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A Case of Acute Osteomyelitis: an Update on Diagnosis and Treatment

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A Case of Acute Osteomyelitis: an Update on Diagnosis and Treatment International Journal of Environmental Research and Public Health Review A Case of Acute Osteomyelitis: An Update on Diagnosis and Treatment Elena Chiappini 1,*, Greta Mastrangelo 1 and Simone Lazzeri 2 1 Infectious Disease Unit, Meyer University Hospital, University of Florence, Florence 50100, Italy; [email protected] 2 Orthopedics and Traumatology, Meyer University Hospital, Florence 50100, Italy; [email protected] * Correspondence: elena.chiappini@unifi.it; Tel.: +39-055-566-2830 Academic Editor: Karin Nielsen-Saines Received: 25 February 2016; Accepted: 23 May 2016; Published: 27 May 2016 Abstract: Osteomyelitis in children is a serious disease in children requiring early diagnosis and treatment to minimize the risk of sequelae. Therefore, it is of primary importance to recognize the signs and symptoms at the onset and to properly use the available diagnostic tools. It is important to maintain a high index of suspicion and be aware of the evolving epidemiology and of the emergence of antibiotic resistant and aggressive strains requiring careful monitoring and targeted therapy. Hereby we present an instructive case and review the literature data on diagnosis and treatment. Keywords: acute hematogenous osteomyelitis; children; bone infection; infection biomarkers; osteomyelitis treatment 1. Case Presentation A previously healthy 18-month-old boy presented at the emergency department with left hip pain and a limp following a minor trauma. His mother reported that he had presented fever for three days, cough and rhinitis about 15 days before the trauma, and had been treated with ibuprofen for 7 days (10 mg/kg dose every 8 h, orally) by his physician. The child presented with a limited and painful range of motion of the left hip and could not bear weight on that side. Examination of the other joints was unremarkable, and no inflammatory signs were evidenced. Blood tests were performed and showed white blood cell (WBC): 23,000 cells/µL; neutrophils: 86%, C-reactive protein (CRP): 7.2 mg/dL; erythrocyte sedimentation rate (ESR): 52 mm/h. Blood cultures were taken at admission, before administration of antibiotic therapy, and yielded negative results. Ultrasound scan of the hip was normal. X-rays of the pelvis and left hip showed a lytic lesion of the proximal femoral metaphysis (Figure1). The child was admitted for suspected acute osteomyelitis of the proximal femur and a Magnetic Resonance Imaging (MRI) was ordered. The gadolinium-enhanced MRI confirmed the clinical suspicion of osteomyelitis (Figure2). After orthopedic consultation, a closed needle biopsy, and drainage of the lesion was performed. Specimens were was sent for histological and microbiological examination and empiric intravenous (IV) antibiotic treatment with ceftazidime and oxacillin was started. Specimen cultures grew methicillin-sensitive Staphylococcus aureus (MSSA). The child showed rapid clinical improvement, and normalization of inflammatory markers. Int. J. Environ. Res. Public Health 2016, 13, 539; doi:10.3390/ijerph13060539 www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2016, 13, 539 2 of 10 Int. J. Environ. Res. Public Health 2016, 13, 539 2 of 10 Int. J. Environ. Res. Public Health 2016, 13, 539 2 of 10 Figure 1. X-rays of the pelvis. Osteolytic lesion of the proximal metaphysis of the left femur (arrow). Figure 1. X-raysX-rays of of the the pelvis. Osteolytic Osteolytic lesion lesion of of the the proximal proximal metaphysis of the left femur (arrow). Figure 2. MRI confirms osteomyelitis of the femoral neck with a possible involvement of the growth Figure 2. MRI confirms osteomyelitis of the femoral neck with a possible involvement of the growth plateFigure without 2. MRI involvement confirms osteomyelitis of the joint cavity of the (arrow). femoral ( necka) T1-weighted with a possible image involvement showing metaphyseal of the growth plate without involvement of the joint cavity (arrow). (a) T1-weighted image showing metaphyseal fluidplate collection without involvementwith surrounding of the jointedema; cavity (b (arrow).) T1-weighted (a) T1-weighted SPIR image image enhancing showing metaphysealthe fluid fluid collection with surrounding edema; (b) T1-weighted SPIR image enhancing the fluid component.fluid collection with surrounding edema; (b) T1-weighted SPIR image enhancing the fluid component. component. AfterAfter 7 days, 7 days, intravenous intravenous therapy therapy was was stopped stopped and and replaced replaced with with oral oral flucloxacillin flucloxacillin (25 (25 gm/kg gm/kg After 7 days, intravenous therapy was stopped and replaced with oral flucloxacillin (25 gm/kg everyevery 6 6h) h) forfor anan additional additional 4 weeks.4 weeks. Six monthsSix mont afterhs dischargeafter discharge the child the showed child clinical showed improvement clinical every 6 h) for an additional 4 weeks. Six months after discharge the child showed clinical improvementand reached and pain-free reached full pain-free range of fu motionll range of of his motion left hip. of Gait his wasleft hip. normal, Gait aswas well normal, as blood as well tests, as and improvement and reached pain-free full range of motion of his left hip. Gait was normal, as well as bloodX-rays tests, findings. and X-rays findings. blood tests, and X-rays findings. 2. Introduction2. Introduction 2. Introduction OsteomyelitisOsteomyelitis is isan aninfection infection of ofbone bone sustaine sustainedd most most commonly commonly by by bact bacteria,eria, although although fungal fungal Osteomyelitis is an infection of bone sustained most commonly by bacteria, although fungal etiologyetiology is rarely is rarely described, described, particularly particularly in immunocompromised in immunocompromised children children [1]. According [1]. According to the time to the etiology is rarely described, particularly in immunocompromised children [1]. According to the time periodtime periodbetween between diagnosis diagnosis and symptom and symptom onset, onset, osteomyelitis osteomyelitis is classified is classified as acute as acute (<2 (<2 weeks), weeks), period between diagnosis and symptom onset, osteomyelitis is classified as acute (<2 weeks), sub-acutesub-acute (2 weeks–3 (2 weeks–3 months), months), or chronic or chronic (>3 mont (>3 months).hs). Bacteria Bacteria may reach may reachbone marrow bone marrow through through the sub-acute (2 weeks–3 months), or chronic (>3 months). Bacteria may reach bone marrow through the bloodstream,the bloodstream, or spreading or spreading from fromnearby nearby tissue. tissue. Infection Infection can canalso alsobe subsequent be subsequent to an to aninjury injury that that bloodstream, or spreading from nearby tissue. Infection can also be subsequent to an injury that exposesexposes bone bone to toa contaminated a contaminated environment environment [1]. [1 ]. exposes bone to a contaminated environment [1]. TheThe estimated estimated incidence incidence of ofacute acute osteomyelitis osteomyelitis is isabout about 8 cases 8 cases per per 100,000 100,000 children/year children/year [2,3] [2, 3] The estimated incidence of acute osteomyelitis is about 8 cases per 100,000 children/year [2,3] ChildrenChildren under under 5 years 5 years of ofage age are are affected affected in inabout about 50% 50% of ofthe the cases, cases, with with a M:F a M:F ratio ratio of of2:1. 2:1. Acute Acute Children under 5 years of age are affected in about 50% of the cases, with a M:F ratio of 2:1. Acute osteomyelitisosteomyelitis is isapproximately approximately two two times times more more frequent frequent than than septic septic arthritis, arthritis, and and its itsincidence incidence is is osteomyelitis is approximately two times more frequent than septic arthritis, and its incidence is steadilysteadily increasing. increasing. Gafur Gafur et al.et al.[4][ observed4] observed that that the the incidence incidence of ofacute acute osteomyelitis osteomyelitis has has tripled tripled over over steadily increasing. Gafur et al. [4] observed that the incidence of acute osteomyelitis has tripled over thethe last last 20 20years years while while the the incidence incidence of ofseptic septic arthritis arthritis remained remained constant. constant. Early Early detection detection is crucial is crucial the last 20 years while the incidence of septic arthritis remained constant. Early detection is crucial givengiven that that a delay a delay in inthe the diagnosis diagnosis of ofonly only 4 days 4 days is isa risk a risk factor factor for for long-term long-term sequelae sequelae (Table (Table 1).1). given that a delay in the diagnosis of only 4 days is a risk factor for long-term sequelae (Table 1). Int. J. Environ. Res. Public Health 2016, 13, 539 3 of 10 Table 1. Risk factors for long term sequelae. Risk Factors for Long-Term Sequelae Late diagnosis (>4 days) Inadequate treatment Neonate (prematurity, hypoxia, central venous catheterization) Sickle cell disease Infection by MRSA or Panton-Valentine Leukocidin positive strains Possible complications include septic arthritis, subperiosteal abscess, pyomyositis, deep vein thrombosis, sepsis, and multiorgan failure. Even if the mortality is less than 1%, permanent disabilities can occur, such as growth arrest with limb length discrepancy. Moreover, acute osteomyelitis can evolve to the chronic form. Most of pediatric osteomyelitis originates as a bloodstream infection. The route of entry may be the respiratory tract, particularly for K. kingae, S. pyogenes and S. pneumoniae, while the
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