Evidence Of Osteomyelitis Research Articles

Predictors of limb saving in diabetic foot ulcer.

This study was aimed to determine the various factors which could serve as predictor of saving of lower limb from amputation in patients with diabetic foot ulcer (DFU). This three-year retrospective study was conducted in the Diabetes and Endocrinology Unit of Hayatabad Medical complex Peshawar, Pakistan. Demographic, clinical, laboratory and radiological information of the diabetic patients with DFU admitted between January 2020 to December 2022 was retrieved from the hospital files. Information regarding initial and final decision regarding amputation and the outcome of the ulcer was also recorded. A total of 502 patients of diabetes mellitus (DM) with DFU were included in the study, of whom there were 279 (55.6%) males and 223 (44.4%) females. The mean age of the study population, mean duration of DM and mean HbA1c were 55.2 ± 9.8 years, 13.7 ± 6.7 years and 11.2 ± 2.4 %, respectively. Patients who had an amputation of their lower limbs had an increased age (p= 0.034), raised total leucocyte count (TLC) (p= <0.001), higher HbA1c (p= 0.025), had osteomyelitis (p= <0.001), and had a higher-grade ulcer (p= <0.001). On binary logistic regression analysis, ulcer grade (OR=7.4, p= <0.001), osteomyelitis (OR=11.8, p= <0.001), and initial decision of no amputation at the time of admission (OR=33.6, p=<0.001) were independently associated with the lower limb salvage. DFU which were of grade I to II, had no evidence of osteomyelitis and for which an initial decision was of no amputation were more likely to be salvaged.

Use of Fluconazole-impregnated Beads to Treat Osteomyelitis Caused by Coccidioides in a Pigtailed Macaque (Macaca nemestrina).

A 3-y-old male pigtailed macaque (Macaca nemestrina) presented for swelling of the left distal forearm and decreased use of the arm. The monkey had been raised at an indoor-outdoor facility in Arizona and transferred to an indoor facility in Washington 2 mo prior to presentation. A preliminary diagnosis of fungal osteomyelitis of the radius was made based on radiographs and Coccidioides titers. In addition to systemic antifungal treatment, surgery was performed to debride the bony lesion and implant polymethylmethacrylate beads impregnanted with the anti-fungal fluconazole. Histologic examination of the debrided material confirmed the diagnosis of fungal osteomyelitis. The surgical procedure resulted in clinical improvement, as evidenced by weight gain and decreased Coccidioides titers. The beads were removed in a second surgery, and the bony lesion completely resolved. With continued systemic fluconazole treatment, the monkey remained healthy with no further evidence of osteomyelitis. Coccidioides is an emerging pathogen that causes significant morbidity and mortality in both humans and animals. Bone infections can be resistant to systemic treatment, and the implantation of fluconazoleimpregnated beads may offer a successful treatment strategy for fungal osteomyelitis.

Answer to October 2021 Photo Quiz.

We report an unusual pyomyositis with concomitant pulmonary lesions in an HIV-positive patient. Due to the difficulty of collecting sputum, gastric lavage was performed. The abscess in the leg was drained (Fig. 1B in photo quiz case presentation). The gastric lavage and the abscess drainage were analyzed using an acid-fast bacilli smear (Fig. 1C in photo quiz case presentation) and Xpert MTB/RIF assay. Gastric lavage, purulent drainage, and blood culture were positive for Mycobacterium tuberculosis. The typical formation of serpentine cords was demonstrated upon culture of abscess drainage (Fig. 1D in photo quiz case presentation). Gastric lavage was M. tuberculosis nucleic acid positive by Xpert MTB/RIF assay. The diagnosis of tuberculosis (TB) pyomyositis was confirmed. Anti-TB therapy (rifampin) was started. Pyomyositis is the accumulation of purulent material within individual muscle groups, and the most common organisms implicated in pyomyositis include Staphylococcus aureus (1). Typical cases of pyomyositis involve fever and pain, which are specific to a muscle group, generally the lower extremities (1, 2). TB pyomyositis, defined as M. tuberculosis infection of skeletal muscle, is more common in immunocompromised patients, but even in these patients, it is considered to be a rare extrapulmonary manifestation of TB. The clinical manifestations may be insidious, with nonspecific symptoms, such as fever, night sweats, malaise, and weight loss (3). Ohnishi et al. reported three cases of TB pyomyositis in women coinfected with TB/HIV with a CD4 below 200 cells/mm3 (4). Pathogenesis for TB pyomyositis can include contiguous spread, lymphatic or hematogenous spread, and direct inoculation (3, 5). We hypothesize that in this case it was a hematogenous spread because of the absence of trauma or infection, with no evidence of osteomyelitis. TB pyomyositis is very difficult to clinically diagnose and distinguish from other soft tissue diseases. Diagnosis depends on a high clinical suspicion of infection in a susceptible population. TB should be considered in patients who present with soft tissue swelling and pain, particularly if they have an abnormal chest X-ray (6). Drainage through surgery and aggressive anti-TB therapy is normally required (7). The case presented here is noteworthy given the rarity of this manifestation of TB and highlights the need for early diagnosis. With timely diagnosis and adequate clinical and surgical treatment, the prognosis is good. Prompt diagnosis requires a high index of suspicion, especially in immunocompromised patients. Fluid cultures should be sent for acid-fast bacilli staining (Fig. 1C in photo quiz case presentation) and culture (8). In laboratories serving areas of high M. tuberculosis incidence with limited economic resources, cord factor detection (Fig. 1D in photo quiz case presentation) is a fast and valid criterion for identifying these mycobacteria using liquid or solid medium (9).

AN ENIGMATIC ELUSIVE LESION OF THE MANDIBLE THAT REFUSED TO HEAL: A PATHOLOGIST’S NIGHTMARE!!!

<h3>Case report</h3> A 62-year-old woman complained of a nonhealing extraction socket in the lower left back teeth region. She underwent extraction of tooth no. 37 at a private clinic, after which an ulceroinfiltrative lesion developed on the operated side. Multiple biopsies from the lesion were inconclusive. The patient was referred to ONCO OPD at the medical hospital. Fine-needle aspiration cytology and histopathology of an excised lymph node confirmed reactive lymphadenitis. Computed tomography revealed an osteolytic lesion radiologically simulating carcinoma or a chondrosarcoma. Because of persistent debilitating symptoms, the patient underwent white-light examination with left segmental mandibulectomy. Frozen sections were negative for malignancy. Biopsy at the general pathology lab depicted parakeratotic lining with dense inflammation. No evidence of osteomyelitis, necrosis, dysplasia, or malignancy was noted. All margins were free from malignancy. Lymph nodes dissected showed reactive morphology. ZN, PAS, and Gram stain were all negative. Later, a 5 × 2 cm ulceroinfiltrative lesion redeveloped in the region of teeth 32 to 42 slowly progressing toward tooth 45. Positron emission tomography/computed tomography of the lesion showed focal FDG uptake in the anterior mandibular region. Because of increased suspicion of malignancy, white-light examination up to tooth 47 was carried out. Histopathology showed degenerated bony fragments and flakes of lamellated keratin. No evidence of dysplasia or malignancy was noted. The lesion continued to spread even after successful surgical intervention with an adequate surgical margin. The patient was eventually lost because of severe cardiac arrest during her last surgical intervention for mandibular arch reconstruction. This could be a case of a lifetime in which multiple consultations with oral and general pathologists failed to reach a conclusive diagnosis.

Diabetic Myonecrosis: A Case Study

Abstract Background: Diabetic myonecrosis is a rare complication of diabetes mellitus with less than 200 cases reported in the literature since initial description in 19651. Diabetic myonecrosis most commonly affects the thigh and usually presents with acute muscle pain, edema, and erythema in the absence of trauma or fever1. The pathogenesis has yet to be elucidated—atherosclerosis, microangiopathy, vasculitis, and ischemia-reperfusion injury have been theorized. Laboratory findings are relatively nonspecific—of the findings reported in a systematic review, CRP was elevated in 90%, ESR elevated in 83.3%, WBC elevated in 42.5%, and CK elevated in 31.6%1. Definitive diagnosis can be made by muscle biopsy which demonstrates muscle necrosis and edema; however, it is not routinely recommended due to procedural complications. MRI is the diagnostic modality of choice for diabetic myonecrosis which is both sensitive and specific for the diagnosis2. Clinical Case: 76-year-old male with T2DM presented to regional hospital with severe right lower leg pain in the absence of fever, tachycardia, hypotension, or recent trauma. Physical exam demonstrated discrete erythema of distal 2/3 of posterior right lower leg extending to the ankle distally. Labs demonstrated normal CK, elevated ESR, HgbA1c 8.2%, and negative blood cultures. MRI of the right lower extremity demonstrated abnormal prolongation of T2 relaxation time involving posterior muscle compartment including soleus and gastrocnemius with associated perifacial and subcutaneous edema. These findings were consistent with diabetic myonecrosis without evidence of osteomyelitis or abscess. Rest, optimal glycemic control, and aspirin were recommended and patient improved gradually with complete clinical resolution on outpatient follow-up. Conclusions: Diabetic myonecrosis is a rare complication of diabetes and should be considered in patients presenting with acute muscle pain. Among cases described in literature, 5.7% have affected the soleus and 5% have affected the gastrocnemius respectively1. The diagnostic modality of choice is contrast enhanced MRI with typical findings including hyperintense signal on T2 weighted images with associated muscular, perifascial, and/or subcutaneous edema3. The optimal treatment is yet unknown, but reasonable strategies based on case series include rest, glycemic control, and NSAID therapy1.

Evidence of osteomyelitis in Cuban aborigines

Paleopathology is the branch of science that is responsible for the study of diseases suffered by our ancestors, in Cuba some studies have been carried out on pathologies suffered by the aborigines. The objective is to present a specimen of human diaphyseal bone found in the funerary site of the "Cueva de los Chivos" in the Sumidero de Jibacoa Valley, Guamuhaya mountain massif, municipality of Manicaragua, Villa Clara province, Cuba in excavations carried out between the years 2000 and 2002 by the archeology group of the Center for Environmental Studies and Services of CITMA in Villa Clara. Presentation: It is a tibia fragment due to its thickness and triangular shape with periosteal thickening, cortical irregularity and a large number of crypts, whose radiography shows the presence of bone sequestration with the corresponding involvement and signs of periostitis. The skeletal remains found show evidence of having suffered from chronic osteomyelitis. Based on the archaeological materials found at the funerary site, it was determined that these belonged to pre-agricultural pottery groups that populated the island between 2000 and 6000 years ago. Conclusions: The Cuban aboriginal groups had elementary knowledge of orthopedic conditions such as bone infections and their treatment in all probability, evidenced by the chronicity of osteomyelitis presented in this specimen which survived for a period of time.

Clinical and Multimodal Imaging Findings in Disseminated Mycobacterium Chimaera

To characterize the ophthalmic clinical and multimodal imaging findings of disseminated Mycobacterium chimaera infection after cardiothoracic surgery. Observational case series. Four patients (8 eyes) with disseminated M.chimaera infection. Patients were evaluated with biomicroscopy, OCT and OCT angiography, fundus autofluorescence, and fluorescein and indocyanine green angiography. Clinical and multimodal imaging findings of patients with disseminated M.chimaera infection. All 4 patients were white men with a mean age of 65.5 years (range, 60-75 years) who had aortic valve or root infection, or both, with M.chimaera diagnosed by culture, gene sequencing, or both. All 4 patients demonstrated bilateral choroidal lesions on funduscopy and evidence of osteomyelitis by imaging, culture analysis, or both at the time of ocular diagnosis. Indocyanine green and OCT angiography revealed numerous additional subclinical choroidal lesions and were used to track disease response to therapy. Fluorescein angiography and fundus autofluorescence were useful in determining lesion age and activity. All patients were treated with 3- or 4-drug antimycobacterial therapy. Three underwent revision of cardiothoracic surgery with removal of infected graft. One patient went on to demonstrate progressive ocular disease that was noted before each of his surgical revisions. Two patients showed improvement in ocular and systemic disease, however one of them developed a choroidal neovascular membrane. The final patient was a single encounter whose clinical and imaging findings showed longstanding inactive disease. Ophthalmologists should be aware of the systemic and ocular findings of this rare life-threatening disease. Multimodal imaging is useful in corroborating a diagnosis of ocular M.chimaera andparticularly in evaluating patient response to therapy, because choroidal activity seems to mimic systemic activity. Treating physicians should be aware of the co-occurrence of choroiditis and osteomyelitis. Choroidalneovascular membrane can also be a late complication of this disease.

Prevalence of dental and mandibular disorders in culled sheep in Spain.

At the slaughterhouse, 1465 culled sheep heads were studied in order to identify disorders of the mandibular cheek teeth. Of these, 227 (15.5%) had evidence of osteomyelitis. The lesional profile showed that the mandible was affected in a similar proportion on both sides (46.7% on the right side vs 50.7% on the left side), mainly in the middle region (55.3%) and with most of the lesions closed without fistulisation (89.4%). In addition, swelling was palpable, with an increase in thickness in the area of the affected body (2.65 ± 0.065 cm vs 1.74 ± 0.030 cm). In 78.6% of the animals, the regional lymph nodes were enlarged. Concerning the mandibular cheek teeth, more than half of the animals lacked at least one tooth (57.0%), with the first premolar being the most frequently missing tooth (34.8%) and the third molar the least (8.2%). The impaction of food around the teeth was very common with the posterior molars being more frequently affected. In the knowledge of the authors, this is the first study that analyses the prevalence of mandibular molar and premolar disorders in sheep, and these are revealed as an important condition affecting culled sheep.

Burkholderia pseudomallei peri-prosthetic infection following medial malleolar internal fixation: a case report

BackgroundMelioidosis-associated peri-prosthetic infection is extremely rare. To date, melioidosis associated septic arthritis of the ankle joint following a medial malleolar internal fixation has not been reported.Case presentationWe describe a 49-year-old male with a history of long standing diabetes who presented with fever, constitutional symptoms and right ankle pain for 1 week. Ten years ago, he underwent a medial malleolar screw fixation following a traumatic closed fracture. His initial right ankle radiographs showed no evidence of osteomyelitis. He underwent a wound debridement and washout of the right ankle joint. The peripheral blood and pus from the ankle joint was culture positive for Burkholderia pseudomallei with very high antibody titres. His subsequent radiographs showed features of chronic osteomyelitis. He was treated with a prolonged course of antibiotics and repeated wound debridement. At follow up after 6 months, he had no clinical features of recurrent infection.ConclusionsMelioidosis should be entertained in the differential diagnosis of peri-prosthetic infections in high risk patients.

Foot salvage using microsurgical free muscle flaps in severely crushed foot with soft tissue defects

ObjectiveManagement of complex foot injuries including skin, tendons, vessels, bone, with soft tissue defects is considered as an orthopedic challenge. Microsurgical free muscle flaps provide the best solution in such cases. Patients and methodsThirty two consecutive cases of complex ankle and foot injuries were treated by skin grafted muscle free flap in one stage procedure after radical debridement. Twenty four were males and 8 were females. Right foot was affected in 26 and left was involved in 6 patients. The average age was 22 years (range 6–33 years). The most common cause of injury was motor car accident. All cases had complex soft tissue defect with bone exposure. All cases were candidate for amputation. Gracilis muscle transfer was done in 26 cases and latissimus dorsi free flap in 6 cases. The average follow up was 38 months. ResultsAll the free muscle flaps survived. The involved bone fracture was united at an average 3 months. No evidence of osteomyelitis was noted. Full weight bearing was restored 3 months post-operatively. All patients were satisfied with the cosmetic appearance and functional capacity of their operated limbs. ConclusionSkin-grafted free muscle flap as one-stage procedure is a good solution for reconstruction of complex ankle and foot injuries.

Pro-Calcitonin, Erythrocyte Sedimentation Rate and C - reactive Protein in Predicting Diabetic Foot Ulcer Characteristics; a Cross Sectional Study.

Considering the importance of early diagnosis of diabetic foot ulcers and its complications, this study aimed to evaluate the accuracy of erythrocyte sedimentation rate (ESR), C - reactive protein (CRP), and pro-calcitonin (PCT) in predicting the ulcer class, osteomyelitis, and peripheral arterial disease (PAD). This cross-sectional study was performed on 200 consecutive patients suffering from diabetic foot ulcer who were referred to Infectious Disease Ward. The levels of PCT, ESR, and CRP were measured for all patients and the screening performance characteristics of each marker in predicting the ulcer class, osteomyelitis, and PAD was calculated. The levels of PCT, ESR and CRP were significantly higher in patients with class IV foot ulcer compared to those with class III ulcers (p<0.001). Patients with evidence of osteomyelitis had significantly higher level of PCT, ESR and CRP. The best cutoff points of PCT, ESR and CRP in predicting osteomyelitis were 0.35 ng/ml (86.1% sensitivity, 45.3% specificity), 56.5 mm/hours (95.8% sensitivity, and 50.0% specificity) and 44 mg/ml (90.3% sensitivity, 57.0% specificity), respectively. The presence of PAD was significantly associated with increased levels of the three biomarkers. The best cutoff values for PCT, ESR and CRP in predicting PAD were 0.45 (70.8% sensitivity, 71.7% specificity), 61.5 (83.3% sensitivity, 52.0% specificity) and 49 (83.3% sensitivity, 63.8% specificity), respectively. Based on the findings of the present study, although the accuracy of PCT, ESR, and CRP in predicting the severity of diabetic foot ulcers was fair, increase in the three parameters can predict the occurrence of osteomyelitis and PAD following diabetic food development with good accuracy and acceptable sensitivity.

A Rare Case of Rib Osteomyelitis in an Intravenous Drug Abuser

Osteomyelitis (OM) is one of the most common invasive bacterial infections. Rib osteomyelitis is a rare disease that occurs in ~1% or less of all osteomyelitis. It can result from direct inoculation from traumatic wounds, by spreading from adjacent tissue affected by cellulitis or septic arthritis, or through hematogenous seeding. We present a case of a 32-year-old female with a history of Intravenous drug abuse who presented with localized left-sided chest pain. A CT thorax contrast study was obtained that showed edema around the anterior aspects of the left 3rd to fifth ribs and involves the inferior border of the pectoralis muscle with buckling of the left 4th rib with fluid density in the fascial planes. Subsequently, an MRI was done that revealed the pathological fracture of the anterior aspect of the left forth rib with evidence of osteomyelitis of the left 4th and 5th ribs, as well as early insufficiency fracture of the left fifth rib. Blood cultures were negative. She was treated conservatively with empiric antibiotics due to lack of seeding and bacteremia.

Exposed versus Buried Kirschner Wires Used in Displaced Pediatric Fractures of Lateral Condyle of Humerus.

Background:Comparision of results and complications of exposed versus buried Kirschner wires (K-wires) after open reduction of lateral condyle fractures is scarce and mainly from western population; hence, we envisaged to study the safety and efficacy of exposed and buried K-wires used for fixation of displaced pediatric fracture of the lateral condyle of humerus in Indian setup.Materials and Methods:A prospective, nonrandomized, comparative study was conducted in 50 patients with age <12 years, presenting with displaced fracture of lateral condyle of humerus of <2 weeks duration, without associated ipsilateral upper limb injury, who were treated by open reduction and internal fixation with either exposed or buried K-wires (n = 25 in each group). At a minimum followup of 3 months, status of fracture reduction, union, evidence of osteomyelitis, carrying angle at the elbow, and elbow range of motion (ROM) were assessed clinicoradiologically.Results:Four (16%) patients in exposed group and 1 (4%) in buried group had superficial infection, while 3 (12%) patients in exposed group and 2 (8%) in buried group had deep infection. All the patients with infection responded well to oral antibiotics and regular dressings. Buried group had higher incidence of secondary skin and wire-related complications.Conclusion:There was no statistical difference between the two groups but exposed K wires are easy to remove so are preferred over buried K wires.

Novel nano-hydroxyapatite/polyurethane composite scaffold in the treatment of chronic osteomyelitis

To evaluate the bone repair efficacy of the new nano-hydroxyapatite (n-HA)/polyurethane (PU) composite scaffold in the treatment of chronic osteomyelitis in tibia. A novel levofloxacin@mesoporous silica microspheres (Lev@MSNs)/n-HA/PU was successfully synthesized. Its surface structure was observed by scanning electron microscopy (SEM). Fifty adult female New Zealand rabbits were randomly selected, and osteomyelitis was induced in the right tibia of the rabbit by injecting bacterial suspension ( Staphylococcus aureus; 3×10 7 CFU/mL), which of the method was described by Norden. A total of 45 animals with the evidence of osteomyelitis were randomly divided into 4 groups, and the right medullary cavity of each animal was exposed. Animals in the blank control group (group A, n=9) were treated with exhaustive debridement only. The remaining animals were first treated by exhaustive debridement, and received implantations of 5 mg Lev@PMMA (group B, n=12), 1 mg Lev@MSNs/n-HA/PU (group C, n=12), and 5 mg Lev@MSNs/n-HA/PU (group D, n=12), respectively. At 12 weeks postoperatively, the right tibia of rabbits were observed by X-ray film, and then gross observation, methylene blue/acid fuchsin staining, and SEM observation of implant-bone interface, as well as biomechanical test (measuring the maximal compression force) were performed. X-ray films showed that the infection were severer than those of preoperation in group A, while the control of inflammation and bone healing of rabbits in group D were obviously better than those at preoperation. The gross observation showed extensive bone destruction in group A, a significant gap between bone tissue and the material in groups B and C, and close combination between bone tissue and the material in group D. The histology of the resected specimens showed that there was no obvious new bone formation around the materials in groups B and C, and there was abundant new bone formation around the periphery and along the voids of the materials and active bone remodeling in group D. The SEM observation of the bone-implant interface demonstrated that no new bone formation was observed at the bone-implant interface in groups B and C. However, bony connections and blurred boundaries were observed between the material and host bone tissue in group D. The biomechanical test showed the maximal compression force of groups B and D were significantly higher than that of groups A and C ( P<0.05), but there was no significant difference between groups B and D ( P>0.05). The novel synthetic composite Lev@MSNs/n-HA/PU exhibit good antibacterial activities, osteoconductivity, and biomechanical properties, and show great potential in the treatment of chronic osteomyelitis of rabbits.

The first evidence of an infectious disease in early penguins

Traces of skeletal response to trauma are poorly documented for early (i.e. Paleogene, 66–23 Ma) penguins (Sphenisciformes) and infectious diseases that afflicted these seabirds have not been previously put on record. We report osteomyelitis (OM), typically a bacterial infection of bone, in a proximal pedal phalanx of a ‘giant’ penguin from the Eocene (56–34 Ma) of West Antarctica. Osteomyelitis had apparently complicated healing of a fracture. The injury left an oblique scar within the proximal aspect of the plantar surface, resulting in deformation of the articular surface. The recognised evidence of OM includes characteristic periosteal reaction as well as focal bone-loss and necrosis.

MP24-16 UROSYMPHYSEAL FISTULATION - WHAT'S IN A NAME?

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion I1 Apr 2017MP24-16 UROSYMPHYSEAL FISTULATION - WHAT'S IN A NAME? Simon Bugeja, Stella Ivaz, Stacey Frost, Mariya Dragova, Daniela E Andrich, and Anthony R Mundy Simon BugejaSimon Bugeja More articles by this author , Stella IvazStella Ivaz More articles by this author , Stacey FrostStacey Frost More articles by this author , Mariya DragovaMariya Dragova More articles by this author , Daniela E AndrichDaniela E Andrich More articles by this author , and Anthony R MundyAnthony R Mundy More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.3310AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Urosymphyseal fistulation is a recently described condition which is also referred to in the literature as osteitis pubis or pubic osteomyelitis. The morbidity of this is considerable particularly the pain it generates, which is often uncontrollable and unbearable. The name of the condition reflects our understanding of the nature and cause of the problem and in view of the discrepancy in terminology we have assessed the clinical, biochemical, microbiological and histological evidence in our own group of patients to determine the nature of the condition. METHODS There were 37 patients treated in our centre in the last five years (2012 - 2016 inclusive). We have complete data in 27 of these. Blood studies, imaging and microbiological investigations were performed preoperatively; microbiology and histology specimens were taken at the time of surgery; and there was further imaging and blood studies postoperatively. RESULTS The only imaging investigation that was 100% reliable was MRI scanning. The white blood cell count was normal in 6 patients and the average elevation was to 12.3 x103/μL. The CRP was elevated in every patient up to a level of a mean of 26.5mg/L. There appeared to be no specific correlation between the CRP and the symptoms. Urine culture was positive in only 12 patients (44.4%) with an even spread between coliforms, pseudomonas spp. and candida spp. The tissue culture was positive in 11 (40.7%) of the patients and did not necessarily match the urine culture. Histological assessment showed chronic inflammation in both the symphysis and the adjacent bone in 9 patients. There were external beam radiotherapy-related changes in all of these. There were chronic inflammatory changes in the symphysis alone in 18 patients. There was no evidence of osteomyelitis in any patient. CONCLUSIONS Essentially the characteristic intraoperative finding was of a thick-walled fluid containing cavity within the pubic symphysis which was sometimes related to inflammatory changes in the surrounding bone and sometimes to post-irradiation changes in the bone but never to any acute inflammatory change. Correlating the symptoms, the clinical findings, the surgical findings and the haematological and microbiological findings suggest that the fundamental problem is the urine leak and direct fistulation into (and sometimes through) the pubic symphysis. The more extensive the leak the worse the pain. The urinary and tissue microbiology did not correlate with each other or with the symptoms. The correct terminology for this condition, we believe, is Urosymphyseal Fistulae. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e307-e308 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Simon Bugeja More articles by this author Stella Ivaz More articles by this author Stacey Frost More articles by this author Mariya Dragova More articles by this author Daniela E Andrich More articles by this author Anthony R Mundy More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

A striking case of florid multifacial soft-tissue infection on an FDG-PET scan

Background: A 24-year-old male had a road traffic accident in which he sustained a crush injury to his right lower leg and a compound fracture of the right femur, which were respectively treated with below knee amputation and metallic nailing of the right femur. The patient presented to the outpatient clinic 7 years later with 1-month history of pain and swelling of the right thigh; however, he didn’t report any fever. An FDG-PET scan was prescribed to rule out infection. Procedure: 18F-flourodeoxyglucose (329 MBq) was injected intravenously and PET/CT imaging performed after 60 minutes on a PET/CT camera (GE 710). A CT scan without oral or intravenous contrast, without breath holding, was acquired at low mA level for attenuation correction and localization purposes only. Arms were held up. Subsequently PET images from vertex to toe were obtained. PET, CT and fused images were reconstructed in the transaxial, coronal and sagittal axes (Figure 1). Findings: The PET/CT scan images show extensive accumulation of FDGavid fluid in the right thigh starting from the level above the nail in the mid gluteal region. Focal uptake is seen in the soft-tissue above the femoral neck with the high FDG uptake (SUVmax 12.7). There is FDG-avid fluid surrounding the intramedullary nail (SUVmax 3.8 to 5.9). The PET/CT scan shows extensive hypermetabolic fluid uptake in the right thigh in different soft-tissue regions including: 1) subcutaneously in the lateral aspect of the right thigh, 2) from mid to lower right thigh (SUVmax 12.6), 3) intrafacial, 4) sub-facial, 5) intraseptal, 6) inter and intramuscular (SUVmax 9 to 15.5). See Figures 1-3. Conclusion: The PET/CT scan findings were consistent with multiple hypermetabolic abscesses at different soft-tissue levels in the right thigh. There was however no evidence of osteomyelitis seen. Comments: Hybrid positron emission tomography/computed tomography (PET/CT) with the glucose analogue, 18F-fluoro-2- deoxyglucose (18F-FDG), is being increasingly used for the diagnosis of musculoskeletal infection. Activated granulocytes present at sites of infection/inflammation use glucose as an energy source and avidly take up FDG, which is transported into the cells and phosphorylated by hexokinase to 18F-fluoro2-deoxyglucose-6- phosphate, that is not further metabolized. Increased cellular metabolism in the activated inflammatory cells results in an increased expression of glucose transporter (GLUT) proteins by these cells, which coupled with an increase in the affinity for glucose by the glucose transporters secondary to the effects of cytokines and growth factors, results in high FDG uptake at sites of infection/ inflammation [1, 2]. This striking case of florid and extensive soft-tissue infection in the right thigh 7 years post surgery demonstrates the effectiveness of this new infection imaging modality in the non-invasive diagnosis of infection. The combination of PET and CT provides complementary information at a higher resolution and sensitivity as compared with singlephoton emitting radionuclides. FDG-PET technique demonstrates the metabolic changes that occur earlier compared to the anatomical changes seen by CT or MRI alone. The high metabolic activity of infective abscesses due to a high degree of FDG avidity coupled with structural CT changes of infection facilitates rapid interpretation of both the severity and the extent of infection and helps delineate osseous from soft-tissue involvement. The PET/ CT scan in this case showed multiple hypermetabolic areas which were precisely localized to the soft-tissue and showed no bone involvement. The findings are extremely helpful in determining and instituting the appropriate treatment and also useful for monitoring the therapeutic efficacy.

The first evidence of osteomyelitis in a sauropod dinosaur

Osteomyelitis is reported for the first time in a sauropod dinosaur. The material (MCS-PV 183) comes from the Anacleto Formation (Campanian, Late Cretaceous), at the Cinco Saltos locality, Rio Negro Province, Argentina. The specimen consists of 16 mid and mid-distal caudal vertebrae of a titanosaur sauropod. Evidence of bacterial infection is preserved in all of these vertebrae. The main anomalies are as follows: irregular ‘microbubbly’ texture of bone surfaces produced by periosteal reactive bone, abscesses on the rims of the anterior articular surfaces of two centra, numerous pits on centra anterior articulation surfaces, erosions on the anterior articulation of the vertebral centra, a vertical groove in posterior articular face of all the centra and disruption of the prezygapophysis and postzygapophysis (mainly the articular face) from the vertebra 19 and beyond. The last anomaly is increasingly pronounced in more distal elements of the series. Thin sections reveal that the anomalous cortical tissue is composed of avascular and highly fibrous bone matrix. The fibres of the bone matrix are organized into thick bundles oriented in different directions. Both morphological and histological abnormalities in the MCS-PV 183 specimen are pathognomonic for osteomyelitis.

“Rubber Band Syndrome of the Arm”

Dear Sir, A 5 year old girl was brought to the plastic surgery outpatient clinic for the treatment of a discharging sinus within a circumferential scar in the right arm of 6 months duration. The scar was found to be unstable with firm consistency and multiple discharging sinus within the scar. The rest of the limb was clinically normal [1]. The scar and the sinus history dates back to 9 months where the girl had sustained fracture of the arm managed by a local bone setter. The parents noticed the scar and the sinus after the removal of wooden sticks used for immobilization. The radiograph showed united fracture shaft of humerus with no evidence of osteomyelitis. The blood parameters were normal. Considering the clinical and radiological bone union with a discharging sinus in the circumferential scar, we had planned for exploration, excision of the unstable scar and soft tissue cover by multiple Z plasties. Interestingly, on exploration we found a very unusual rubber band embedded circumferentially (Fig. 1) inside the scar along the subcutaneous plane which could be the reason for the discharging sinus. Thorough wound debridement, removal of the band and soft tissue cover was done. The girl was comfortable in the post-operative period and was discharged. The wound healed and the girl was symptom free since then. Fig. 1 Intra-operative picture showing rubber band being in the arm There has been few literature studies which described unsual foreign bodies tied circumferentially in the limbs for various reasons which later cause serious constriction bands, ulcers, discharging sinus and compartment syndrome [2–4]. These circumferential constricting foreign bodies produce inherent heat on stretching and coolness on relaxing. This thermodynamics makes the rubber band gradually breach the skin and remain in the planes of the limbs depending upon the place and its position. Our case is an unsual presentation of the rubber band tied around the arm during native treatment of bone fracture causing superficial skin necrosis, circumferential scar and discharging sinus. We propose this short communication as rubber band syndrome in the arm and suggest clinical suspicion in all native treated wounds, bone fractures and non allopathic treatments with circumferential scar and discharging sinus.

Evidence of osteomyelitis in the dentary of the late Triassic rhynchocephalian Clevosaurus brasiliensis (Lepidosauria: Rhynchocephalia) from southern Brazil and behavioural implications

Clevosaurus was a cosmopolitan Rhynchocephalia genus restricted to the Late Triassic and the Early Jurassic. In Brazil, C. brasiliensis is one of the most conspicuous species collected from the Candelária Sequence (Riograndia Assemblage Zone, Norian age) of the Santa Maria Supersequence. Several jaws of C. brasiliensis are housed in the Laboratório de Paleontologia de Vertebrados of the Instituto de Geociências-UFRGS. Some of these jaws bear a relatively small protuberant bony callus on the anterolateral margin of the dentary, evidenced by a different tissue pattern incorporating small pits and discrete grooves. This pattern closely resembles a common bone infection known in the mandible of the extant Sphenodon punctatus. Although this similarity, the infection may be the result of two possible processes: as consequence of orthal jaw shearing movements during feeding at the moments that the dentary impacts with the enlarged premaxillary tooth or due to injuries produced after fights between conspecific individuals (as is the case for S. punctatus). If the second hypothesis is correct, the same pathological processes probably occurred in the Late Triassic C. brasiliensis indicating that similar ethological conditions were already present at the beginning of the Mesozoic, during the initial radiation of the lepidosaurian clade.