CASE REPORT

Brodie's –An Uncommon Cause of Leg Pain

Muhammad Umar Amin1, Mobeen Shafique1, Jawad Jalil2, Muhammad Nafees3 and Shamraiz Khan3

ABSTRACT A rare case of Brodie's abscess of distal left tibia is presented in a child which was initially missed on clinical grounds alone. Differentiation from different was done on radiological grounds. The patient was managed surgically with high dose intravenous antibiotics. Brodie’s abscess is very rarely encountered in our reporting of X-rays.

Key words: Brodie’s abscess. Leg pain. Nuclear bone scan. X-ray. Fever. Sclerosis. Tibia.

INTRODUCTION scintigraphy was advised to confirm active bone pathology. Bone scan was performed with 20 Mci of Brodie’s abscess is a subacute form of hematogenous 99mTc-MDP intravenously. Dynamic flow and blood pool , which results if an organism is less study of the ankle region was acquired anteriorly. virulent or a child’s resistance is strong. Brodie’s Multiple anterior and posterior static images were abscess is difficult to diagnose because characteristic acquired 2 hours postinjection followed by SPECT. The signs and symptoms of the acute form of the disease are nuclear bone scan revealed increased blood perfusion minimal and non-specific. The initial infection is in the left ankle region. Delayed image showed focal localized to a small area and is walled off by increased tracer uptake in the distal end of left tibia. inflammatory fibrous tissue, usually in the metaphysic of Tracer uptake in the rest of the skeleton was uniform. tubular rarely traversing the physis into the SPECT reconstruction images also showed focal epiphysis. These lesions are accompanied by minimal increased tracer uptake in the distal end of the left tibia. or absent and may be so small that detection on plain radiograph is not possible.1 The Patient was initially managed with erythrocin in the preponderance of Brodie's in the lower ward. However, his symptoms were not relieved and extremities is probably due to trauma. patient persistently complained of pain and swelling. This case report describes the uncommon condition Surgical exploration of the lesion was planned. The involving distal left tibia. lesion was curetted completely, abscess was drained and wound was closed. Histopathology of the specimen CASE REPORT revealed chronic granulomatous infection with presence A 13 years old male child presented with fever and low- of inflammatory cells. No evidence of any benign tumor grade pain in the left ankle region for 3 months. The pain was seen on histopathology. High dose antibiotics were was localized and occurred continuously. Local continued for 2 months. Patient made an uneventful examination revealed slight tenderness without any recovery and his pain settled. Presently, she has no pain redness of overlying skin. or any symptom of recurrence. Plain X-ray of left tibia revealed a focal lytic lesion surrounded by a sclerotic bone rim, in the metaphyseal region extending upto the growth plate. No pathological fracture was visualized. Epiphysis of ankle joint was normal. Based on the clinical history and radiological picture, a provisional diagnosis of Brodie’s abscess was made and his 99mTc-MDP three phase skeletal

1 Department of Radiology 1/Pediatrics2, Figure 1: X-ray left ankle shows a Figure 2: Nuclear bone scan lytic lesion having sclerotic margins showing increased radiotracer Combined Military Hospital, Bahawalpur. (black arrows). White arrows uptake in the Brodie’s abscess 3 Department of Radiology, Military Hospital, Rawalpindi. indicate uninvolved growth plate. (black arrow). Correspondence: Dr. Muhammad Umar Amin, Radiology Department, Combined Military Hospital, Bahawalpur. E-mail: [email protected] DISCUSSION Received October 24, 2007; accepted January 7, 2008. Brodie's abscess is localized form of osteomyelitis, is

Journal of the College of Physicians and Surgeons Pakistan 2008, Vol. 18 (3): 183-184 183 Muhammad Umar Amin, Mobeen Shafique, Jawad Jalil, Muhammad Nafees and Shamraiz Khan usually found in the cancellous tissue near the end of Imaging with standard radiographs, bone scintigraphy, the long bone. A well-circumscribed area of bone and MRI has been described in the literature. destruction has a surrounding zone of reactive sclerosis, Multifocality could be excluded with bone scintigraphy. sometimes accompanied by a periosteal reaction. It may CT-guided trans-osseous biopsy and curettage can also have a finger-like extension into the neighbouring bone be performed in suspected cases of Brodie's abscess.8 towards the , which, when present, is is the most common organism pathognomonic of infection tunneling. If a is cultured from Brodie's abscess. Curettage and antibiotics present, an is simulated. Brodie’s for 6 weeks was adequate for treatment in most cases.9 abscess typically enhances on the delayed isotope bone scan as was seen in this case. CT demonstrates central Brodie's abscess involving the adjacent and necrosis and sequestration of the Brodie’s abscess epiphysis of a long-bone, communicating through and even in the presence of significant surrounding damaging the growth cartilage of the epiphyseal plate sclerosis. On MR scan, it is to be expected that the have also been described in the literature.10 central vascular material in the osteoid osteoma will exhibit brighter signal and enhancement while necrotic REFERENCES 2 tissue in the Brodie’s abscess will not. It has a 1. Mandell GA. Imaging in the diagnosis of musculoskeletal characteristic layered or target appearance. The central infections in children. Curr Probl Pediatr 1996; 26: 218-37. abscess cavity is of low-signal on T-1 weighted and 2. Sutton D. Textbook of radiology and imaging. 6th ed. New York: 3 high-signal intensity on T-2 weighted images. Churchill Livingstone; 1998: p.1159-60. Alter et al. have also reported a case report with a one-year 3. Marti-Bonmati L, Aparisi F, Poyatos C. Vilar J. Brodie’s abscess: follow-up period, demonstrating the successful diagnosis MR imaging appearance in 10 patients. J Magn Reson Imaging 1993; and surgical treatment of a Brodie’s abscess of the distal 3: 543-6. metaphysis of the right tibia in an 11-year-old female.4 The 4. Alter SA, Sprinkle RW. Brodie's abscess: a case report. X-ray diagnosis is easy if the radiologist knows the J Foot Ankle Surg 1995; 34: 208-14. clinical data. The preponderance of Brodie's abscesses 5. Kozlowski K. Brodie’s abscess in the first decade of life. Report in the lower extremities is probably due to trauma.5 of eleven cases. Pediatr Radiol 1980; 10: 33-7. Brodie's abscess of the cuboid bone has also been 6. Bagatur AE, Zorer G. Brodie's abscess of the cuboid bone: a described in the literature.6 The differential diagnosis of case report. Clin Orthop Relat Res 2003; (408): 292-4. Brodie's abscesses radiologically includes osteoid 7. Lopes TD, Reinus WR, Wilson AJ. Quantitative analysis of the osteoma, nonossifying , giant cell tumor, plain radiographic appearance of Brodie's abscess. Invest Radiol eosinophilic granuloma, chondroblastoma and fibrous 1997; 32: 51-8. dysplasia, as the major lesions.7 Chondroblastoma 8. Strobel K, Hany TF, Exner GU. PET/CT of a Brodie’s abscess. occurs in the epiphysis while the lytic lesion seen in our Clin Nucl Med 2006; 31: 210. case was in the metaphysis. Fibrous dysplasia shows 9. Stephens MM, MacAuley P. Brodie's abscess: a long-term marked sclerosis. This was not seen in this case. review. Clin Orthop Relat Res 1988; (234):211-6. Aneurysmal was excluded, as the lesion was 10. Bogoch E, Thompson G, Salter RB. Foci of chronic non-expansile. No central nidus was seen in this case circumscribed osteomyelitis (Brodie's abscess) that traverse the thus, excluding osteoid osteoma. epiphyseal plate. J Pediatr Orthop 1984; 4: 162-9.

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184 Journal of the College of Physicians and Surgeons Pakistan 2008, Vol. 18 (3): 183-184