Predicting the pathogen of diabetic toe osteomyelitis by two consecutive ulcer cultures with bone contact

In this study, we investigate the accuracy of two consecutive ulcer cultures with bone contact compared to bone biopsy for the diagnosis of diabetic toe osteomyelitis. The same nurse and orthopaedic surgeon obtained all samples: sample A-1: bone contact swabbing through the ulcer; sample A-2: a second culture swabbing from the bone surface within 24 h; sample B: surgical bone biopsy in the operating theatre. The kappa statistic measure between samples A-1 and A-2 (bone contact swabs) indicated 82.35% agreement. The sensitivity, specificity, positive and negative predictive values of the two samples A compared to B were 96%, 79%, 92% and 88%, respectively, for the causative pathogen. These results were similar with prior antibiotic treatment, discordant bone surface swabs or with monomicrobial infections. As a conclusion, two consecutive diabetic toe cultures with bone contact accurately predict the pathogen of diabetic toe osteomyelitis in 90% of cases.

Relationship between antibiotic concentration in bone and efficacy of treatment of staphylococcal osteomyelitis in rats: azithromycin compared with clindamycin and rifampin

We examined the effect of azithromycin (CP-62,993), a new oral macrolide-like antibiotic, alone and in combination with rifampin, as treatment for experimental staphylococcal osteomyelitis. Clindamycin was used as a comparison drug. Rats (n = 10 to 15 per group) were infected by direct instillation of Staphylococcus aureus into the tibial medullary cavity. After 10 days, 21-day treatments with azithromycin (50 mg/kg of body weight, once daily, by the oral route), rifampin (20 mg/kg, once daily, subcutaneously), or clindamycin (90 mg/kg, three times daily, by the oral route) were started. The drugs were used singly or in combination (azithromycin plus rifampin or clindamycin plus rifampin). Peak azithromycin concentrations in bone were > 30 times higher than levels in serum, but the drug had little effect on final bacterial titers (5.13 +/- 0.46 log10 CFU/g of bone; for controls, 6.54 +/- 0.28 log10 CFU/g). Clindamycin was more active than azithromycin (3.26 +/- 2.14 log10 CFU/g of bone; 20% of sterilized bones), but rifampin was the most active single drug (1.5 +/- 1.92 log10 CFU/g; 53% of sterilized bones). Therapy with rifampin or clindamycin alone was associated with the emergence of resistance. Rifampin plus azithromycin (0.51 +/- 1.08 log10 CFU/g of bone; 80% of sterilized bones) and rifampin plus clindamycin (0.87 +/- 1.34 log10 CFU/g of bone; 66% of sterilized bones) were the most active regimens. Thus, azithromycin is ineffective as a single drug for the treatment of experimental staphylococcal osteomyelitis, despite high levels in bone that markedly exceeded the MIC, but it may be an attractive partner drug for rifampin.

Imaging of chronic recurrent multifocal osteomyelitis of childhood first presenting with isolated primary spinal involvement

OBJECTIVE: Initial presentation with primary spinal involvement in chronic recurrent multifocal osteomyelitis of childhood (CRMO) is rare. Our objective was to review the imaging appearances of three patients who had CRMO who initially presented with isolated primary spinal involvement. DESIGN AND PATIENTS: The imaging, clinical, laboratory and histology findings of the three patients were retrospectively reviewed. Imaging included seven spinal MR imaging scans, one computed tomography scan, nine bone scans, two tomograms and 16 radiographs. These were reviewed by two musculoskeletal radiologists and a consensus view is reported. All three patients presented with atraumatic spinal pain and had extensive bone spinal pathology. The patients were aged 11, 13 and 12 years. There were two females and one male. RESULTS AND CONCLUSIONS: The initial patient had thoracic T6 and T8 vertebra plana. Bone scan showed additional vertebral body involvement. Follow-up was available over a 3 year period. The second patient had partial collapse of T9 and, 2 years later, of C6. Subsequently extensive multifocal disease ensued and follow-up was available over 8 years. The third patient initially had L3 inferior partial collapse and 1 year later T8 involvement with multifocal disease. Follow-up was available over 3 years. The imaging findings of the three patients include partial and complete vertebra plana with a subchondral line adjacent to endplates associated with bone marrow MR signal alterations. Awareness of the imaging appearances may help the radiologist to include this entity in the differential diagnosis in children who present with spinal pathology and no history of trauma. Histopathological examination excludes tumor and infection but with typical imaging findings may not always be necessary.

Silent chronic osteomyelitis lasting for 30 years before outburst of symptoms

A 56-year-old male patient presented with left knee and thigh pain after suffering a knee contusion. History revealed a complex fracture of the distal femur 30 years prior to presentation. Initial blood tests upon admission showed elevated C reactive protein values. Subsequent imaging and biopsies showed a correlate to osteomyelitis, upon which the diagnosis of a late onset osteomyelitis as an outburst of silent chronic osteomyelitis was made. The patient was successfully treated surgically by means of aggressive debridement and discharged after confirmation of negative biopsies.

Septic osteitis and osteomyelitis in foals - are antimicrobials alone enough?

The case report by Lawrence and Fraser (2012) describes the successful management of 2 weanlings with septic osteitis of the proximal sesamoid bones, using prolonged (6 weeks) antimicrobial therapy alone. Doxycycline, an antimicrobial with excellent bone penetration properties, was deemed essential to treatment success. In contrast to the poor outcome in previously reported cases of septic sesamoid bone osteitis, the authors were able to show the value of a conservative approach over surgical debridement. The question is to what extent are we able to extrapolate this to the general treatment of septic osteitis and osteomyelitis in young horses?

Pressure Ulcer-Related Pelvic Osteomyelitis: A Neglected Disease?

Background. Decubitus ulcers can become complicated by pelvic osteomyelitis. Little is known about the epidemiology of pressure ulcer-related pelvic osteomyelitis. Methods. We performed a retrospective cohort study of adult patients with pressure ulcer and pelvic osteomyelitis admitted to an academic center from 2006 to 2011. Data on clinical presentation, diagnostic evaluation, and treatment during the index admission were collected. Outcome measures included length of hospital stay and number of readmissions in the subsequent year. Results. Two hundred twenty patients were included: 163 (74%) were para/quadriplegic and 148 (67%) were male (148; 67%). Mean age was 50 (±18) years. Pelvic osteomyelitis was the primary admission diagnosis for 117 (53%). Fifty-six (26%) patients had concurrent febrile urinary tract infection. Wound cultures collected for 113 patients (51%) were notable for methicillin-resistant Staphylococcus aureus (37; 33%), Streptococci (19; 17%), and Pseudomonas spp (20; 18%). Plain films were obtained in 89 (40%) patients, computed tomography scans were obtained for 81 (37%) patients, and magnetic resonance images were obtained for 40 (18%) patients. Most patients received osteomyelitis-directed antibiotics (153; 70%), 134 of 153 (88%) of which were scheduled to receive ≥6 weeks of treatment. Fifty-five (25%) patients underwent surgery during the index admission; 48 (22%) patients received a combined medical-surgical approach. One third of patients had ≥2 readmissions during the subsequent year. Patients treated with a combined approach were less likely to be readmitted than those who received antibiotics alone (0 [range, 0-4] vs 1 [0-7] readmissions; P = .04). Conclusions. This is one of the largest cohort studies of pressure ulcer-related pelvic osteomyelitis to date. Significant variations existed in diagnostic approach. Most patients received antibiotics; those treated with a combined medical-surgical approach had fewer hospital readmissions.

Primary tuberculosis of the TMJ: presentation of a case and literature review

Tuberculosis (TB) is a frequent health problem. The prevalence of extrapulmonary TB has increased in the last couple of years. Head and neck tuberculosis forms nearly 10% of all extrapulmonary manifestations of the disease. TB of the temporomandibular joint (TMJ) is rare; only a few cases have been reported. The clinical appearance of TB infection of the TMJ has been described as unspecific, resembling arthritis, osteomyelitis, cancer or any kind of chronic joint diseases. This article describes a 22-year-old woman with pain and left preauricular swelling. Magnetic resonance imaging and computed tomography showed an expansive process with destruction of the left condyle and condylar fossa. A fine needle aspiration examination of the swelling showed non-specific granulomatous inflammation. In the following days, a preauricular fistula developed, of which a swab and biopsy specimens were taken. Histological and microbiological examinations revealed an infection with Mycobacterium tuberculosis. The initial antituberculosis treatment consisted of a combination of four antibiotics and could be reduced to two antibiotics in the course of treatment. The treatment was completed successfully after 9 months.

Orbital involvement in Pott's puffy tumor: a systematic review of published cases

Pott's puffy tumor (PPT) is a frontal subperiosteal abscess associated with underlying frontal bone osteomyelitis. It represents a well-known source of sinogenic intracranial infection, but the orbital complications related to this entity are rarely reported. The goal of this study was to characterize the orbital involvement in PPT.

Influence of secondary infection on amputation in chronic critical limb ischemia

OBJECTIVES: To evaluate the influence of secondary infection on major amputation in chronic critical leg ischemia (CLI). DESIGN: Prospective, controlled observational study. MATERIALS AND METHODS: Sixty-seven patients with CLI and ischemic lesions participated in the study. Presence of infection was defined by clinical, laboratory and radiological criteria. Patients were categorized as having no local infection, soft tissue infection or osteomyelitis treated without antibiotics, amoxicillin/clavulanacid for 1 month or ciprofloxacin and clindamycin for 3 months, respectively. Clinical outcome was assessed at 2, 6 and 12 months. Study endpoints were major amputation and mortality. Analyses were performed using the Kaplan-Meier method. RESULTS: Forty-seven of 67 patients had a local infection. Major amputation was lower in patients with successful revascularization as compared to patients unsuitable for or with failed (without) revascularization (0% vs 26%, p<0.01). In patients with successful revascularization the probability of complete healing was lower with secondary infection (23% vs 71%, p=0.03). In patients without revascularization complete healing was rare (<10%), but secondary infection did not influenced major amputation, mortality or serious adverse events. CONCLUSION: Secondary infection reduces the likelihood of successful healing following revascularisation of CLI.

Adductor insertion avulsion syndrome, "thigh splints": relevance of radiological follow-up

We present a case of chronic osteomyelitis in a 13-year-old girl which was originally diagnosed as adductor insertion avulsion syndrome ("thigh splints") on the basis of the clinical presentation, patient history, initial radiographs and MRI examination. However, at follow-up with persistent pain and altered radiographic and MRI appearances, surgical biopsy was indicated. Histopathological findings confirmed a bone abscess. This case underlines the necessity of clinical follow-up and imaging in certain patients with apparent thigh splints.

Disseminated Tuberculosis Following Total Knee Arthroplasty in an HIV Patient

Skeletal tuberculosis is now uncommon in developed countries. In immunocompromised patients - particularly in the HIV-infected - who present with subacute or chronic joint pain refractory to conventional treatment, osteoarticular tuberculosis should still be included in the differential diagnosis. We report on a lethal case of disseminated tuberculosis in an HIV-infected subject. Dissemination may have resulted from the implantation of an articular prosthesis in a knee joint with unsuspected osteoarticular tuberculosis. The diagnosis was established months later when the patient presented with far-advanced tuberculous meningitis, miliary tuberculosis of the lungs, femoral osteomyelitis and extended cold abscesses along the femoral shaft. Failure to respond to a conventional four-drug regimen is explained by the resistance pattern of his multi-drug resistant strain of Mycobacterium tuberculosis, which was only reported after the patient's death. This case illustrates the diagnostic challenges of osteoarticular tuberculosis and the consequences of a diagnostic delay in an HIV-infected individual.

Supramalleolar lateral closing wedge osteotomy for the treatment of varus ankle arthrosis

BACKGROUND: Medial ankle joint pain with localized cartilage degeneration due to medial joint overload in varus malalignment of the hindfoot lends itself to treatment by lateral closing wedge supramalleolar osteotomy. METHODS: From 1998 to 2003, nine patients between the ages of 21 to 59 years were operated. The etiology of the malalignment and degeneration was posttraumatic in eight and childhood osteomyelitis in one. Preoperative and postoperative standing radiographs were analyzed to determine the correction of the deformity and the grade of degeneration. Function and pain were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. The average followup was 56 (range 15 to 88) months. RESULTS: The average time to osseous union was 10 +/- 3.31 weeks. There were no operative or postoperative complications. The average AOFAS score improved from 48 +/- 16.0 preoperatively to 74 +/- 11.7 postoperatively (p<0.004). The average pain subscore improved from 16 +/- 8.8 to 30 +/- 7.1 (p<0.008). The average tibial-ankle surface angle improved from 6.9 +/- 3.8 degrees of varus preoperatively to 0.6 +/- 1.9 degrees of valgus postoperatively (p<0.004). In the sagittal plane, the tibial-lateral-surface angle remained unchanged. At the final followup, two patients showed progression of radiographic ankle arthrosis grades. In one patient, it rose from grade 0 to I. In the other patient it advanced from grade II to III, with subsequent ankle arthrodesis required 16 months after the index procedure. Seven patients returned to their previous work. CONCLUSIONS: Lateral supramalleolar closing wedge osteotomy was an easy and safe procedure, effectively correcting hindfoot malalignment, relieving pain, restoring function, and halting progression of the degeneration in the short-term to mid-term in seven of nine patients.

[Pulmonary nodules in a patient on long-term steroid treatment]

We report on a patient who was chronically treated with steroids. She simultaneously developed pulmonary nocardiosis as well as a soft tissue infection and osteomyelitis by mycobacterium abscessus. Both infections are rare, but more frequently occur in immunocompromised hosts. The patient was healed after 12 month of adequate antibiotic treatment.