Case 1:
A four-month-old girl was presented to our hospital due to a right thigh
swelling since four days ago. The parents did not report any fever, poor
feeding, or irritability. On physical examination vital signs were
stable. There was a 5*7 cm fluctuating mass with sharp borders at the
anterior surface of her right thigh (Figure 1). No erythema, deformity,
discharge, or tenderness was detected. Both hips and knees had a normal
range of motion. The general physical examinations including lung and
heart auscultation, abdominal examination, and the examination of lymph
nodes were normal. There was no history of insect bite or trauma. The
patient had an appropriate growth and developmental history with no
prenatal or perinatal difficulties. She had received the routine
vaccination for Iranian children that included BCG, the first dose of
hepatitis B, the first dose of OPV (Oral Polio Vaccine), and the first
dose of DPT (Diphtheria, Pertussis, and Tetanus). The lab results were
as follows: White Blood Cell (WBC): 11500/μl (Polymorphonuclear
leukocyte (PMN): 29% and Lymphocyte: 66%), Hemoglobin: 9.6 gr/dl,
Platelet: 519000/μl, and Erythrocyte Sedimentation Rate (ESR): 50 mm/h.
Blood Urea Nitrogen (BUN), Creatinine (Cr), Blood Sugar (BS), and
electrolytes were normal. Ultrasound results demonstrated a large
collection of thick fluid (49*29*32 mm) with debris and septations in
the depth of the anterior thigh muscle. X-ray imaging was otherwise
normal. On the first day of admission needle aspiration of the lesion
was done and 5 milliliters of green purulent fluid was drained and sent
for gram staining, acid-fast staining, and culture. Gram staining and
routine culture were negative. The patient received intravenous
Cloxacillin without significant improvement and so open surgical
drainage was done and light yellow cheesy material was drained and sent
for acid-fast staining. Both samples sent for acid-fast staining showed
more than 10 acid-fast bacilli per field. On Loewenstein Jensen culture
media, light yellow slow-growing colonies were reported. The patient had
no abnormal findings on chest Computed Tomography (CT) scan and
immunological screening tests. The patient received Isoniazid, Rifampin,
and Ethambutol with diagnosis of mycobacterial cold abscess and there
was no improvement after three weeks. Clarithromycin was added and the
patient improved significantly after two weeks. These medications were
continued for four months and Isoniazid and Rifampin for further two
months. The patient had good growth and development with no further
re-accumulation of pus or any other remarkable health problem during the
one-year follow-up.