Low-grade Osteomyelitis Research Articles

Acute Arthritis/Osteomyelitis in Children

OSTEOMYELITIS IN CHILDREN: Osteomyelitis (OM) is defined as an infection of the bone marrow and adjacent osseous structures with potential surrounding soft tissue extent. It can occur at any age, generally in children 1–16 years old. In children, it is predominantly caused by hematogenous spread of infection, typically bacterial. Generally, the metaphysis is involved. Transphyseal spread to the epiphysis and joint is rare but can occur in children younger than 18 months, or in older children with closed growth plates, due to a different blood perfusion to the epiphysis. The first imaging modality of choice is conventional radiography (CR), but CR has limited sensitivity in early stages. Osseous destruction is evident only 10–14 days after the initial infection. In low-grade osteomyelitis, nonspecific soft tissue swelling and subtle bone resorption or a lytic lesion at the metaphysis may be seen, as in more advanced stages, lytic bone destruction, and periosteal formation are seen. Magnetic resonance imaging (MRI) is the preferred modality for early detection of lesions. Brodie’s abscess is a subtype of osteomyelitis typically seen in children, with intraosseous abscess formation (Figure 1). Another specific subtype of OM is chronic recurrent multifocal osteomyelitis (CRMO), which is characterized by multiple sterile inflammatory bone lesions with a relapsing and remitting course. Whole-body MRI is increasingly being used for evaluation. OM has a variable imaging appearance and often mimics other bone diseases. It is important for radiologists to be able to differentiate because the prognosis varies widely. Differential diagnoses include primary bone neoplasms, with Ewing sarcoma being the major differential diagnosis. ACUTE ARTHRITIS: Arthritis, which is simply defined as inflammation of a joint, may affect one or more joints and often is accompanied by swelling, redness, tenderness, warmth, and pain with movement. Arthritis has many etiologies. In a child with acute-onset monoarthritis, the differential diagnosis must always include septic arthritis as this is a medical urgency and requires prompt treatment. Arthritis can also be related to trauma, hematologic diseases (haemophilia, leukemia, etc.), but multiple other etiologies can be differentiated as well. The differential diagnosis of a child suspected of having systemic juvenile arthritis (JIA) is often difficult, early in the disease course. It is a significant cause of short- and long-term disabilities. Imaging in JIA serves to exclude alternative diagnoses, for classification of JIA, and for follow-up of treatment. Since late treatment can cause severe damage to joints and impair skeletal maturation, early detection is critical. Historically, imaging was based on radiography, but CR mainly detects late changes. MRI can detect both early and late changes, and is the modality of choice, especially for imaging of complex joints (Figure 2). US can evaluate multiple joints at the same time and can assist needle aspiration or joint infiltration.

Comment on "Plant thorn synovitis of elbow in children".

We read with interest the article titled “Plant thorn synovitis of elbow in children”1 and based on our clinical experiences2 would like to share some important aspects of these thorn injuries, which have not been highlighted in this paper. Acacia thorn injuries are common in Northern and Central India, where the Acacia Arabica plants are found in abundance especially in villages and on road side. The sharp thorns of these plants can easily penetrate the exposed parts of the extremities, both upper and lower limbs. These injuries are most commonly seen in foot, as in rural India there is a still a trend towards barefoot walking and/or not wearing strong shoes. The senior author had published already the world's largest series of acacia thorn injuries in 1990,2 in which he described foot to be the most common site (14 out of 22 patients). Incidentally, the present paper has failed to include this important landmark publication in their reference. Acacia Arabica thorns contain severely irritating toxins or alkaloids which trigger severe inflammatory response in the soft tissues and also in the bones.3 The authors would also like to bring to the readers' attention the presence of bony lesions in association with acacia thorn injuries. These lesions may be osteolytic, osteoblastic or mixed lesions and can easily be confused with chronic low grade osteomyelitis or benign neoplasms, if adequate history is not taken.2 Although not noticed in any of the cases in the present series, the radiographs should always be assessed for the presence of any lesions. The authors have described the presence of acacia thorns in the synovium, which were identified macroscopically per operatively. We do not have similar experience, as we had noticed that the acacia thorns if broken and entrapped in the synovium may not be easily visible to the naked eye all the times and hence careful microscopic examination of the total excised tissue should be done to look for the thorns in the specimen. Ultrasonagraphy and MRI can also be useful adjuncts for the diagnosis of thorn injuries. We do agree with the authors that an awareness and high index of suspicion about the possibilities of thorn injuries is crucial in reaching to an early diagnosis and hence a careful history about the foreign body prick, like thorns must be elucidated in all these patients.

Low-grade Osteomyelitis of the Fifth Metatarsal with Possible Concomitant Freiberg’s Disease of the Metatarsal Head

Freiberg’s disease, metatarsal avascular necrosis, is most often seen in healthy athletic adolescent girls. Presenting symptoms include vague pain, swelling, and loss of motion in the involved metatarsophalangeal joints. Low-grade osteomyelitis often is difficult to identify. In this case report, we present a 14-year-old girl with low-grade osteomyelitis of the fifth metatarsal accompanied by possible Freiberg’s disease in the same metatarsal.

Ribbing disease: a case report and literature review

Ribbing disease (RD) is a rare bone dysplasia characterized by benign endosteal and periosteal new bone formation confined to the diaphysis of the long bones of the lower extremities in young adults. The etiology and optimal treatment for the disease are unknown. It is often initially diagnosed as a low-grade osteomyelitis or a bone-forming neoplasia. It may also be confused with other causes of increased bone density. The onset is usually after puberty and the most common presenting symptom is pain that does not resolve with medical treatment and sometimes is intolerable. We report the case of a 22-year old woman with clinical and radiological manifestations of RD. In spite of different medical treatment modalities, pain did not resolve and the patient consulted multiple physicians. Intramedullary reaming of the tibia was performed to relieve the severe pain. To the authors' knowledge, in this report we present a case of RD for the third time in the orthopaedic literature and also she is the second case in the English literature to undergo a definite surgical treatment modality as intramedullary reaming for the solution of her pain. Owing to the rarity of the disease we aimed to report the complete findings of our encounter with the disease and to emphasize the role of an orthopaedic surgeon in consultation and intervention for the treatment of intolerable pain which is the most important symptom of this disease.

Low-grade osteomyelitis after single shot epidural anaesthesia via the caudal approach

Low-grade osteomyelitis after single shot epidural anaesthesia via the caudal approach

Postextraction osteomyelitis in a bone marrow transplant recipient

This report describes a case of mandibular osteomyelitis after a dental extraction in a patient who subsequently underwent bone marrow transplantation (BMT) for lymphoblastic lymphoma. Surgical guidelines consistent with National Cancer Institute recommendations were followed for the extraction, which was performed before initiation of the myelosuppressive conditioning regimen. However, moderate tenderness developed at the extraction site beginning 10 days after marrow infusion. On day 26 the patient became febrile and blood culture-positive for Staphylococcus epidermidis. Radiographs exposed on day 28 demonstrated changes consistent with low-grade osteomyelitis, including diffuse loss of lamina dura and an irregular osseous rarefaction extending 1 cm posterior to the extraction site. Although the indwelling Hickman catheter was the presumed source for bacteremia, clinical and radiographic data led to consideration of mandibular osteomyelitis as an alternative cause. Characteristics of this infection in BMT recipients are reviewed. Recommendations for dental extractions and prophylactic antibiotic regimens for catheterized BMT recipients are also discussed. Although mandibular osteomyelitic lesions are not common in profoundly immunosuppressed BMT recipients, prompt recognition and treatment are essential when the disease occurs.

Neuralgia-inducing cavitational osteonecrosis (NICO): Osteomyelitis in 224 jawbone samples from patients with facial neuralgia

A somewhat obscure etiologic theory for facial neuralgias presumes a low-grade osteomyelitis of the jaws that produces neural degeneration with subsequent production of inappropriate pain signals. Animal investigations and treatment successes with human patients based on this theory lend it credence. The present study examined 224 tissue samples removed from alveolar bone cavities in 135 patients with trigeminal neuralgia or atypical facial neuralgia. All tissue samples demonstrated clear evidence of chronic intraosseous inflammation. The most common microscopic features included dense marrow fibrosis or “scar” formation, a sprinkling of lymphocytes in a relative absence of other inflammatory cells (especially histiocytes), and smudged, nonresorbing necrotic bone flakes. Very little healing or new bone formation was visible. These lesions were able to burrow several centimeters to initiate distant cavities. The present preliminary investigation cannot prove etiology, but the presence of intraosseous inflammation in every single jawbone specimen in these patients and certain clinical and treatment aspects of these lesions (to be reported later) has led the authors to recommend the term neuralgia-inducing cavitational osteonecrosis or NICO for these lesions.

Low grade osteomyelitis of the jaws with actinomycosis

Five cases of chronically infected extraction wounds containing sequestra have been investigated histopathologically. In each case actinomyces-like colonies were reported closely related to necrotic bone surfaces. In one case, bacteriologie investigation of the curettings proved the microorganism to be Actinomyces naeslundi. It would be presumptuous to conclude that each of the above cases would have yielded similar results bacteriologically, but there must be a strong possibility that the microorganisms were all actinomyces of one type or other.

Melioidosis: Roentgen Manifestations in a Long Bone1

Melioidosis, a disease of current interest in patients returning from Viet Nam, has received attention in regard to its pulmonary roentgen findings (2). Although the lungs are most commonly involved, other affected organs include liver, spleen, lymph nodes, prostate, bone, and skin. Involvement in the ribs, spine, and pelvis has been described where destruction and associated sclerosis have been noted. Oderr and Shaw described bone findings as those of low grade osteomyelitis without appreciable bony reaction (3). Borchardt et al. described a lytic lesion involving the cortex of the proximal femur of a patient with subperiosteal calcification, but they did not illustrate this case (4). The present case is that of a 19-year-old Negro male, who, following an acute febrile illness, returned from Viet Nam with a draining sinus over the left tibia. Chest and spine roentgenograms were normal, but films of the left tibia (Figs. 1 and 2) revealed progressive medullary destruction and subperiosteal calcification t...

Unusual complications of osteomyelitis

The fact that these malignancies are usually engrafted on an old ulcer, does little to alarm the patient already inured to his osteomyelitis. Usually the disability here is slight or nil. The patient disregards the slight increase in symptoms and just “drops in” to the clinic for a checkup. The findings of chronic discharge, foul odor, pains of a mild nature, the clinical appearance of the lesion and a biopsy report furnish evidence enough that surgery must be instituted. The two cases showing the relatively short drainage period, should impress one with the probability that a low grade osteomyelitis may exist for many years, with an exciting factor such as trauma or infection as the inciting cause. It is hardly conceivable that lowered skin resistance would be a predisposing factor in the malignancies, since perfectly normal skin was present before any clinical appearance of the lesions. It is quite possible that in the other five cases the continued irritation, and poor skin resistance would lead to infection and malignancy. The patients who developed the toxic neuritis show a latent period between the acute onset of the osteomyelitis and the primary surgical intervention during which deafness started, continued and was not arrested nor helped by the treatment of the osteomyelitis. The treatment of skin malignancies by amputation or by wide curettement of the involved parts insures a good result. The first of the toxic neuritis patients developed a brain abscess and succumbed; the second is still living with a complicating amyloidotic condition.