Intraosseous Gas Research Articles

Emphysematous Spinous Osteomyelitis and Acute Pyelonephritis in Diabetic Patient.

Spontaneous emphysematous osteomyelitis with concurrent pyelonephritis is exceedingly rare and fatal entity that needs prompt diagnosis. Imaging play a crucial role in its diagnosis. We present a case of 52 years old woman known case of diabetes and hypertension presenting to ER with high grade fever and right flank pain. CT scan abdomen and pelvis revealed intraosseous gas extending in epidural space and in retro peritoneum, suggesting emphysematous osteomyelitis, which was later confirmed by E coli in blood culture. Right kidney was also swollen and enlarged with surrounding perinephric stranding. Our case also highlights the importance of radiological imaging in Emergency settings particularly in patients with comorbid. Being familiar with this rare entity thus can help in early diagnosis and initiation of treatment.

Emphysematous Osteomyelitis: Literature Review and a Case Report

Emphysematous osteomyelitis is a rare form of osteomyelitis characterized by the presence of intraosseous gas. It is caused by gas-forming organisms, most commonly being members of the Enterobacteriaceae family (particularly Escherichia coli) or anaerobes. Comorbidities such as diabetes mellitus, malignancy, alcohol abuse, Crohn’s disease, and other etiologies causing immune suppression, predispose to this condition. A prompt diagnosis of this potentially fatal condition is required to expedite early management. We present a patient diagnosed with multifocal emphysematous osteomyelitis involving the pelvic bones, left proximal femur, vertebral bodies, ribs, and clavicle caused by E. coli to highlight the unusual diffuse involvement by this rare disease. In addition, we reviewed 58 reported cases of emphysematous osteomyelitis including our case. Our purpose in revising all these cases was to observe any significant difference in outcome (if any exists in mortality) based on age, gender, causative organism, site of involvement, and treatment received. However, we could not observe any significant difference in outcome.

Emphysematous osteomyelitis: a rare and aggressive disease

Emphysematous osteomyelitis is an extremely rare entity consisting of the presence of intraosseous gas that can extend to the joints and adjacent soft tissues. It is an aggressive infectious process associated with high mortality, especially in patients with risk factors such as tumors or diabetes mellitus. Because early diagnosis and immediate treatment are crucial to prevent the potentially devastating consequences of this condition, imaging tests such as computed tomography play a fundamental role in its diagnosis and management. Therefore, radiologists must be aware that intraosseous gas is a rare but alarming sign that is pathognomonic of emphysematous osteomyelitis, especially in the axial skeleton.

A Rare Case Report of Emphysematous Osteomyelitis of the Femur in a Pediatric Patient: Imaging Findings and Review of the Literature

Emphysematous osteomyelitis (EO) is a rare yet life-threatening condition that must be considered in patients presenting with intraosseous gas on imaging. Anaerobic bacteria or members of the Enterobacteriaceae family are typically implicated in EO. The presence of significant comorbidities, such as malignancy and diabetes mellitus, can increase the risk of developing this condition, and high mortality rates have been reported. Prompt diagnosis and management are critical for improving patient outcomes, and radiologists play a vital role in identifying and interpreting imaging findings suggestive of EO.in this article we report the exceptional case of emphysematous osteomyelitis of the femur in a 12-year-old girl with no prior medical history. Microbiological analysis of the collected samples revealed the presence of Staphylococcus aureus.

Osteomielitis enfisematosa: una entidad rara y agresiva

Emphysematous osteomyelitis is an extremely rare entity consisting of the presence of intraosseous gas that can extend to the joints and adjacent soft tissues. It is an aggressive infectious process associated with high mortality, especially in patients with risk factors such as tumors or diabetes mellitus. Because early diagnosis and immediate treatment are crucial to prevent the potentially devastating consequences of this condition, imaging tests such as computed tomography play a fundamental role in its diagnosis and management. Therefore, radiologists must be aware that intraosseous gas is a rare but alarming sign that is pathognomonic of emphysematous osteomyelitis, especially in the axial skeleton.

Emphysematous Pyelonephritis and Emphysematous Osteomyelitis: A case report

Background. Emphysematous osteomyelitis and emphysematous pyelonephritis are both rare entities responsible for a high death rate. The first is defined by the presence of intravertebral or intraosseous gas, while the second is infectious damage to the renal parenchyma and perilesional tissues caused by gas-producing microorganisms and is, therefore, characterized by the formation of gas. Imaging plays a crucial role in making a rapid diagnosis and, thus, the initiation of the necessary treatment.
 Case Report. A 66-year-old woman with a medical history of type 2 diabetes mellitus and hypertension presented with the altered general condition and flank pain for 5 days, associated with fever and chills. The patient’s vital signs were remarkable with a disturbed biological workup, which led to emergency abdominal and pelvic computed tomography scanning that revealed emphysematous osteomyelitis of the spine and emphysematous pyelonephritis.
 Conclusions. The coexistence of emphysematous pyelonephritis and emphysematous osteomyelitis is a rare life-threatening entity, occurring in patients with comorbidities such as diabetes mellitus. Computed tomography is currently the gold standard in making the positive diagnosis, staging, for a quick and better management and, thus, a favorable prognosis.

POSTTRANSFUSION PURPURA: A RARE ENTITY

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Post-transfusion purpura (PTP) is a rare disease characterized by life-threatening thrombocytopenia after transfusion of any platelet-containing blood products, such as platelets(PLT) or packed red blood cells (PRBCs). We report an interesting case of PTP in a young lady after receiving multiple blood products. CASE PRESENTATION: A 36-year-old female with a past medical history of diabetes mellitus and left-sided below-knee amputation (BKA) was admitted to the Intensive Care Unit (ICU) for emphysematous osteomyelitis with intraosseous gas in the calcaneus, cuboid, and fifth metatarsal base of the right lower extremity. She underwent right-sided BKA, requiring multiple PRBC transfusions due to a combination of blood loss during surgery and chronic anemia. The initial platelet count was normal at 329,000/uL. Five days after the PRBC transfusion, it trended down to 17,000/uL and there was concurrent development of a purpuric rash over both arms. Bloodwork was notable for elevated prothrombin time and activated partial thromboplastin time. Hemolysis workup and Coombs test were negative. Fibrinogen was elevated, ruling out disseminated intravascular coagulation. PTP was suspected based on the clinical presentation and exclusion of other etiologies. Anti-human platelet antigen-1a (HPA-1a) antibodies were obtained. Empiric treatment with intravenous immunoglobulin (IVIG) and steroids was promptly initiated. Platelet count improved to 157,000/uL after four doses of IVIG. The patient tested positive for HPA-1a. However, due to the urgent need for treatment, the test sample for the anti-platelet antibodies was drawn after the initiation of IVIG. The development of thrombocytopenia in the classic time frame with the characteristic rash and improvement after receiving IVIG make PTP the most likely diagnosis. She was recommended to receive only washed PRBCs in the future to prevent a recurrence. DISCUSSION: PTP is a rare, underdiagnosed, and potentially fatal reaction, with the development of severe thrombocytopenia 2-14 days after transfusion of platelet-containing blood products. It is considered to be caused by alloimmunization against platelet antigens, with HPA-1a being the most common antibody1. Some cases of HPA-1b mediated PTP have been reported as well2. Diagnosis is often subtle and challenging, therefore a strong clinical suspicion is needed. A history of blood product transfusion a few days before the development of thrombocytopenia should make the physician think about the possibility of PTP. Treatment includes IVIG, steroids, or plasmapheresis3, and initiation of treatment should not wait for diagnostic confirmation. CONCLUSIONS: Clinicians should have high clinical suspicion for PTP in patients with acute, severe thrombocytopenia which develops after blood transfusions, and treatment should be initiated early to favorably alter the course of the disease. REFERENCE #1: Post-transfusion purpura. Kaplan C. Transfus Altern Transfus Med. 2002;4:26–28. REFERENCE #2: Anti-HPA-1b mediated posttransfusion purpura: a case report. Arewa OP, Nahirniak S, Clarke G. Case Rep Med. 2013;2013:3. REFERENCE #3: High-dose IgG for post-transfusion purpura-revisited. Mueller-Eckhardt C, Kiefel V. Blut. 1988;57:163–167. DISCLOSURES: No relevant relationships by Keerthy Joseph, source=Web Response No relevant relationships by SANA MULLA, source=Web Response No relevant relationships by Ruqqiya Mustaqeem, source=Web Response No relevant relationships by Jayamohan Nair, source=Web Response No relevant relationships by Vihitha Thota, source=Web Response

ATYPICAL AND PROMINENT PNEUMATOCYST IN THE CERVICAL VERTEBRAE AS AN INCIDENTAL FINDING ON CBCT: A CASE REPORT

<h3>BACKGROUND</h3> A pneumatocyst is an intraosseous gas collection. Although the etiology remains unclear, it has been associated with several conditions including osteomyelitis, trauma, osteonecrosis, and degenerative disease. They are uncommon lesions, with a reported rate varying from 0.13% to 3.9%. Pneumatocysts are more commonly seen in the sacroiliac joint and less commonly seen in the spinal vertebrae. <h3>CASE REPORT</h3> We present a case of a 61-year-old male patient who was referred for evaluation of the mandibular left lateral incisor for implant placement. Upon radiographic examination using a cone beam computed tomography (CBCT) scan, we found a prominent well-localized, hypodense entity in the body of C3 as an incidental finding. The size of the entity was approximately 11 mm in height and 6 mm in the antero-posterior dimension. It was the largest pneumatocyst we have recorded in the last 5 years. The radiographic presentation of the entity was concerning for a possible malignant neoplasm. A second opinion was requested from a neuroradiologist from the university hospital, who confirmed that it was consistent with a pneumatocyst. The air density of the lesion was a key feature that helped in the diagnosis. <h3>DISCUSSION/CONCLUSIONS</h3> The pathophysiology of pneumatocysts is not clear, but it is believed to be related to gas accumulation from the vertebral spaces that extends into the vertebral body. The lesions do not cause any symptoms and are discovered usually as an incidental finding. There are very few case reports of pneumatocyst in the spine in the literature. These lesions can enlarge with time and become fluid-filled and eventually contain granulation tissue. In 2D radiographs they have been mistaken for other aggressive lesions like multiple myeloma and metastases. It is therefore important to have an understanding of the presentation of these entities in CBCT scans. The air density and regular borders are key imaging features that help in the diagnosis.

A Rare Case of Emphysematous Osteomyelitis of Femur in an Intravenous Drug User

Emphysematous osteomyelitis (EO) is a rare condition characterized by the appearance of gas locules within the bone on imaging, usually as a result of anaerobic bacterial infection. We present the case of a 46-year-old known intravenous (IV) drug user who was admitted to the emergency department with intractable pain in the right groin. He was febrile with elevated white cell count and C-reactive protein. He underwent an X-ray and CT of the pelvis which demonstrated intraosseous gas in the proximal right femur. A diagnosis of EO was made radiologically, allowing for prompt antibiotic treatment and a plan for surgical debridement. There are only a handful of published cases of EO in the literature, only one of which has described IV drug use as the underlying factor.

Intraosseous gas distribution as a marker of postmortem interval

• Computed tomography (CT) and magnetic resonance imaging (MRI) have been increasingly used for forensic purposes; • This Study was conducted by evaluation of post-mortem CT image in flood victims; • The findings and pattern of intraosseous gas distribution were investigated; • We have found 5 pattern with timing correlation; • The evaluation of the distribution patterns of intraosseous gas has the potential to be exploited as a valuable marker for estimation of PMI. The postmortem interval is probably the most important puzzle piece in clarifying the circumstances in case of death occurred in unknown conditions. Over the years, radio-imaging modalities have proved their worth in forensic field, providing additional and significant improvements and findings. CT-scan is characterized by wide availability, fast scan times and sustainable healthcare costs. Detection of gas, hemorrhage and bone fractures are points of strength of CT-scan. A reliable evaluation of the post-mortem interval is interesting in the victims of a mass disaster, also following a natural disaster, for the individuation of responsibility in the efficiency of the help and assistance. This work is based on the postmortem CT-scan evaluation of 26 people sadly died during a tragic flood occurred in 2009 in Giampilieri (Italy). In particular, the gas distribution within the skeletal bones was evaluated, with recognition of specific patterns that were then related to the time of death. The identification of intraosseous gas could represent a helpful tool in the estimation of postmortem interval.

Extensive multifocal emphysematous osteomyelitis: fatal outcome in a patient with psychiatric history

Emphysematous osteomyelitis is a rare entity with potentially devastating consequences, even after prompt and aggressive intervention. It is characterized by intraosseous gas and may be complicated by adjacent abscess formation. There are a handful of previously reported cases of emphysematous osteomyelitis, but none to the degree as reported here. Specifically, we report an extremely rare case of extensive multifocal emphysematous osteomyelitis involving both the axial and appendicular skeleton in a 20-year-old woman.

Coexistent Emphysematous Osteomyelitis and Pyelonephritis – A Report of Two Cases

Emphysematous osteomyelitis is defined as the presence of intraosseous gas associated with any infection which is a fatal condition if prompt diagnosis and treatment is not provided. It is commonly caused by anaerobes or the members of Enterobacteriaceae family. Here, we report two cases of emphysematous osteomyelitis with coexistent pyelonephritis.

A patient with neutropenic fever and intraosseous gas.

A patient with neutropenic fever and intraosseous gas.

Emphysematous Osteomyelitis of the Spine: A Case Report and Literature Review

Emphysematous osteomyelitis is a rare but potentially fatal infection. It is caused by gas-forming organisms and is characterized by the presence of intraosseous gas. A 75-year-old woman with untreated diabetes mellitus presented with difficulty in moving and anorexia. Laboratory studies revealed inflammation, a urinary infection, and diabetic ketoacidosis. Klebsiella pneumoniae was detected in both urine and blood cultures. Computed tomography and magnetic resonance imaging revealed emphysematous lesions in the paravertebral soft tissue, spinal canal, and iliopsoas muscle, with intraosseous gas at L1 and L2. These findings led to a diagnosis of emphysematous osteomyelitis. We herein review 35 reported cases of emphysematous osteomyelitis including our case.

Emphysematous Osteomyelitis - A Rare Cause of Gas in Spine - A Case Report

Emphysematous osteomyelitis is rare condition characterised by the presence of intraosseous gas. About 25 such cases have been reported in the literature with only 10 cases involving spine. These infections are commonly seen in elderly morbid patients and are highly fatal. We report a 65 year old female patient with history of sudden onset of back pain and weakness of both the lower limbs with radiological images revealing the features of emphysematous osteomyelitis of L5 vertebra, which was treated with surgical decompression and stabilisation, and post-operative antibiotics. We also review literature to describe the clinical and radiological features for diagnosis and the treatment options available for such infections.

Osteoradionecrosis after Radiation Therapy for Head and Neck Cancer: Differentiation from Recurrent Disease with CT and PET/CT Imaging

Our aim was to compare the CT and PET/CT imaging features of osteoradionecrosis with those of recurrent disease after treatment of head and neck malignancy. We retrospectively reviewed maxillofacial and neck CT scans obtained for suspected osteoradionecrosis or tumor recurrence for the presence of the following: 1) discrete solid mass, 2) cystic mass, 3) interruption of the bony cortex, 4) bony fragmentation, 5) bony trabecular loss, 6) intraosseous gas, and 7) bony sclerosis. Trabecular bone loss was further categorized as permeative (<75% loss of trabecula) or lucent (>75% loss). PET/CT studies performed for suspected osteoradionecrosis or tumor recurrence were evaluated for mean standard uptake value and maximum standard uptake value. Ten maxillofacial CT, 53 neck CT, and 23 PET/CT studies were performed in 63 patients. Osteoradionecrosis was diagnosed by pathology or imaging stability in 46 patients, and tumor recurrence, in 17 patients. Bony sclerosis was found to be significantly more prevalent in osteoradionecrosis and was never seen with tumor recurrence (P = .013). Patients with tumor recurrence were more likely to have a solid (P < .001) or cystic mass (P = .025), which was rare in osteoradionecrosis. While patients with tumor recurrence had significantly higher mean standard uptake values and maximum standard uptake values, there was significant overlap in mean standard uptake values and maximum standard uptake values between the 2 groups. There is significant overlap of standard uptake values in patients with osteoradionecrosis and tumor recurrence. CT findings provide more reliable diagnostic tools, with a solid or cystic mass strongly associated with tumor recurrence and bony sclerosis seen only with osteoradionecrosis.

A case of emphysematous osteomyelitis of the midfoot: imaging findings and review of the literature.

Emphysematous osteomyelitis is a rare but potentially fatal condition that must be considered whenever intraosseous gas is identified on imaging. The organisms implicated in most cases of emphysematous osteomyelitis are anaerobes or members of the Enterobacteriaceae family. Significant comorbidities, such as malignancy and diabetes mellitus, frequently predispose to this condition, and high mortality rates have been reported. The radiologist must be aware of the implications of identifying intraosseous gas in order to facilitate early diagnosis and expedite management. We report a unique case of a 58-year-old male with diabetes mellitus who presented with emphysematous osteomyelitis of the midfoot and necrotising fasciitis of the ipsilateral distal lower limb. Specimen cultures in this case revealed a pure growth of Group G Streptococcus.

Anaerobic osteomyelitis associated with intraosseous and soft-tissue pneumatosis

IntroductionA 13-year-old girl with paraplegia from a traffic accidentpresented to our hospital with fever and swelling of the leftthigh for 1 month. Initial laboratory findings revealedleukocytosis, elevated C-reactive protein (31 mg/dl) andincreased creatinine (2.38 mg/dl). A plain radiograph of theleft hip and CT showed gas within the femur head, iliacbone and surrounding soft tissue, and extensive soft-tissueswelling in the pelvis, hip joint and thigh (Figs. 1 and 2).Surgical debridement and drainage of the soft-tissue abscesswereperformed.Culturesofboththeabscessandthefemoralhead grew Bacteroides fragilis, B. thetaiotaomicron andFusobacterium necrophorum.Intraosseous gas was first detected by CT in 1981 whenreported in three cases of polymicrobial osteomyelitis [1].This condition is extremely rare, particularly in the absenceof a compound fracture, surgery or other direct communica-tion between the bone and air [2]. The pathogens are oftenpolymicrobial and anaerobic. The presumed mechanism forthe formation of intraosseous gas involves anaerobic metab-olismwiththeproductionofhydrogenandcarbondioxide[2].Anaerobic osteomyelitis can become fulminant and invasive.References

Intraosseous and intraarticular pneumatosis in anaerobic osteomyelitis

A 14-year-old diabetic girl presented with fever and pain and swelling of the left hip for 1 week. There was no history of trauma or biopsy. Laboratory examination revealed leucocytosis with raised erythrocyte sedimentation rate and C-reactive protein. CT revealed gas within the femur, left hip joint and surrounding soft tissues (Figs. 1 and 2). There was marrow and soft-tissue oedema with multiple cortical breeches. Cultures from purulent material in the soft tissues yielded mixed skin flora and Bacteroides fragilis. Bone biopsy confirmed osteomyelitis. Intraosseous gas has been reported after biopsy, penetrating wounds and fractures. Very few cases of intraosseous and intraarticular pneumatosis have been reported in the setting of osteomyelitis [1, 2]. In the absence of direct communication of bone with air, it is highly suggestive of osteomyelitis, and the pathogens are usually anaerobic and/or polymicrobial. The presumed mechanism is anaerobic metabolism with production of hydrogen and carbon dioxide gases [1]. The presence of intraosseous gas usually signifies fulminant infection requiring aggressive treatment. The other rare causes of intraosseous gas are lymphangiomatosis of bone, necrosis and neoplasm [1].

Acetabular pneumatocyst containing air-fluid level

The presence of intraosseous gas most commonly occurs in osteomyelitis, vacuum phenomenon, and postsurgery or posttraumatic states. Several cases of subchondral gas-filled lesions, called pneumatocysts, have also been described in the sacroiliac joint and clavicle, none of them with intralesional air-fluid level. These pneumatocysts are innocuous lesions of uncertain origin. We describe one case of acetabular pneumatocyst containing air-fluid level in a 62-year-old man with long-standing ankylosing spondylitis involving hip joint. To our knowledge, this is the first reported case of a pneumatocyst in an acetabular location containing air-fluid level.