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Melanie Pitone, MD; Benjamin Alouf, MD
Author Affiliations: Division of Pediatric Emergency Medicine (Dr Pitone) and Department of Pediatrics (Dr Alouf), Alfred I. duPont Hospital for Children, Wilmington, Del.

Arch Pediatr Adolesc Med. 2006;160:300.

An otherwise healthy 3-month-old male infant had umbilical erythema and watery stools. He had been slightly fussy and cried during feeding. His parents reported intermittent emesis and diarrhea over the last several weeks, with body temperature to 38.8°C. During this illness, he developed redness of the umbilicus that, after resolving spontaneously, recurred over the last 2 days.

On examination, his weight was 7.1 kg (75th percentile); temperature, 38.1°C; heart rate, 153/min; respiratory rate, 40/min; blood pressure, 62/47 mm Hg; and oxygen saturation, 98% on room air. He appeared mildly ill, pale, and quiet. His lips were dry, he had a 2/6 flow murmur heard best at the left sternal border, his skin was mottled, and his feet were cool. The abdomen was soft without apparent tenderness. Periumbilical erythema and induration extended a distance of 0.5 cm around the umbilicus.

Initial laboratory testing revealed a white blood cell count of 34 800/µL, with a differential of 60% neutrophils and 26% lymphocytes. The hemoglobin level was 10.3 g/dL, the platelet count was 1.103 x 10⁶/µL, and the C-reactive protein level was 2.9 mg/dL. Abdominal radiography revealed a single dilated loop of bowel in the midabdomen with adjacent thickening of the anterior abdominal wall. Isotonic saline improved his perfusion and color. The patient began receiving intravenous piperacillin and tazobactam for broad-spectrum bowel and skin flora coverage.

The following day, the surrounding erythema had improved. However, spontaneous purulent drainage was noted at the umbilicus (Figure 1), so an ultrasound was performed (Figure 2).

View larger version (69K): [in this window] [in a new window] [as a PowerPoint slide]   Figure 1. Erythema and purulent collection at the umbilicus. Methicillin sodium–sensitive Staphylococcus aureus was isolated from a culture of drainage fluid.

View larger version (69K): [in this window] [in a new window] [as a PowerPoint slide]   Figure 2. The ultrasound revealed an infected urachal remnant associated with urinary retention.

What is your diagnosis?

SECTION EDITOR: ALBERT C. YAN, MD; ASSISTANT SECTION EDITOR: SAMIR S. SHAH, MD

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Arch Pediatr Adolesc Med. 2006;160(3):301.
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