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The Journal of Emergency Medicine, Vol. 41, No. 2, pp. 157–160, 2011Copyright © 2011 Elsevier Inc.

Printed in the USA. All rights reserved0736-4679/$–see front matter

doi:10.1016/j.jemermed.2010.02.027

ClinicalCommunications: Pediatrics

NECK PAIN AND STIFFNESS IN A TODDLER WITH HISTORY OF BUTTONBATTERY INGESTION

Audrey Tan, DO,* Sigrid Wolfram, MD,* Mary Birmingham, MD,* Nathaniel Dayes, MD,†Eugene Garrow, MD,‡ and Shahriar Zehtabchi, MD*

*Department of Emergency Medicine, †Department of Surgery, and ‡Department of Pediatric Surgery, State University of New York,Downstate Medical Center/Kings County Hospital Center, Brooklyn, New York

Reprint Address: Audrey Tan, DO, Department of Emergency Medicine, State University of New York Downstate Medical Center, 450

Clarkson Avenue, Box: 1228, Brooklyn, NY 11203

e Abstract—Background: Button batteries within the gas-trointestinal system are dangerous and must be suspectedafter any foreign body ingestion. Common complicationsinclude esophageal perforation, fistula formation, andesophageal scarring. Objectives: Spondylodiscitis resultingfrom button battery ingestion is extremely rare and, to ourknowledge, has been described in the literature only once todate. Case Report: We will describe a case in which a14-month-old girl developed spondylodiscitis of T1/T2 afteran uncomplicated clinical course involving the ingestionand removal of an esophageal button battery. Discussionwill include mechanisms in which button batteries causeharm and notable differences between the previously re-ported case and ours. Conclusions: We present this case toincrease awareness of spondylodiscitis in patients withneck pain or stiffness and a history of button batteryingestion. © 2011 Elsevier Inc.

e Keywords—button battery; foreign body ingestion;spondylitis; discitis; spondylodiscitis

INTRODUCTION

Foreign body ingestion is a common presenting com-plaint in pediatric emergency departments (EDs). In themajority of cases, the ingested object passes spontane-ously through the gastrointestinal tract and treatmentconsists of careful observation (1). Despite this fact,

RECEIVED: 14 July 2009; FINAL SUBMISSION RECEIVED: 15 N

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serious morbidity and mortality do occur. Approximately1500 deaths per year in the United States are attributed tothe ingestion of foreign bodies (2).

Button batteries are among the most dangerous in-gested foreign bodies due to the possibility of seriouscomplications. Problems occur when a battery becomeslodged within the gastrointestinal tract, most com-monly in the esophagus, and complications includefistula formation, esophageal perforation, and esoph-ageal strictures.

Spondylodiscitis resulting from button battery inges-tion is a rare complication that has been described onlyonce previously in the literature. We will discuss a caseof an ingested button battery resulting in spondylodiscitisof T1–T2 vertebral bodies, as well as the clinical impli-cations of the case.

CASE REPORT

A 14-month-old girl presented to the Pediatric ED withabnormal posturing of her neck. The symptoms startedabruptly 4 days prior when the patient was noted to beholding her neck in a flexed position and had a restrictedrange of motion with tenderness on palpation of theposterior neck. The patient’s mother denied any feveror trauma. There was no suspicion of accidental drugingestion.

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158 A. Tan et al.

The patient’s past medical history was significant foran admission to the hospital 1 month prior for the re-moval of an impacted esophageal button battery. Thepatient had presented to the ED with the complaint ofcough, congestion, and fever for 2 weeks. A chest X-raystudy demonstrated a button battery in the upper third ofthe esophagus at the level of carina (Figure 1). PediatricSurgery performed a rigid endoscopy and removed a3-volt, 2 cm � 0.2-cm lithium button battery from theesophagus without complication. Erythematous changes,swelling, and superficial ulcerations were noted on theposterior esophageal wall with no visible perforation. Inthe Pediatric Intensive Care Unit, the patient was givenintravenous clindamycin and feedings were initiallywithheld. Subsequently, a barium esophagogram showedno leak of contrast. The patient was discharged after 2days with resumption of normal feeding and activities.

At the current visit, the patient’s vital signs werewithin normal limits. On physical examination, the pa-tient’s neck was extended at C2–C3 and flexed at C6–C7. Range of motion was restricted on lateral rotation ofthe neck. Midline neck tenderness at the level of C3–C7region and anterior neck lymphadenopathy was noted.No drooling was present. The airway was patent, lungswere clear, and abdominal examination was normal.

A soft tissue neck X-ray study was ordered, whichrevealed a lucency in the region of the lamina of C3. Acomputed tomography (CT) study of the cervical spinewithout contrast revealed diffuse erosive changes in T1and T2 vertebral bodies, with extensive soft tissue in-

Figure 1. Chest plain film demonstrating a button batterywithin the esophagus at the level of the carina. This X-raystudy was obtained approximately 1 month before the cur-

rent presentation.

flammation in the pre-vertebral space (Figure 2). Noabnormalities of C3 were noted on the CT scan.

A subsequent magnetic resonance imaging study re-vealed erosions of the inferior endplate of T1 vertebralbody and superior endplate of T2 vertebral body. Therewas a signal abnormality of the intervertebral disc ofT1/T2 with posterior bulging into the canal. Thesefindings were consistent with spondylodiscitis. Thin-ning of the posterior wall of the esophagus was notedat T1 with contiguity of the signal abnormality fromthe esophagus to the area anterior to the T1/T2 verte-bral bodies (Figure 3).

The patient was started on intravenous ampicillin/sulbactam and admitted to the Pediatric Intensive CareUnit. A barium esophagogram performed 4 days afteradmission demonstrated no evidence of perforation. A

Figure 2. Cat scan of the cervical spine demonstrating ero-sion of the vertebral body of T2.

Figure 3. T1- (left) and T2-weighted (right) sagittal magnetic

resonance images demonstrating spondylodiscitis of T1–2.

Button Battery Ingestion in a Toddler 159

concurrent endoscopy demonstrated an esophageal gran-uloma at 12–14.5 cm from the incisors but otherwise, nofriability or abnormal fistulas were noted.

Inpatient administration of intravenous ampicillin/sublactam was continued for a total duration of 4 weeks.Upon completion of the regimen, the patient had fullmobility of the cervical spine and no tenderness of thearea. She was discharged on oral amoxicillin/clavulanatefor 2 weeks.

DISCUSSION

Button battery ingestion accounts for � 2% of the for-eign bodies ingested by children (3). In the majority ofcases, the battery spontaneously passes through the gas-trointestinal tract and once past the esophagus, manage-ment consists of serial radiographs to monitor progres-sion (2). In contrast, if a button battery becomes lodgedwithin the esophagus, the potential for severe complica-tions increases secondary to the toxic effects on localsurrounding tissue (4).

Button batteries may lead to complications via fourmechanisms. The first is the absorption of toxic sub-stances, which occurs primarily with mercury-containingbatteries. Although there are only two case reports in theliterature showing elevated mercury levels after inges-tion, this remains a theoretical risk due to the high levelsfound in the batteries (5). Of note, only one case has beenreported in the literature of systemic absorption of lith-ium after the ingestion of a lithium button battery (6).The second mechanism involves electrical discharge andmucosal burns. On contact with tissues, batteries releasea low-voltage direct current. This liberates intracellularpotassium and causes cell death (4). The third mecha-nism is caustic injury due to electrolyte leakage (5). Thefinal mechanism is necrosis due to direct pressure (4).

Documented complications of button battery inges-tion include tracheoesophageal and aortoeophageal fis-tulas, esophageal burns, esophageal perforations, andesophageal strictures (7–9).

The development of spondylodiscitis has been docu-mented as a complication of foreign body ingestion in afew cases and as a complication of button battery inges-tion only once to date. Two case reports were found ofspondylodiscitis resulting from the ingestion of sharpobjects, namely, a fishbone and a pin (10,11). In 1996, a6-year-old boy developed an esophageal perforation, me-diastinitis, and a C6–C7 spondylodiscitis after the inges-tion of a plastic gear wheel (12).

A recent case report documented T1–T2 spondylodis-citis from a button battery ingestion in a 1 ½-year-oldboy (13). Although this case is similar to the one we have

described, there are several differences. The child in the

previously described case presented with repeated vom-iting and refusal of food. On physical examination, thischild had crepitus on palpation of the chest wall. Charredesophageal tissue was noted around the button batteryand its removal was complicated by pneumothoraces,necessitating bilateral chest tube placement. Finally, asthe spondylodiscitis developed, the patient developedintermittent fever, suggestive of an infection. The patientdescribed in our case had a more benign clinical course.She initially presented with only coughing and fever.There were no complications during the removal of thebutton battery. Despite this, she developed spondylodis-citis that did not manifest itself with fever.

We considered the possibility that this child devel-oped spondylodiscitis spontaneously and irrespective ofher history of button battery ingestion. However, child-hood spondylodiscitis is extremely rare (14). It typicallyinvolves the vertebrae of the lower thoracic and upperlumbar spine (14). The etiology of spondylodiscitis hasnot been well established but an association has beenmade with a preceding traumatic event (15). Given ourpatient’s history, it is unlikely that she spontaneouslydeveloped spondylodiscitis, particularly considering therarity of the disease and the anatomic proximity of thetwo disease processes.

Finally, the delay in the patient’s symptoms can beexplained by the presence of a microperforation causedby the button battery. Although small enough to avoiddetection via esophagogram, the microperforation wassignificant enough to allow the leakage of a small butsignificant amount of food, bacteria, acid, and othercomponents. This provided an ideal environment for thedevelopment of an infection in the neighboring vertebra.

CONCLUSION

We have described a case of a 14-month-old girl whodeveloped spondylodiscitis after an uncomplicated clin-ical course involving the removal of an impacted esoph-ageal button battery. This diagnosis should be consideredin children presenting with decreased mobility or abnor-mal posturing of the neck after a history of any foreignbody ingestion. Complications should be considereddays and, as demonstrated by this case, even weeks aftera battery ingestion and removal. Additionally, a benignclinical course should not decrease one’s clinical suspi-cion, particularly in the pediatric population.

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