Indian J Pediatr DOI 10.1007/s12098-015-1789-0
SCIENTIFIC LETTER
Carnett Sign Revisited- Abdominal Wall Abscess Mimicking Painful Splenomegaly Ganesan Rajaguru 1 & Rangan Srinivasaraghavan 1 & Niranjan Biswal 1
Received: 10 January 2015 / Accepted: 12 May 2015 # Dr. K C Chaudhuri Foundation 2015
To the Editor: A 6-y-old boy presented to the emergency with complaints of specks of blood in the vomitus and passage of dark black stools for 2 d. There was a history of fever and left sided upper abdominal pain of 1 wk duration. There was no associated rash, joint pains or bleeding from other sites. He had sustained a blunt trauma to abdomen 3 wk prior to these complaints. Abdominal examination revealed a firm, tender mass in the left hypochondrial region with well defined margin extending for 5 cm below the left costal margin. Attempted palpation of the mass was associated with guarding and rigidity. There was no warmth or erythema over the surface. The platelet count was normal. There was neutrophilic leucocytosis (Total leukocyte count of 16,700/ cu.mm with neutrophil percentage of 80 %). The initial ultrasound abdomen showed normal intra-abdominal contents with normal splenic size and portal vein Doppler study. But in view of strong suspicion of moderate splenomegaly, a repeat ultrasound was ordered. The intra-abdominal findings were again reported to be normal. But this time a high frequency ultrasound was done which picked up the abdominal wall abscess measuring 1.5×2.6×1.4 cm abscess in the internal oblique muscle plane. Incision and drainage was done and thick pus was drained. The child was started on intravenous antibiotics and responded well to the treatment. Thus a final diagnosis of abscess of the abdominal wall muscle plane was made. The hematemesis was probably due to gastritis secondary to drugs. The blunt trauma would have resulted in a small hematoma which could have got infected.
* Niranjan Biswal [email protected] 1
Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry 605006, India
A mass of the abdominal wall will become more prominent with tensing of the abdominal wall musculature, whereas an intra-abdominal mass or intra muscular plane will become less prominent or disappear [1]. On examination at admission, when asking the child to flex his abdominal muscles the mass became less prominent. Hence, we concluded that the mass must be intra-abdominal. But the ultrasound was reported as normal intra-abdominal cavity with an abdominal wall abscess. Abdominal pain originating from abdominal musculature can be diagnosed by Carnett sign [2]. Carnett sign is elicited by asking the child to lie supine and lift both the legs or lift the head and shoulder thereby contracting the abdominal musculature. If the area of abdominal tenderness remains unchanged or increases with this maneuver it indicates that the cause of pain is in the abdominal wall and not intra-abdominal. We were not aware of this sign and hence we had mistaken the abscess in the intra-abdominal musculature for tender splenomegaly. Incidentally detected intra-abdominal abscess or hematoma during ultrasound for suspected intra-abdominal mass is a commonly reported occurrence. Using high-frequency ultrasound (5- to 12-MHz) linear transducers with extended or panoramic views we can differentiate the different layers of the abdominal wall [3] and hence diagnose collections in the muscle plane. Sometimes, intra abdominal disease with involvement of peritoneum (membrane lining of the abdominal cavity) may give a false positive Carnett test. To avoid misdiagnosis, it is prudent to apply this test to individuals with localized abdominal pain rather than those with diffuse abdominal pain [4]. Thus a strong suspicion of abdominal wall collection is needed in children with abdominal pain with a mass, especially with a preceding history of trauma. A knowledge of Carnett sign would be helpful to add credence to the suspicion. Early ultrasound would obviate the needless investigations and treatment delay.
Indian J Pediatr Conflict of Interest None. Source of Funding None. 2.
References 1.
Ferguson CM. Inspection, auscultation, palpation, and percussion of the abdomen [Internet]. In: Walker HK, Hall WD, Hurst JW, editors.
3.
4.
Clinical methods: the history, physical, and laboratory examinations. Boston: Butterworths; 1990. [cited 2014 Sep 28]. Available at: http:// www.ncbi.nlm.nih.gov/books/NBK420/. Suleiman S, Johnston DE. The abdominal wall: an overlooked source of pain. Am Fam Physician. 2001;64:431–8. Gokhale S. Sonography in identification of abdominal wall lesions presenting as palpable masses. J Ultrasound Med. 2006;25:1199–209. Carnett JB. Intercostal neuralgia as a cause of abdominal pain and tenderness. Surg Gynecol Obstet. 1926;42:625–32.
SCIENTIFIC LETTER
Carnett Sign Revisited- Abdominal Wall Abscess Mimicking Painful Splenomegaly Ganesan Rajaguru 1 & Rangan Srinivasaraghavan 1 & Niranjan Biswal 1
Received: 10 January 2015 / Accepted: 12 May 2015 # Dr. K C Chaudhuri Foundation 2015
To the Editor: A 6-y-old boy presented to the emergency with complaints of specks of blood in the vomitus and passage of dark black stools for 2 d. There was a history of fever and left sided upper abdominal pain of 1 wk duration. There was no associated rash, joint pains or bleeding from other sites. He had sustained a blunt trauma to abdomen 3 wk prior to these complaints. Abdominal examination revealed a firm, tender mass in the left hypochondrial region with well defined margin extending for 5 cm below the left costal margin. Attempted palpation of the mass was associated with guarding and rigidity. There was no warmth or erythema over the surface. The platelet count was normal. There was neutrophilic leucocytosis (Total leukocyte count of 16,700/ cu.mm with neutrophil percentage of 80 %). The initial ultrasound abdomen showed normal intra-abdominal contents with normal splenic size and portal vein Doppler study. But in view of strong suspicion of moderate splenomegaly, a repeat ultrasound was ordered. The intra-abdominal findings were again reported to be normal. But this time a high frequency ultrasound was done which picked up the abdominal wall abscess measuring 1.5×2.6×1.4 cm abscess in the internal oblique muscle plane. Incision and drainage was done and thick pus was drained. The child was started on intravenous antibiotics and responded well to the treatment. Thus a final diagnosis of abscess of the abdominal wall muscle plane was made. The hematemesis was probably due to gastritis secondary to drugs. The blunt trauma would have resulted in a small hematoma which could have got infected.
* Niranjan Biswal [email protected] 1
Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry 605006, India
A mass of the abdominal wall will become more prominent with tensing of the abdominal wall musculature, whereas an intra-abdominal mass or intra muscular plane will become less prominent or disappear [1]. On examination at admission, when asking the child to flex his abdominal muscles the mass became less prominent. Hence, we concluded that the mass must be intra-abdominal. But the ultrasound was reported as normal intra-abdominal cavity with an abdominal wall abscess. Abdominal pain originating from abdominal musculature can be diagnosed by Carnett sign [2]. Carnett sign is elicited by asking the child to lie supine and lift both the legs or lift the head and shoulder thereby contracting the abdominal musculature. If the area of abdominal tenderness remains unchanged or increases with this maneuver it indicates that the cause of pain is in the abdominal wall and not intra-abdominal. We were not aware of this sign and hence we had mistaken the abscess in the intra-abdominal musculature for tender splenomegaly. Incidentally detected intra-abdominal abscess or hematoma during ultrasound for suspected intra-abdominal mass is a commonly reported occurrence. Using high-frequency ultrasound (5- to 12-MHz) linear transducers with extended or panoramic views we can differentiate the different layers of the abdominal wall [3] and hence diagnose collections in the muscle plane. Sometimes, intra abdominal disease with involvement of peritoneum (membrane lining of the abdominal cavity) may give a false positive Carnett test. To avoid misdiagnosis, it is prudent to apply this test to individuals with localized abdominal pain rather than those with diffuse abdominal pain [4]. Thus a strong suspicion of abdominal wall collection is needed in children with abdominal pain with a mass, especially with a preceding history of trauma. A knowledge of Carnett sign would be helpful to add credence to the suspicion. Early ultrasound would obviate the needless investigations and treatment delay.
Indian J Pediatr Conflict of Interest None. Source of Funding None. 2.
References 1.
Ferguson CM. Inspection, auscultation, palpation, and percussion of the abdomen [Internet]. In: Walker HK, Hall WD, Hurst JW, editors.
3.
4.
Clinical methods: the history, physical, and laboratory examinations. Boston: Butterworths; 1990. [cited 2014 Sep 28]. Available at: http:// www.ncbi.nlm.nih.gov/books/NBK420/. Suleiman S, Johnston DE. The abdominal wall: an overlooked source of pain. Am Fam Physician. 2001;64:431–8. Gokhale S. Sonography in identification of abdominal wall lesions presenting as palpable masses. J Ultrasound Med. 2006;25:1199–209. Carnett JB. Intercostal neuralgia as a cause of abdominal pain and tenderness. Surg Gynecol Obstet. 1926;42:625–32.
