Reactivation of Dormant Tibial Methicillin- Resistant Staphylococcus aureus Osteomyelitis after 17 Years: A Case Report and Literature Review

Abstract

Introduction: Staphylococcus aureus is the most common cause of osteomyelitis with significant morbidity and mortality outcomes. Methicillin-susceptible Staphylococcus aureus (MRSA) osteomyelitis reactivation years after the primary episode are a well-known phenomenon. However, there are few case reports documenting dormant MRSA osteomyelitis recurrence years later. Our case report of dormant MRSA tibial osteomyelitis reactivation after 17-years, represents one of the longest documented recurrence intervals from initial bout of MRSA, as well as, the diagnostic and therapeutic challenges involved. Case report: A 55-year-old male reports suffering a Gustilo & Anderson grade 1 open left tibial plafond fracture in 2004 that was managed with wound debridement and Taylor Spatial Frame. Initial management was with debridement and primary closure of the wound and application of a Taylor spatial frame (TSF) as definitive management of the fracture. One month following application of the frame, the patient reports he suffered a pin site infection. This was developed into MRSA osteomyelitis. The wound underwent surgical debridement and once the fracture was consolidated enough at three months, removal of external frame and intramedullary reaming and irrigation was performed. No further soft tissue coverage was required. The patient was treated with a prolonged course of intravenous vancomycin, followed by oral clindamycin. Since this episode, the patient has been asymptomatic and denied any further hospitalisations with return to full function without limitations. The patient does not report any recurrent wounds, discharge, sinus or pain. Seventeen years later, after a closed to the knee, the patient present febrile with knee pain. He was found to have MRSA tibial osteomyelitis, predominantly within the proximal tibia. This was treated with targeted surgical debridement, local antibiotics via an antibiotic impregnated cement nail and prolonged antibiotics. The patient has remained asymptomatic with apparent resolution of infection 6-months post treatment. Conclusion: Our case report represents one of the longest document recurrence intervals of MRSA. Patients with MRSA osteomyelitis should have appropriate treatment and follow-up with orthopaedic surgeons and infectious disease physicians to monitor disease progression and to ensure resolution of the infection.