660 Khan, Samual

sion produced by adenosine decreased perfu- Learning point sion to a compromised end-artery. Concomi- tant localised vascular steal may have Adenosine perfusion imaging is a useful Postgrad Med J: first published as 10.1136/pgmj.73.864.660 on 1 October 1997. Downloaded from contributed to regional hypoperfusion of the diagnostic technique with a very low rate of cerebellum, although any relationship between significant adverse effects. Heightened suspicion for an ischaemic event is, however, warranted in adenosine and neurologic abnormalities re- patients with known or suspected vascular disease mains conjectural. whose adverse symptoms do not resolve promptly

1 Wilson RF, Wyche K, Christensen BV, Zinuner S, Laxson 7 Cerqueira MD, Verani MS, Schwaiger M, Heo J, Iskandrian DD. Effects of adenosine on human coronary arterial AS. Safety profile of adenosine stress perfusion imaging: circulation. Circulation 1990; 82: 1950-66. results from the Adenoscan Multicenter Trial Registry. Jf 2 Watt AH, Penny WJ, Sigh H, Routledge PA, Henderson Am Coll Cardiol 1994; 23: 384-9. AB. Adenosine causes transient dilatation of coronary 8 Coyne EP, Belvedere DA, Vande Streek PR, Weiland FL, arteries in man. BrJ_ Clin Pharmacol 1987; 24: 665-8. Evans RB, Spaccavento U. Thallium-201 scintigraphy after 3 Ogilby JD, Iskandrian AS, Untereker WJ, Reo J, Nguyen intravenous infusion of adenosine compared with exercise TN. Effect of intravenous adenosine infusion on myocardial thallium testing in the diagnosis of coronary artery disease. Jf perfusion and function. Circulation 1992; 86: 887-95. Am Coil Cardiol 1991; 17: 1289-94. 4 Belardinelli L, Linden J, Berne RM. The cardiac effects of 9 Gupta NC, Esterbrook DJ, Hillman DE, Mohiuddin SM. adenosine. Prog Cardiovasc Dis 1989; 32: 73-97. Comparison of adenosine and exercise thallium-201 single 5 Patterson RE, Kirk ES. Coronary steal mechanisms in dogs photon emission computed tomography myocardial perfu- with one-vessel occlusion and other arteries normal. sion imaging. JAm Coll Cardiol 1992; 19: 248-57. Circulation 1983; 67: 1009-15. 10 Klabunde RD. Dipyridamole inhibition of adenosine 6 Epstein SE, Cannon RO, Talbot TL. Hemodynamic metabolism in human blood. Eur I Pharmacol 1983; 93: principals in the control of coronary blood flow. Am J 21-6. Cardiol 1985; 56: 4E-10E.

Symmetrical Brodie's

AFW Chambler, PJ Chapman-Sheath, MF Pearse, J Hollingdale

Summary scribed the pain as dull in nature with no Chronic recurrent multifocal osteomyeli- radiation, and troubling him at rest and at tis is often confused with symmetrical night. There was no history of trauma or Brodie's abscess as it has a similar patho- foreign travel. There were no hereditary genesis. We report an otherwise healthy haematological disorders within his family. 17-year-old boy presenting with a true On examination he was apyrexial, there were http://pmj.bmj.com/ symmetrical Brodie's abscess. We con- no local signs of inflammation but there was clude that a symmetrical Brodie's abscess marked tenderness over the distal end of both presenting in an otherwise healthy patient tibiae. There was full range movement of lower is a separate clinical condition with a limb joints. He showed a normal gait, but different management protocol. walking or running caused discomfort. Blood tests revealed a raised erythrocyte sedimenta- Keywords: tibia, Brodie's abscess, tion rate (ESR) (53 mm/h). Plain X-rays on September 27, 2021 by guest. Protected copyright. showed lytic lesions at the distal end of both tibiae (figures 1 and 2). Brodie's abscess is defined as a centrally Under general anaesthetic, the lesions were placed, sharply circumscribed, lytic lesion in explored under tourniquet control. Free fluid the adjacent to the growth plate. Sir was evacuated from the lesions and sent for Benjamin Brodie first described a subacute abscess in 1832. Chronic recurrent multifocal osteomyelitis is often given the Department of name of symmetrical Brodie's abscess in error, Orthopaedics, although they have a similar pathogenesis. We Central Middlesex report an otherwise healthy 17-year-old boy Hospital NHS Trust, presenting with a true symmetrical Brodie's Acton Lane, London NW1O 7NS, UK abscess. AFW Chambler PJ Chapman-Sheath Case report MF Pearse J Hollingdale An Asian boy aged 17 years attended ortho- of pain in Correspondence to: paedic out-patients complaining ...... Mr AFW Chambler, both lower legs. He located the pain to the 22 Queensmill Road, distal end of both tibiae. The pain had become London SW6 6JS, UK more severe recently, stopping him from Accepted 22 January 1997 participating in sporting activities. He de- Figure I X-ray of left ankle Symmetrical Brodie's abscess 661

mal , fibrous dysplasia, eosinophilic granuloma, brown tumours of hyperparathyr- oidism and fibrocortical defects. Radiological Postgrad Med J: first published as 10.1136/pgmj.73.864.660 on 1 October 1997. Downloaded from investigation using MRI and/or radioisotope bone scan can recognise these malignancies, but ultimately, histological analysis may be required. Biochemical profiles would be useful to elicit the rare brown tumour. Pathogenesis is due to an insidious bacter- aemia with septic embolic producing sub- acute osteomyelitis. The patient may be septic or possess an infection remote from the symptomatic area. Consequently, 90% of Figure 2 X-ray of right ankle Brodie's are located in the lower limb, at the distal ends of the tibia (70% of tibial lesions) or in the femur (60% of culture which grew Staphlyococcus aureas. The femoral lesions).' Staphylococcus is the com- cavaties were curetted and lavaged. Post- monest causative organism, although 25% of operatively he was treated with antibiotics for subacute osteomyelitis cases have negative six weeks. He was discharged from out- cultures.2 Unusual organisms such as Salmo- patients' clinic after an 18-month follow-up nella and tuberculosis are found in patients completely asymptomatic, pain-free while play- with sickle cell disease or who are immuno- ing sporting activities and no tenderness on compromised. palpatation. Blood results showed an ESR of There are several radiographic findings 7 ,um/h, C-reactive protein < 5 mg/l, and white associated with subacute osteomyelitis and cell count of 6 x 109/l. authors have attempted to classify these ap- pearances. 244 However, in all reported studies, Discussion Brodie's abscess has been the most commonly encountered form. Sir Benjamin Brodie first described a subacute It is rare for the abscess to present bilaterally bone abscess in 1832.' Brodie's abscess is (1 in 1000). Symmetrical Brodie's abscess is defined as a centrally placed, sharply circum- often confused with chronic recurrent multi- scribed, lytic lesion in the metaphysis adjacent focal osteomyelitis,5 as it has the same patho- to the growth plate. It is generally found in genesis. In chronic recurrent multifocal adolescents, with males most at risk.2 Patients osteomyelitis, patients have been systemically often present with mild pain with exacerba- unwell with multiorgan dysfunction associated tions, local warmth and occasional soft tissue with a bacteraemia giving rise to the multifocal swelling. Laboratory findings may show a osteomyelitis. We conclude that a symmetrical raised ESR and leucocytosis. Frequently, Brodie's abscess presenting in an otherwise

however signs and symptoms may be absent, healthy patient is a separate clinical condition http://pmj.bmj.com/ which presents a diagnostic dilemma. Differ- with a different management protocol. This ential diagnosis of uninfectious causes include report is the first recorded in the English Ewing's sarcoma, giant cell tumour, aneurys- literature.

1 Brodie BC. An account of some cases of chronic abscess of 4 Harris NH, Kirkaldy-Willis WH. Primary subacute pyo- the tibia. Medico-Chirug Trans 1832; 175: 239-49. genic osteomyelitis. J7 Bone joint Surg 1965; 47B: 526.

2 Stephens MM, MacAulay P. Brodie's abscess. A long-term 5 Day DL, Griffiths H. Bilateral Brodie's abscess. J7 Orthop on September 27, 2021 by guest. Protected copyright. review. Clin Onhop 1988; 234: 211. 1989; 12: 885-8. 3 Brailsford JF. Brodie's abscess and its differential diagnosis. BMJ 1938; 2: 119 - 23.