Diagnosis Of Osteomyelitis Research Articles

Acute osteomyelitis and septic arthritis in children : Areferral hospital-based study in Iran.

Information concerning the epidemiology of acute osteomyelitis (OM), septic arthritis (SA) and concurrent OM and SA in children is limited. The aim of this study was to describe the epidemiology of OM, SA and concurrent OM and SA in children. During the 4years of the study, 63,999 patients were admitted to the Children's Hospital, Tehran, Iran. We identified 111 patients with OM and/or SA during the 4‑year period. There were 72cases of OM (11cases per 10,000 children) and 90cases of SA (11cases per 10,000 children). Concurrent OM and SA accounted for 0.17% of all cases (n= 51). The erythrocyte sedimentation rate and C‑reactive protein were elevated in the majority of both infections. Staphylococcus aureus was the most frequent pathogen responsible for both OM and SA in any age group. The lower limb was the most frequently affected (femur: 33/72, 46%; tibia or fibula: 22/72, 31%; foot: 5/72, 7%). The most frequent involved joints were hips (n= 31, 34%) and knees (n= 31, 34%). The present study showed high frequency of patients with concurrent SA and OM. Therefore, prompt recognition and proper diagnosis of pediatric OM and SA is highly recommended.

Cyclooxygenase-2 (COX-2) polymorphism rs689466 may contribute to the increased susceptibility to post-traumatic osteomyelitis in Chinese population

Background: Cyclooxygenase-2 (COX-2) enzyme is one of the major mediators during inflammation reactions, and COX-2 gene polymorphisms of rs20417 and rs689466 have been reported to be associated with several inflammatory diseases. However, potential links between the two polymorphisms and risk of developing post-traumatic osteomyelitis remain unclear. The present study aimed to investigate associations between the rs20417 and rs689466 polymorphisms and susceptibility to post-traumatic osteomyelitis in Chinese population.Methods: A total of 189 patients with definite diagnosis of post-traumatic osteomyelitis and 220 healthy controls were genotyped for rs20417 and rs689466 using the SNaPshot genotyping method. Chi-square test was used to compare differences of genotype distributions as well as outcomes of five different genetic models between the two groups.Results: Significant association was found between rs689466 and post-traumatic osteomyelitis by recessive model (GG vs. AA + AG) (OR = 1.74, 95% CI: 1.098–2.755, p = .018). Although no statistical differences were identified of rs689466 between the two groups by allele model (p = .098) or homozygous model (p = .084), outcomes revealed a tendency that allele G may be a risk factor and people of GG genotype may be in a higher risk to develop post-traumatic osteomyelitis in Chinese population. However, no significant link was found between rs20417 and susceptibility to post-traumatic osteomyelitis in this Chinese cohort.Conclusions: To our knowledge, we reported for the first time that COX-2 gene polymorphism rs689466 may contribute to the increased susceptibility to post-traumatic osteomyelitis in Chinese population.

Methods of diagnosis of acute epiphyseal osteomyelitis in children

Summary. The article presents the analysis of different method for diagnosis of epiphyseal osteomyelitis, including radiography, ultrasonography, computed tomography, magnetic resonance tomography, and radioisotope bone scans. We address the advantages, disadvantages, and possibilities of each method from the standpoint of early diagnosis of osteomyelitis in children.
 Based upon the literature, the most effective and reliable methods for early diagnosis of epiphyseal osteomyelitis in pediatric patients are magnetic resonance and ultrasound. The present diagnostic methods involve no radiation exposure. Using an ultrasonic diagnostic method does not require complete immobility of the patient, can be used from the moment of birth, has widespread availability, and has a relative low cost to allow its use in any medical institution.

Evaluation of diabetic foot infection in nuclear medicine.

Diabetic foot infection is not only the most common cause of hospitalization among diabetic patients, but is also associated with high morbidity, mortality and major utilization of the resources. Managing diabetic patients with suspected foot infection is highly dependent on an early and accurate determination of its presence and location. Medical imaging is often used in the workup of these patients, as clinical diagnosis of osteomyelitis is often difficult, and invasive bone biopsy is infrequently used due to many limitations. In this article, we review the role and accuracy of commonly used medical imaging modalities in the evaluation of diabetic patients with suspected foot infection including osteomyelitis with particular emphasis on molecular nuclear medicine imaging. The impact of imaging on patients' management is also discussed. We finally comment on possible future directions in hybrid molecular imaging techniques.

A Simple Approach for Diagnosis of Chronic Tuberculous Osteomyelitis: A Case Report

Introduction: Osteomyelitis is a secondary complication in 1% to 3% of patients with pulmonary tuberculosis (TB). Definite diagnosis of TB-associated osteomyelitis is challenging for clinicians, as biopsies of deep osteoarticular tissues are necessary. Case Presentation: We present the case of a 50-year-old man, admitted to Imam Khomeini hospital, Tehran, Iran in March 2014. According to his self-report, he had a chronic ulcer on his left foot since September 2012. In physical examinations, there was a painful sinus tract orifice (2 × 2 cm) on the left medial malleolus. Magnetic resonance imaging (MRI) of the foot revealed osteomyelitis in the left ankle. Two biopsies were taken from the wound edge, and Mycobacterium tuberculosis was detected via polymerase chain reaction (PCR) assay. Conclusions: Today, in the diagnosis of TB-associated osteomyelitis, it is a common practice to obtain 3 osteoarticular tissue biopsies for microbiological evaluation, PCR analysis, and histopathological assessment. We suspect that biopsies from the edge of the sinus tract orifice may help diagnose TB osteomyelitis.

The Role of Imaging in Childhood Osteomyelitis

: Osteomyelitis in childhood can be a challenging diagnosis. Imaging plays an important role in the diagnosis of osteomyelitis in children, and the imaging findings are crucial in the treatment decision. Pediatric hematogenous osteomyelitis may have variable radiological expression, which is influenced by the age and condition of the patient, the virulence of the causative agent, the stage of the disease, or the selected imaging tool. Different imaging modalities exist for imaging of osteomyelitis which include: conventional radiography, Three-phase bone scintigraphy, ultrasound (US), computed tomography (CT) and magnetic resonance (MR) imaging. Conventional radiography is the initial step in evaluation of osseous changes. In most cases it will be the only imaging technique used in the diagnosis, as well as treatment. Ultrasonography, is a very useful modality. It allows correlating the physical exam with US findings and comparing the affected side with the opposite side. After conventional imaging MRI is the most important imaging modality for the evaluation of osteomyelitis. MRI excellent delineation of the osseous component as well as, soft tissue extension, joint effusion and complications of osteomyelitis such as abscess formation, especially in case of failure to respond to therapy. CT scan is more useful and superior to MR in detecting cortical destruction, air and sequesters. Bone scintigraphy using 99Tc methylene diphosphonate may help to confirm suspected osteomyelitis by showing increased uptake in all three phases of the dynamic perfusion.

A Rare Clinical Entity: Staphylococcus-Related Glomerulonephritis.

Staphylococcus aureus is a rare cause of postinfectious glomerulonephritis, and Staphylococcus-related glomerulonephritis primarily occurs in middle-aged or elderly patients. Patients with Staphylococcus-related glomerulonephritis also present with hematuria, proteinuria of varying degrees, rising serum creatinine levels, and/or edema. The severity of renal insufficiency is proportional to the degree of proliferation and crescent formation. Here, we present a diabetic patient admitted with a history of 1 week of left elbow pain. Laboratory results revealed that erythrocyte sedimentation rate was 110 mm/hour, serum creatinine level was 1 mg/dL, C-reactive protein level was 150 mg/L, and magnetic resonance imaging showed signal changes in favor of osteomyelitis at the olecranon level, with diffuse edematous appearance in the elbow skin tissue and increased intra-articular effusion. After diagnosis of osteomyelitis, ampicillin/sulbactam and teicoplanin were administered. After day 7 of admission, the patient developed acute kidney injury requiring hemodialysis under antibiotic treatment. Kidney biopsy was performed to determine the underlying cause, which showed Staphylococcus-related glomerulonephritis. Recovery of renal functions was observed after antibiotic and supportive treatment.

Seeing is Believing? Preoperative Magnetic Resonance Imaging for Pressure Ulcers: Implications for Surgical Management.

Background:Pressure ulcers represent a particularly difficult disease process and remain a financially important entity. The underlying bone in advanced ulcers may harbor osteomyelitis. Radiologic diagnosis of osteomyelitis is confounded by chronic pressure and shear. We sought to determine the test characteristics of preoperative magnetic resonance imaging (MRI) in the diagnosis of osteomyelitis compared to intraoperative bone culture.Methods:A retrospective review of patients undergoing flap reconstruction who had preoperative MRI and intraoperative bone cultures between 1995 and 2015 was included. Recorded variables included age, sex, level of spinal cord injury and duration, preoperative MRI interpretation, microbiologic bone culture, smoking history, comorbidities, colostomy or urostomy, healing time, complications, length of stay, and discharge facility.Results:A total of 152 patients (175 flaps) were reconstructed, of which 41 patients (73 flaps) met inclusion criteria. Most patients were male (82.2%) with an average age of 50.4 years. Overall complication rate was 32.4% (n = 23) of which 34.7% (n = 8) were major. Positive and negative predictive MRI values were 84.6% and 16.7%, respectively. There were no significant differences in healing time or complication rate in those with or without osteomyelitis. Intraoperative growth was associated with decreased postoperative complications (hazard ratio = 0.361; P = 0.037).Conclusion:Test properties of MRI for diagnosis of osteomyelitis in patients with chronic pressure ulcers have limited ability to diagnose osteomyelitis and do not aid in surgical management, but do increase health-care expense. The diagnosis of osteomyelitis by intraoperative bone cultures does not predict inferior outcomes and paradoxically may be associated with fewer postoperative complications.

Malignant transformation in chronic osteomyelitis

IntroductionCarcinomatous degeneration is a rare and late complication developing decades after the diagnosis of chronic osteomyelitis. ObjectivesTo present the results from a retrospective study of six cases of squamous cell carcinoma arising from chronic osteomyelitis. MethodsSix cases of chronic osteomyelitis related to cutaneous squamous cell carcinoma were identified. The cause and characteristics of the osteomyelitis were analyzed, as well as time up to malignancy, the suspicion signs for malignancy, the localization and histological type of the cancer, and the type and result of the treatment. ResultsThe mean time between osteomyelitis onset and the diagnosis of malignant degeneration was 49.17 years (range: 32–65). The carcinoma resulted from tibia osteomyelitis in five cases and from femur osteomyelitis in one. The pathological examination indicated cutaneous squamous cell carcinoma in all cases. All the patients were staged as N0M0, except for one, whose lomboaortic lymph nodes were affected. The treatment consisted of amputation proximal to the tumor in all patients. No patient presented signs of local recurrence and only one had carcinoma metastasis. ConclusionEarly diagnosis and proximal amputation are essential for prognosis and final results in carcinomatous degeneration secondary to chronic osteomyelitis.

Classical Hodgkin lymphoma masquerading as chronic recurrent multifocal osteomyelitis: a case report

BackgroundHodgkin lymphoma is a hematologic malignancy usually confined to lymphatic structures and commonly associated with constitutional symptoms. Bony involvement and musculoskeletal symptoms are uncommon and typically seen in advanced disease. In this case, we report an unusual presentation of classical Hodgkin lymphoma and highlight diagnostic challenges leading to the misdiagnosis and treatment as chronic recurrent multifocal osteomyelitis.Case presentationA 38-year-old white man presented with lower extremity musculoskeletal pain. Imaging studies revealed multifocal lytic and sclerotic osseous axial lesions. Multiple core needle bone marrow and excisional lymph node biopsies were non-diagnostic. Having met the criteria, a tentative diagnosis of chronic recurrent multifocal osteomyelitis was given. He was treated with non-steroidal anti-inflammatory medications with partial clinical response but had persistent symptoms. A second medical opinion was pursued. An open bone marrow biopsy was performed and yielded a diagnosis of classical Hodgkin lymphoma after 13 months of diagnostic uncertainty. A chemotherapy regimen of doxorubicin, bleomycin, vinblastine, and dacarbazine was instituted with complete symptomatic and radiologic response.ConclusionsThis case illustrates diagnostic difficulties of a musculoskeletal presentation of Hodgkin lymphoma, challenges of non-diagnostic bone marrow and lymph node biopsies, and resultant diagnostic delays in delivering a potentially curative therapy. Had the additional open bone marrow biopsy not been performed, the diagnosis and treatment of Hodgkin lymphoma would have been missed.

Abstract No. 523 - Clinical utility of image-guided biopsy in diagnosis and management of vertebral osteomyelitis: A retrospective cohort study

Abstract No. 523 - Clinical utility of image-guided biopsy in diagnosis and management of vertebral osteomyelitis: A retrospective cohort study

Musculoskeletal manifestations in sickle cell anemia

Sickle cell anemia is an inherited hemoglobin disorder characterized by substitution of glutamic acid by valine at the sixth position of the beta globin chain. The sequence of events leads to pain crisis. Ischemia of the tissues resulting from decreased blood flow is believed to occur in pain crisis. Repeated or prolonged sickling causes red cell death in the form of hemolytic anemia. The majority of hospital admissions are due to painful crisis. These patients are at increased risk for both osteomyelitis and infarction of the long bones. Magnetic resonance imaging has been shown to be helpful in the diagnosis of early osteomyelitis and its differentiation from infarction in sickle cell disease patients with acute bone crisis. Others findings include dactylitis, medullary infarcts, diploic space widening, fish mouth vertebrae, and avascular necrosis. We present a case series on the various musculoskeletal manifestations of sickle cell disease.

Vertebral Osteomyelitis: Unexpected Cause of Back Pain

Osteomyelitis is an inflammation of bone caused by a pyogenic organism. Osteomyelitis is one of the most important musculoskeletal infections, commonly occurring in long bones. Vertebral osteomyelitis is fairly rare and is often overlooked. It is usually acquired hematogenously, although there are other ways of infection. Only about half of patients develop fever > 38 °C and symptoms are unspecific. The most common organism is <i>Staphylococcus aureus</i>, with <i>Pseudomonas aeruginosa</i> being an unexpected pathogen accounting for about 6%. We present a case of a 56-year-old Hispanic male that visited emergency room presenting with back pain of 3 weeks of evolution being discharged home. Patient returned 2 days after with no improvement. Blood test returned under normal range. Physical exam showed a focal tenderness at thoracic level. Blood culture recovered <i>Pseudomonas aeruginosa</i> sensitive to levofloxacin. CT/MRI was performed and showed vertebral osteomyelitis. Antibiotic was started for 6 weeks. Therapy was guided with erythrocyte sedimentation rate (ESR)/C-reactive protein (CRP). Patient was evaluated monthly for 6 months and improved. Vertebral osteomyelitis is a challenging diagnosis. The consequences of the disease are dire if not diagnosed on time. Historically, the diagnosis of vertebral osteomyelitis remains in a positive culture of bone biopsy. Nowadays, when handling a suspected hematogenous vertebral osteomyelitis, blood culture has gained importance. Whether a blood culture recovered a pathogen, therapy should be based on sensitivity and can be guided following ESR/CRP levels. This type of management can preclude invasive and expensive methods, such as bone biopsy. J Med Cases. 2017;8(8):246-248 doi: https://doi.org/10.14740/jmc2870w

Physicians' Perspectives on the Diagnosis and Treatment of Chronic Nonbacterial Osteomyelitis.

Background/Purpose. Understanding the practices of pediatric rheumatologists in diagnosing and treating chronic nonbacterial osteomyelitis (CNO) can provide important information to guide the development of consensus treatment plans. The objectives of this study were to determine physicians' approaches to (1) diagnosing and monitoring CNO, (2) ordering a bone biopsy, and (3) making treatment decisions. Methods. A survey was distributed among members of the Childhood Arthritis and Rheumatology Research Alliance using a web-based questionnaire. Results. 121 of 277 (41%) attending physician members completed the survey. Plain radiographs (89%) were most commonly used followed by regional MRI (78%), bone scintigraphy (43%), and whole-body MRI (36%). The top three reasons for performing a biopsy were constitutional findings (66%), unifocal bone lesions (64%), and nocturnal bone pain (45%). Nearly all responders (95%) prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) as initial therapy. For patients who failed NSAID treatment, methotrexate (67%), tumor necrosis factor inhibitors (65%), and bisphosphonates (46%) were the next most commonly used treatments. The presence of a spinal lesion increased the use of bisphosphonate treatment. Conclusion. The diagnostic approach and disease activity monitoring for CNO varied among surveyed physicians. Our survey findings provided important background for the development of consensus treatment plans for CNO.

An unusual case of maxillary osteomyelitis in a young female

Osteomyelitis of facial bones is an uncommon condition. Maxillary osteomyelitis is rare compared to mandibular osteomyelitis because the extensive blood supply and strut-like bone of the maxilla make it less vulnerable to chronic infections. We report an unusual case of maxillary osteomyelitis involving the right half of the maxilla in a 27-year-old, systemically healthy female. She reported with pain in the upper right region of the jaw since 1 year. Her past dental history revealed that she underwent dental extraction 1 year back in the same region due to pain and mobility of teeth. Intraoral examination revealed exposed necrotic bone in the right maxillary region with mobility of teeth and pus discharge. Radiographic investigations confirmed the diagnosis of osteomyelitis of the right maxilla. The patient was advised hemimaxillectomy, following which the patient was given a surgical and later a permanent obturator to close the surgical defect.

A case report on chronic osteomyelitis of the right tibia in a pediatric male patient and its management

The present case explains the treatment strategies followed for a chronic osteomyelitis case of a pediatric patient in a secondary care public hospital, Ooty, Tamil Nadu, India. He was presented with the complaints of pain and swelling on the right leg, which was treated with nonsteroidal anti-inflammatory drugs such as diclofenac and ibuprofen. Similarly, the tissue abscess observed was managed with parenteral antibiotics such as cefotaxime and amikacin. Surgery was done to remove the devascularized tissue and postoperative care was given with chymoral forte and vitamin supplements (Vitamin B complex, calcium and Vitamin C). In this patient, the reason for the occurrence of chronic osteomyelitis may be a complication of the previous surgery due to the accidental fall. Therefore, proper care should be given in the management of traumatic injuries in children and early diagnosis of osteomyelitis is essential to prevent the complications.

The Relationship between Bone Biopsy and Bone Culture results in Patients with Osteomyelitis from Pressure Ulcers

Osteomyelitis is a n infectious process of the bone caused by prolonged immobility, bacterial dissemination through blood, immune-suppression, trauma, or vascular insufficiency. The diagnosis of osteomyelitis is made by multiple modalities. Some of these include bone cultures, bone biopsy, imaging, and clinical determination [1]. In this study we plan to chronicle patients with suspected osteomyelitis secondary to prolonged immobility resulting in pressure ulceration. Our aim is to find correlations between bone cultures and biopsy findings of the bone. The relationship between the two entities can help guide extended antibiotic therapy.

Epidemiology and Management of Acute, Uncomplicated Septic Arthritis and Osteomyelitis: Spanish Multicenter Study.

Acute osteoarticular infection (OAI) is a potentially severe disease. The aim of this study was to evaluate the etiology, clinical characteristics and therapeutic approach of OAI in children in Spain. Medical records from children <14 years with OAI from 25 hospitals between 2008 and 2012 were reviewed. Confirmed osteomyelitis (OM) and septic arthritis (SA) required a positive bacterial isolate; otherwise, they were considered probable. Probable SA with <40,000 cells/mm in joint fluid was not included. A total of 641 children were evaluated. Two hundred and ninety-nine cases (46%) were OM, 232 (36%) SA, 77 (12%) osteoarthritis and 33 (5%) spondylodiscitis. Children with OM were older (63 vs. 43 months for SA; P < 0.001). Magnetic resonance imaging and bone scintigraphy had the highest yield for OM diagnosis (94%). Arthrocentesis was performed in 96% of SA. A microorganism was isolated in 246 patients (38%: 33% OM vs. 55% SA; P < 0.001): Staphylococcus aureus was the most common (63%), followed by Kingella kingae (15%) and Streptococcus pyogenes (9%). Ninety-five percent of children initially received IV antibiotics, mostly cefotaxime + cloxacillin (60%) or cloxacillin (40%). Total treatment duration was 38 (±31) days for OM and 28 (±16) days for SA (P < 0.0001). Twenty percent of children with OM (46% because of complications) and 53% with SA (95% initial arthrotomy) underwent surgery. Patients with SA were compared according to initial arthrotomy (n = 123) versus arthrocentesis (n = 109), and no clinical differences were observed, except for higher rate of hip SA in the former (50% vs. 9%; P < 0.001). Children with arthrocentesis had less sequelae [6.6% vs. 1%; P = 0.03, odds ratio = 0.58 (95% confidence interval: 0.45-0.76)], but not in the multivariate analysis. This is the largest pediatric cohort of OAI in Spain. S. aureus was the most common isolate, although K. kingae was recovered in a high proportion of cases. Conservative management was applied in half of the patients. There was a low rate of sequelae, even with nonsurgical approaches.

Hematogenous Calcaneal Osteomyelitis in Children.

III.

Sausage toe: an upsetting symptom in diabetic patients

With diabetes reaching almost epidemic proportions, foot problems have become increasingly prevalent worldwide, resulting in major economic consequences for both diabetic patients and society. Although some detailed studies regarding this condition are present in the existing literature, no clear consensus has been established regarding the diagnosis and treatment of diabetic foot infection and osteomyelitis. Thus, any sign that may be used to predict osteomyelitis of the foot in diabetic patients is valuable. We believe that the presence of a “sausage toe” could be a reliable sign of osteomyelitis. This cohort study was carried out at the Chronic Wound Clinic of a major institute over a period of 3 years. All diabetic patients who had a sausage toe were identified and followed up prospectively. A swollen toe that had lost its normal contours and resembled a sausage was defined as a sausage toe. All 16 patients included in this study had type II diabetes (min 5-year duration). The mean HbA1c level among the patients was 9.28% (4–5.6% nondiabetic range). All patients had reduced pinprick and vibration sensation but good peripheral pulsation in their affected foot. Overall, six patients were diagnosed with underlying bone infections. Additionally, six patients received hyperbaric oxygen therapy and a total of ten patients required surgical intervention. Four patients required surgical debridement of ulcers that developed during the follow-up. Five patients who were diagnosed with osteomyelitis required local amputations. Complete resolution of six sausage toes was achieved using nonsurgical treatment modalities. The definition of a sausage toe is rather subjective. Although its definition has relatively low specificity, a sausage toe is an easily identifiable and cost-free clinical sign that can be used as an indicator of underlying bone infection.