(851) Pott Puffy . . . Lymphoma?

Introduction: Pott’s puffy tumor is a rare osteomyelitis (OM) of the frontal bone leading to a subperiosteal abscess. In the literature, this typically presents as a fluctuant and tender swelling of the forehead, with fever, headache, periorbital edema, nausea, and emesis. Rapid diagnosis is crucial for best outcomes.

Description: B is a 12 year old who presented multiple times to several emergency departments (ED) for headache and emesis; his fourth presentation was to our hospital. He was given Benadryl, Compazine, and Zofran with no relief. He previously had a normal head CT, so neurology recommended an outpatient brain MRI and he was discharged again.
Sedated MRI demonstrated acute frontal sinusitis, OM, and bifrontal subperiosteal phlegmon suspicious for Pott’s puffy tumor. He was urgently sent to the ED where progressive symptoms including tenderness and swelling of his frontal bone and papilledema, prompted a rapid workup, including ophthalmology and neurosurgery consultation. He was taken urgently for decompressive craniectomy with frontal bone removal due to symptomatic increased intracranial pressure. During the procedure, neurosurgery noted his brain was “taut”, found a hard phlegmon without purulence, and collected cultures. He was admitted to the pediatric intensive care unit post-operatively. He then developed new fevers and hypoxic respiratory failure prompting chest CT which showed large bilateral pleural effusions and diffuse lymphadenopathy (LAD) throughout his mediastinum. Bilateral chest tubes were placed. His LAD was out of proportion to his infection, so a lymph node biopsy was obtained. Biopsy resulted with peripheral t-cell lymphoma and he started induction chemotherapy.

Discussion: Peripheral t-cell lymphoma is an often aggressive form of non-hodgkin lymphoma arising from mature t-cells. Typically children present with “B symptoms” and LAD. It is possible that our patient was severely immunocompromised allowing for development of Pott’s puffy tumor. There have been reports of sinonasal large b-cell lymphoma presenting as Pott’s puffy tumor, but none to our knowledge involving a pediatric patient and peripheral t-cell lymphoma. For similar presentations in pediatric patients with complicated, worsening courses requiring intensive care, t-cell lymphoma should be considered.