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Identification data
Name : Yang Yun Fei
Age/Race/Sex : 19 years old / Chinese / Man
IC : 818!1"#1$%
&his young man com'lained o( a )ila*eral groin 'ain (or *he 'as* *hree mon*hs+ &he
'ain ,as locali-ed. gradual in onse*. dee' sea*ed and aggra/a*ed ,hen he (lexed his
hi' and ,ill only )e relie/ed )y res*+ A mon*h la*er he de/elo'ed a sudden lo,
)ac0ache a(*er he *ried *o li(* a door+ &he 'ain ,as )eara)le and he ,as s*ill a)le *o
,al0+ 1e also had a signi(ican* loss o( ,eigh* and a''e*i*e. e/ening (e/er/s,ea* and
chronic cough+ &here ,as no lim) ,ea0ness/num)ness or his*ory o( con*ac* ,i*h any
*u)erculosis 'a*ien*+ 1is general 'rac*i*ioner re(erred him *o a Ches* 'hysician+
A 'hysical examina*ion re/ealed gi))us o/er 21. 23 and 2! /er*e)rae ,i*h
*enderness+ Flexion and ex*ernal ro*a*ion o( )o*h hi' 4oin*s ,ere res*ric*ed )ecause o(
*he 'ain+ 1o,e/er. *here ,as no neurological de(ici* o( )o*h lo,er lim)s no*ed+ A
rou*ine )lood in/es*iga*ion sho,ed a mar0ed raise o( 5SR 6%# mm/h7 and a reac*i/e
Man*oux *es*+
A 'lain radiogra'h o( a lum)osacral region sho,ed a 23 /er*e)ral )ody colla'se
associa*ed ,i*h loss o( 8soas shado, and 0y'ho*ic angle o( 1+ A ches* radiogra'h
exhi)i*ed a 'a*chy area o( consolida*ion and ca/i*a*ion o/er his righ* a'ical region+ A
Magne*ic Resonance Imaging sho,ed a mar0ed des*ruc*ion o( 23 /er*e)rae )ody ,i*h
an ex*radural com'ression and narro,ing o( s'inal canal+ 9ila*eral 8soas a)scess ,ere
also no*ed+
&he diagnosis o( 8ulmonary &u)erculosis ,i*h s'inal in/ol/emen* and 8soas a)scess
,ere made+ An an*i*u)erculous *rea*men* ,as ini*ia*ed+
1e ,as *hen re(erred *o *he s'ine clinic (or *he ex*ra'ulmonary *u)erculosis+ An
an*erior decom'ression. ins*rumen*a*ion and 'soas a)scess drainage ,ere 'er(ormed
on *he 3#
:uly 31+
&here has )een a resurgence in *he num)er o( *u)erculosis in mos* 'ar* o( *he ,orld
a**ri)u*ed *o *he 1uman Immunode(iciency ;irus 61I;7 e'idemic. large num)ers o(
homeless 'eo'le. increased cro,ding in 'risons and shel*ers. *he emergence o( drug
resis*an* s*rains o( *u)erculosis. 'oor 'a*ien* com'liance ,i*h medica*ions. and
immigra*ion (rom coun*ries ,i*h a high 're/alence o( *u)erculosis 6Nancy 5+<+ e* al.
&here are *hree organisms *ha* can )e rela*ed *o *u)erculosis= Myco)ac*erium
&u)erculosis 6*he mos* common7. Myco)ac*erium A(ricanum and Myco)ac*erium
9o/is+ Myco)ac*erium *u)erculosis is a *hin rod ,i*h round ends. non mo*ile. ,i*hou*
ca'sule and is di((icul* *o s*ain ,i*h usual me*hods 6>ram s*aining7
I( i* is s*ained ,i*h *he car)ol (uschsin or ?iehl Nielsen me*hod. i* ,ill resis*
discolora*ion ,i*h s*rong mineral acid and al0aline. hence is called acid (as* )acillus+
I* gro,s only on enriched medium con*aining egg and 'o*a*o )ase or serum 6al)umin7
)ase+ <ue *o i*s s*ric* aero)ic na*ure. i* has a slo, ra*e o( gro,*hs. as i* is highly
de'enden* on oxygen *ension 6@a**s 1+> and 2i(eso R+M+. 199$7+
In *he Ani*ed S*a*es. 1/# o( ne,ly diagnosed cases o( *u)erculosis are associa*ed ,i*h
ex*ra'ulmonary diseases+ 1/! o( 'a*ien*s ,i*h *u)erculosis ,ho has 1I; ,ill ha/e
ex*ra'ulmonary disease+ 5x*ra'ulmonary *u)erculosis is more common in children
*han in adul*+ &u)erculosis has )een re'or*ed in all )ones o( *he )ody ,i*h #B s'inal
in/ol/emen*s 6#B *horacic s'ine= 3#B cer/ical s'ine and 3#B lum)ar s'ine7+ C*hers
include 13B in 'el/is. 1B in hi' and (emur. and 1B in 0nee and *i)ia 6@a**s 1+>
and 2i(eso R+M+. 199$7+
&he pathophyio!o"y o( s'inal in/ol/emen* may )egin ei*her )y direc* ex*ension
(rom *he lung or )y hema*ogenous s'read+ &he disease )egins in *he an*eroin(erior
'or*ion o( *he /er*e)ral )ody 6/er*e)ral me*a'hysis7+ I* ini*ia*es chronic granula*ion
in(lamma*ory reac*ions and *ends *o s'read )enea*h *he an*erior longi*udinal
ligamen*s *o in/ol/e *he ad4acen* /er*e)ral )odies+ 5le/a*ion o( *he 'erios*eum may
de/asculari-e *he )one and leads *o necrosis and a)scess (orma*ion+ Narro,ing o( *he
disc s'ace occurs in *he la*er s*age ,hen *he des*ruc*ion o( *he cancellous )one on
)o*h sides o( *he disc allo,s *he disc *o hernia*e in*o *he a((ec*ed /er*e)ral )ody+
Csseous in(ec*ion and os*eonecrosis may lead *o a decrease in *he /er*e)ral heigh*+ As
*he an*erior 'or*ion o( *he /er*e)ral )ody is mos* commonly in/ol/ed com'are *o i*s
coun*er'ar*. a 0y'hosis de(ormi*y may s*ill occur des'i*e *he resolu*ion o( *he acu*e
in(ec*ion+ 2esion in *he *horacic s'ine has a grea*er *endency *o,ards 0y'hosis *han
*hose in *he *horacolum)ar or lum)ar s'ine+ 6Chene)a 9+ And Ro)er* >. 199%7+
&he occurrence o( neurological im'airmen* may *hen resul*s (rom
1+ ;er*e)ral lesion= 0y'hosis. seDues*ered /er*e)ral )ody or disc+
3+ 5'idural a)scess
!+ Se/ere arachnoidi*is
"+ In*radural *u)erculoma
A)scess may *rac0 do,n *he *issue 'lane. *hough ex*ension 'os*eriorly in*o *he s'inal
canal can occur a* any le/el o( *he s'ine+
a+ In *he nec0. a)scesses are common in children *han adul* and are
o(*en asym'*oma*ic due *o *he com'ression o( oeso'hagus and *rachea
)+ In *he *horacic region. in/asion o( *he lung may occur resul*ing in
adhesion )e*,een *he 'leura and *he dia'hragm+
c+ In *he lum)ar region. i* may descend do,n *he shea*h o( *he 'soas
muscle *o *he (emoral *riangle region+
d+ In *he sacral region. 'us may *ra/el in*o ei*her *he 'erineum or *he
glu*eal region /ia *he grea*er sacral (oramen+
C!inica! p#eentation o( *he disease de'ends u'on *he s*age o( *he disease. *he age o(
*he 'a*ien*. *he loca*ion and *he 'resence o( neurological in/ol/emen*. a)scesses or
sinus *rac*s+ &he mos* common 'resen*a*ion is 'ain. ,hich is usually insidious onse*
and may mechanical in na*ure during *he ini*ial s*ages o( *he disease+ @eigh* loss.
(e/er and malaise may )e associa*ed ,i*h chronic illness o(*en 'recedes iden*i(ica*ion
o( *he s'inal lesion+ Cer/ical lesion may 'resen* ,i*h *or*icollis. nec0 'ain and
s*i((ness. dys'hagia. or ins'ira*ory s*ridor+ @ea0ness. num)ness and gai* a)normali*y
are also common 'resen*ing sym'*oms+ &hese sym'*oms are no* s'eci(ic (or s'inal
*u)erculosis+ Flan0 mass and *he 'resen* o( ex*ras'inal *u)erculosis s*rongly sugges*
*u)erculosis o( s'ine+ As illus*ra*ed a)o/e. 'a*ien* may 'resen* ,i*h ilio'soas muscle
8hysical examina*ion should include a care(ul assessmen* o( s'inal alignmen*.
ins'ec*ion o( *he s0in ,i*h a**en*ion *o (ungal in(ec*ion and de*ec*ion o( sinuses . an
a)dominal examina*ion *o e/alua*e (or su)cu*aneous (lan0 mass and a *horough
neurological assessmen*+
2a)ora*ory in/es*iga*ions charac*eris*ically sho, a normal ,hi*e )lood cell coun*. an
ele/a*ed 5SR and 'osi*i/e Man*oux *es*+ False nega*i/e resul* 6normal 5SR and
nonreac*i/e Man*oux *es*7 is no* uncommon among 'a*ien*s ,i*h s'inal *u)erculosis+
Cy*ological diagnosis o( /er*e)ral *u)erculosis de'ends on *he adeDuacy o( *issue
sam'ling (or his*ological examina*ion and cul*ure+ C& guided )io'sy is 'resen*ly *he
mos* e((icien* me*hod in es*a)lishing *he diagnosis+
8lain (ilm e/alua*ion o( *he &9 s'ine may demons*ra*e loss o( /er*e)ral heigh* or dis0
in*er/al. erosions. indis*inc*ion o( *he end 'la*es. 'ara/er*e)ral masses. and seDues*rae
<is0 s'ace narro,ing may )e Dui*e su)*le+ &he earlies* change is rare(ac*ion+
1o,e/er. o/er #B o( *he *ra)ecular )one is los* )e(ore a lesion is /isi)le on *he 'lain
(ilm= *his 'rocess may *a0e u' *o $ mon*hs+ In *he *horacic s'ine /isuali-a*ion o( a
'ara/er*e)ral a)scess reDuires an adeDua*ely 'ene*ra*ed /ie,+ In *he lum)ar s'ine
asymme*ry or )ulging o( *he 'soas shado, may )e de*ec*ed+ Scallo'ing o( *he an*erior
/er*e)ral con*our 6aneurysmal a''earance7 is more commonly seen ,i*h children+ No
s'eci(ic or 'a*hognomonic 'lain (ilm signs dis*inguish *u)erculous (rom 'yogenic
s'inal in(ec*ion. and correla*ion ,i*h *he clinical 'resen*a*ion and dura*ion o(
sym'*oms is essen*ial 6Sandra 2+M+ and Mah/ash R. 317+
A )one scan o( *u)erculous s'inal in/ol/emen* is sensi*i/e )u* nons'eci(ic. 'ro/iding
limi*ed ana*omic resolu*ion+ A C& scan is o( grea* /alue in *he delinea*ion o(
encroachmen* o( *he s'inal canal )y 'os*erior ex*ension o( in(lamma*ory *issues. )one
or disc ma*erial. in guidance (or )io'sy and *he 'lanning o( o'era*i/e 'rocedure+ A
MR imaging is mos* use(ul (or delinea*ing so(* *issue masses in )o*h sagi**al and
coronal 'lane. and (or indica*ing *he ex*en* o( *he disease and *he s'read o(
*u)erculosis de)ris under an*erior and 'os*erior ligamen*s+ I* is also use(ul *o e/alua*e
in*ramedullary lesion and isola*ed ex*radural disease+ 1o,e/er. *here is no
'a*hognomonic (inding on MRI *ha* is relia)le *o di((eren*ia*e *u)erculosis (rom o*her
s'inal in(ec*ion or neo'lasm 6Sandra 2+M+ and Mah/ash R+ 317+
&u)erculosis has *o )e dis*inguished (rom o*her causes o( )ac0 'ain ,i*h locali-ed
)ony des*ruc*ions such as 8yogenic S'ondyli*is. An0ylosing S'ondyli*is and *umor
es'ecially me*as*asis *o s'ine has *o )e excluded+
8yogenic s'ondyli*is ,as unli0ely in *his case )e cause o( *he )elo, reasons:
&he di((erences )e*,een a 8yogenic and &u)erculous /er*e)ral os*eomyli*is are as
Pyo"enic T$%e#c$!o$
Single /er*e)ral (ocus Mul*isegmen* in/ol/emen*
Symme*rical colla'se Ey'hosis
S'read in*raosseous S'read along (ascial 'lane
<isc des*royed <isc seDues*ra*ed
An*erior column in/ol/emen* &hree column in/ol/emen*
5'idural a)scess more common 8ara/er*e)ral a)scess more common
More acu*e onse* Insidious chronic onse*
In children o*her s'inal disease *ha* may mimic *u)erculosis radiologically are rare+
&he diagnosis o( &u)erculosis o( *he s'ine ,as a''ro'ria*ed in *his 'a*ien* as
sugges*ed )y *he his*ory and charac*eris*ic radiological (inding+
9io'sy o( sus'icious lesions is recommended in coun*ries in ,hich *u)erculosis is no*
endemic= in endemic coun*ries 6such as India7 su)acu*e or chronic )one in(ec*ion ,i*h
insidious onse* is *rea*ed as &u)erculosis un*il 'ro/ed+ &u)erculosis is sugges*ed ,i*h
acidF(as* )ac*eria on smear and s'ecimen his*o'a*hology demons*ra*ing casea*ing
granuloma*a. )u* cul*ure o( *he as'ira*ed or excised s'ecimen es*a)lishes *he
&he t#eat&ent o( musculos0ele*al *u)erculosis is 'rimarily medical+ C'era*i/e
in*er/en*ion is an ad4unc* *o a''ro'ria*e an*i*u)erculous chemo*hera'hy+ Success(ul
medical *rea*men* reDuires 'rolonged adminis*ra*ion o( a minimum o( *hree drugs *o
,hich *he organisms are susce'*i)le *o. ,i*h a* leas* one o( *hem )eing )ac*ericidal+
Com)ina*ion o( drugs is necessary *o 're/en* s'on*aneous emergence o( drug
resis*ance+ 8rolonged drug *hera'y is necessary *o elimina*e or s*erili-e *he 'ersis*en*
)acilli. ,hich are small 'o'ula*ion o( me*a)olically inac*i/e organisms+
&he medical *hera'y should )e 'receded ,i*h care(ul e/alua*ion o( renal/ li/er (uc*ion
and eye assessme*+ Sym'*om and sign o( drug ad/erse reac*ion / *oxici*y has *o aler*
*he 'hysician and drug regime or dosage has *o ad4us*ed accordingly+
I* ,as concluded (rom *he *hir*een*h re'or* o( *he Medical Reseach Council 619987
*ha* ou*'a*ien* chemo*hera'y ,i*h *he s*andard shor* course regimes. (or six or nine
mon*hs )ased on isonia-id. ri(am'icin and 'yra-inamide should )e *he main
managemen* o( uncom'lica*ed s'inal *u)erculosis+ 9ed res*. s'lin*age. o'era*i/e
*rea*men* or *he addi*ion o( s*re'*omycin *o *he com)ina*ion o( 8AS and isonia-id did
no* gi/e any signi(ican* im'ro/emen* in *he long *erm resul*s+ In 1ong Eong. ,here
*he ini*ial disease ,as less ex*ensi/e. *he radical o'era*ion 6 radical excision o( *he
s'inal lesion ,i*h )one gra(*7 'er(ormed )y *he *eam led earlier )ony (usion and less
residual 0y'hosis. )u* ga/e no o*her )ene(i*s a* 1# years+
&he (ollo,ing are *he common an*i &9 drugs )eing used:
AntiTB D#$" Potentia! ad'e#e effect
Isonia-id: A )ac*eriocidal agen* 1e'a*ic *oxici*y
8eri'heral neuro'a*hy:8yridoxine
Ri(am'icin : A )ac*eriocidal agen* >as*roin*es*inal u'se* i+e+ 4aundice
5*ham)u*ol : A )ac*erios*a*ic agen* Re*ro)ul)ar neuri*is
8yri-inamide: A )ac*eriocidal agen*
S*re'*omycin6I;7: A )ac*eriocidal C*o*oxi*y
&he curren* recommenda*ion (or *rea*men* o( adul*s ,ho ha/e musculos0ele*al
*u)erculosis ,i*h or ,i*hou* 1I; in(ec*ion is as )elo,:
&he (irs* *hree mon*hsF Isonia-id. Ri(am'icin. 8yri-inamide and 5*ham)u*ol 6or
S*re'*omycin (or children ,ho are *oo young *o )e moni*ored (or /isual acui*y7+ &his
is (ollo,ed )y a com)ina*ion o( Isonia-id and ri(am'icin as ou*'a*ien*+ &he drug
regime is *o co/er one year dura*ion o( *rea*men* 6 @a**s 1+>+ and 2i(eso R+M+.
I* has )een sho,n *ha* drug *hera'y alone can )e e((ec*i/e *rea*men* (or *u)erculosis
o( *he s'ine ,i*h an acce'*a)le resolu*ion o( neurological seDuelae and 're/en*ion o(
su)s*an*ial 'rogression o( *he 0y'hosis+ In *he six*h re'or* o( *he Medical Re'or*
Council 619%87. *he resolu*ion o( *he 'ara'aresis on *he alloca*ed regime 6*hree
de)ridemen*/ S81 regime. *hree de)ridemen*/ 81 regime and *hree am)ula*ory/ 81
regime7 occured ,i*hin one year in (i/e o( nine 'a*ien*s+
<es'i*e *he good resul* o( medical *rea*men* *o eradica*e *he a((ec*ing organism.
0y'hosis and neurological im'airmen* remains an unresol/ed 'ro)lem. 'ar*icularly
,hen more *han disc s'aces are in/ol/ed+ 6Ra4ase0aran S+and Soundara'andian S.
&he a)solu*e indica*ion (or o'era*i/e in*er/en*ion are:
a+ Mar0ed neurological de(ici* 'ar*icularly cauda eDuina syndrome
es'escially i( i* is rela*ed *o se/ere 0y'hosis / re*ro'ulsed )one or disc in
neural canal+
)+ 2arge a)scess ,i*h com'ression e((ec* eg+ Res'ira*ory o)s*ruc*ion
c+ Neurological de(ici* ,orsen des'i*e adeDua*e chemo*hera'y
d+ Con*inuing 'rogression o( 0y'hosis or ins*a)ili*y+6 G #H o( 0y'hosis
segmen*ally / G #B o( /er*e)ral )ody des*ruc*ion 7+
&he rela*i/e indica*ion (or o'era*i/e in*er/en*ion are:
a+ &o o)*ain adeDua*e ma*erial (or cul*ure 6 nondiagnos*ic 'ercu*aneous
)io'sy sam'le has )een o)*ained 7+
)+ 8a*ien* ,i*h neurological de(ici* in ,hom 'rolonged )ed res*/
immo)ila-a*ion may lead *o o*her 'ro)lem+
c+ 8resence o( 'ersis*en* 'ain o( s'asm caused )y demons*a)le mechanical
d+ &he 'ain is rela*ed *o s'inal ins*a)ili*y ,here s'on*aneous (usion has no*
occurred+ 6@a**s 1+>+and 2i(eso R+M. 199$7+
8rior *o surgical in*er/en*ion. an*i*u)erculous *hera'y should )e adminis*ered (or a*
leas* *,o ,ee0s *o 're/en* miliary de'osi*+ I* can )e s*ar*ed em'irically 'rior *o
de(ini*i/e diagnosis o( *u)erculosis o( s'ine )eing made+
&he inser*ion o( s*ru* gra(*s in *he s'ace crea*ed a(*er de)ridemen* o( *he a((ec*ed
/er*e)ral )odies 'ro/ides some su''or* an*eriorly. )u* *his is usually some,ha*
insu((icien*+ @hen more *han *,o le/els are a((ec*ed. *he gra(*s (reDuen*ly ei*her (ail
or are resor)ed+ &his has led *o use o( 'os*erior ins*rumen*a*ion (or addi*ional
su''or* / increase s*a)ili*y ei*her a* *he *ime o( de)ridemen* or a* a la*er s*age+ &he use
o( 'os*erior ins*rumen*a*ion (or addi*ional su''or* is associa*ed increased o'era*i/e
*ime. )lood loss and leading *o grea*er )lood loss. 'os*o'era*i/e mor)idi*y
6Ra4ase0aran S+and Soundara'andian S+. 19897+
An an*erior ins*rumen*a*ion is has sho,n decrease in o'era*ing *ime. )lood loss and
'os*o'era*i/e mor)idi*y+ Similar resul* ,as also re'or*ed )y Eos*ui0 e* al+ For (or*y
eigh* 'a*ien*s ,ho had )een managed ,i*h an*erior ins*rumen*a*ion+ 9e**er correc*ion
o( de(ormi*y and main*enance o( correc*ion can )e o)*ained ,i*h an*erior
ins*rumen*a*ion+ &here ,ere no ins*ances o( resor'*ion or (ailure o( gra(* no*ed and
*he *ime *o (usion ,as shor*er+ 8rolonged )ed res* ,as no* reDuired= *he 'a*ien*s ,ere
mo)ili-ed a(*er *he ches* *u)e had )een remo/ed6Chegi- Y+ 5* al. 19997+
An adeDua*e an*erior decom'ression relia)ly leads *o resolu*ion o( 'ara'legia i( i* is
'er(ormed ,i*hin nine mon*hs a(*er *he onse* acu*e 'ara'legia In ano*her s*udy
conduc*ed )y 1o and 2eong (ound *ha* o'era*i/e in*er/en*ion more *han one year
a(*er *he onse* o( 'ara'legia rarely eradica*ed neurological de(ici* com'le*ely. and an
o'era*ion 'er(ormed a(*er *,o years rarely leads *o su)s*an*ial reco/ery o( s'inal cord
(unc*ion+ 6@a**s 1+>+and 2i(eso R+M+.199$+7
I* is di((icul* *o eradica*e *he (ear *ha* *he in(ec*ion s*ill 'ersis* )enea*h *he me*al i( i*
is 'laced in in(ec*ed area+ Cga e*+al+ 6199!7 demons*ra*ed *ha* adhesion o( )ac*eria
occurred on *he iner* sur(aces such as s*ainless s*eel and co/erage ,i*h an
ex*ra'olysaccharide (ilm 6 )io(ilm 7 'ro*ec*ed *he )ac*eria (rom an*i)io*ics and normal
de(ence mechanism in o*her ,ord i* 'ro/ide good resis*an* medium (or coloni-a*ion++
&hey demons*ra*ed adhesi/e 'ro'er*ies o( myco)ac*erium *u)ercosis organism
'roduced much less )io(ilm on s*ainless s*eel dis0s *han o*her )ac*eria no*a)ly
s*a'hylococus e'idermidis+
S'inal *u)erculosis 'rimarily in/ol/es *he an*erior /er*e)ral s*ruc*ures. *here(ore
an*erior a''roaches. are usually recommended+ From an an*erior a''roach. a)scess
can )e e/acua*ed. all a/ascular ma*erial can )e excised. and an*erior decom'ression o(
*he s'inal cord can )e 'er(ormed sa(ely+ &issue is easily o)*ained (or his*ological
s*udy and cul*ure. and *he 0y'hosis can )e correc*ed+
&he 'os*erior a''roach al*hough rare. can )e 'er(ormed ,here 'os*erior s'inal
elemen* is more in/ol/ed *han *he an*erior column or in case )o*h *he an*erior and
'os*erior are in/ol/ed and 'os*erior s*a)ili-a*ion is needed )e(ore an*erior
decom'resiion and ar*hrodesis is 'er(ormed+ I* is also indica*ed in 'a*ien*s ,i*h a
s*a)le s'ine ,ho also ha/e in*ramedullary or 'ossi)ly ex*ramedullary *u)erculoma
and an e'idural a)scess+
&he cos*o*rans/ersec*omy a''roach has limi**ed a''lica*ion )u* is use(ul (or *he
drainage o( a large a)scess in *he *horacic s'ine in 'a*ien*s ,ho is no* medically (i* *o
ha/e (ormal *horaco*omy+
8soas a)scess are en*irely ex*ra'eri*oneal and (ollo, *he course o( ilio'soas muscle+
<rainage may )e accom'lished 'os*eriorly *hrough 'e*i*Is *riangle )y a la*eral
incision along *he iliac cres*. or an*eriorly under inguinal/ 8ou'ar*Is ligamen*.
de'ending on *he si-e o( *he a)scess and area in ,hich i* a''ears+ Cccasionally an
a)scess may *rac* )enea*h inguinal ligamen* and is seen su)cu*aneously in *he
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