm/h. Chest computerized tomography (CT), performed as a follow-up for a pneumonia diagnosed and treated a year previously, revealed no new focal pulmonary lesions. However, at the inferior portion of the chest CT (Fig. 1), a right paraspinal mass measuring 3.9 by 2.0 cm at the level of the right kidney with evidence of destruction and erosion of adjacent lower thoracic vertebral bodies was noted. To investigate this lesion further, an MRI of his thoracic/lumbosacral spine was performed and revealed a multilevel right paraspinal mass extending from T11 to L5-S1, with the lesion(s) extending into the neural foramina, though not into the central canal, without evidence of cord compression. Although there appeared to be erosion of the right lateral margins of several lower thoracolumbar vertebral bodies, most notably T11, T12, L1, and L2, no increased uptake was evident on a bone scan. A review of earlier chest CT films ...