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Restrepo R, Park HJ, Karakas SP, Cervantes LF, Rodriguez-Ruiz FG, Zahrah AM, Inarejos-Clemente EJ, Laufer M, Shreiber VM. Bacterial osteomyelitis in pediatric patients: a comprehensive review. Skeletal Radiol 2024:10.1007/s00256-024-04639-x. [PMID: 38504031 DOI: 10.1007/s00256-024-04639-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 02/24/2024] [Accepted: 02/27/2024] [Indexed: 03/21/2024]
Abstract
Bacterial osteomyelitis, an inflammatory response in the bone caused by microorganisms, typically affects the metaphysis in the skeletally immature. Bacterial osteomyelitis possesses a significant diagnostic challenge in pediatric patients due to its nonspecific clinical presentation. Because the metaphysis is the primary focus of infection in skeletally immature patients, understanding the normal physiologic, maturation process of bones throughout childhood allows to understand the pathophysiology of osteomyelitis. Timely and accurate diagnosis is crucial to initiate appropriate treatment, and prevent long-term sequelae and efforts must be made to isolate the causative organism. The potential causative organism changes according to the age of the patient and underlying medical conditions. Staphylococcus Aureus is the most common isolated bacteria in pediatric pyogenic osteomyelitis whereas Kingella Kingae is the most common causative agent in children aged 6 months to 4 years. Imaging plays a pivotal role in the diagnosis, characterization, evaluation of complications, and follow up of bacterial osteomyelitis. Imaging also plays a pivotal role in the evaluation of potential neoplastic and non-neoplastic mimickers of osteomyelitis. In children, MRI is currently the gold standard imaging modality when suspecting bacterial osteomyelitis, whereas surgical intervention may be required in order to isolate the microorganism, treat complications, and exclude mimickers.
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Affiliation(s)
- Ricardo Restrepo
- Radiology Department, Nicklaus Children's Hospital, 3100 SW 62nd Ave, Miami, FL, 33155, USA.
| | - Halley J Park
- Radiology Department, Nicklaus Children's Hospital, 3100 SW 62nd Ave, Miami, FL, 33155, USA
| | - S Pinar Karakas
- Radiology Department, Nicklaus Children's Hospital, 3100 SW 62nd Ave, Miami, FL, 33155, USA
| | - Luisa F Cervantes
- Radiology Department, Nicklaus Children's Hospital, 3100 SW 62nd Ave, Miami, FL, 33155, USA
| | | | - Anna Maria Zahrah
- Krieger School of Arts and Sciences, Johns Hopkins University, Baltimore, MD, USA
| | | | - Marcelo Laufer
- Infectious Disease Department, Nicklaus Children's Hospital, Miami, USA
| | - Verena M Shreiber
- Orthopedic, Sports Medicine, and Spine Institute, Nicklaus Children's Hospital, Miami, USA
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Weber MA, Bazzocchi A, Nöbauer-Huhmann IM. Tumors of the Spine: When Can Biopsy Be Avoided? Semin Musculoskelet Radiol 2022; 26:453-468. [PMID: 36103887 DOI: 10.1055/s-0042-1753506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Regarding osseous tumors of the spine, characteristic morphology is encountered in hemangioma of the vertebral body, osteoid osteoma (OO), osteochondroma, Paget's disease, and bone islands. In these cases, radiologic imaging can make a specific diagnosis and thereby avoid biopsy, especially when the radiologist has chosen the correct imaging modality to establish the diagnosis, such as thin-slice computed tomography in suspected OO. A benign lesion is suggested by a high amount of fat within the lesion, the lack of uptake of the contrast agent, and a homogeneous aspect without solid parts in a cystic tumor. Suspicion of malignancy should be raised in spinal lesions with a heterogeneous disordered matrix, distinct signal decrease in T1-weighted magnetic resonance imaging, blurred border, perilesional edema, cortex erosion, and a large soft tissue component. Biopsy is mandatory in presumed malignancy, such as any Lodwick grade II or III osteolytic lesion in the vertebral column. The radiologist plays a crucial role in determining the clinical pathway by choosing the imaging approach wisely, by narrowing the differential diagnosis list, and, when characteristic morphology is encountered, by avoiding unnecessary biopsies.
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Affiliation(s)
- Marc-André Weber
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Center Rostock, Rostock, Germany
| | - Alberto Bazzocchi
- Diagnostic and Interventional Radiology, The Rizzoli Orthopedic Institute, Bologna, Italy
| | - Iris-M Nöbauer-Huhmann
- Department of Biomedical Imaging and Image Guided Therapy, Division of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna, Vienna, Austria
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Opara NU. Osteomyelitis infection disguised as Reiter's syndrome in a child: A case report. Clin Case Rep 2021; 9:e05219. [PMID: 34963806 PMCID: PMC8677886 DOI: 10.1002/ccr3.5219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/04/2021] [Indexed: 11/29/2022] Open
Abstract
Reiter's syndrome (reactive arthritis) should always prompt a thorough clinical investigation of a potentially more serious disease condition in every pediatric patient and adults. It should always be regarded as a warning sign and not a disease. This is a case of a 16-year-old African boy with osteomyelitis presenting with symptoms of reactive arthritis (Reiter's syndrome).
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Affiliation(s)
- Nnennaya U. Opara
- Department of Emergency MedicineCharleston Area Medical CenterCharlestonWest VirginiaUSA
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Marton N, Ramos-Oliver I, Cajal AG, de Albert M, Dominguez Oronoz R. Transarticular epithelioid hemangioma of the ankle-a case of a rare vascular neoplasm. Skeletal Radiol 2021; 50:1263-1270. [PMID: 33420574 DOI: 10.1007/s00256-020-03687-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 11/24/2020] [Accepted: 11/29/2020] [Indexed: 02/02/2023]
Abstract
Epithelioid hemangioma of the bone is a rare kind of vascular neoplasm posing a diagnostic challenge because of its ability to mimic malignant tumors. We report a case of a fast-growing, talofibular joint-involving epithelioid hemangioma, which was suspectedly initiated by vascular damage due to trauma and arthroscopy. The ankle mass appeared as a lytic lesion on the CT images and as a T1 hypo-, T2 mildly hyperintense, lobulated structure on the MRI scans. The contrast enhancement pattern was typical to vascular neoplasms. Histologically the lesion consisted of well-formed vessels lined with epithelioid cells with a slightly atypical nuclear morphology, inflammation with a significant number of eosinophils, and low mitotic rate. Immunohistochemistry analysis showed the presence of vascular markers but no rearrangements characteristic of soft tissue sarcomas were registered by the next-generation sequencing. The surgical treatment was curative. The report presents current imaging methods and summarizes the imaging findings of transarticular spreading tumors. The paper also highlights that for the differential diagnosis of vascular tumors showing signs of aggressivity, the pathological analysis is inevitable. Correct diagnosis of the epithelioid hemangioma is essential, as the treatment of more malignant entities is substantially different. An added value of the report is that to the best of our knowledge, a transarticular spreading epithelioid hemangioma of the ankle has never been described before.
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Affiliation(s)
- Nikolett Marton
- Department of Radiology, Jahn Ferenc Hospital, 1 Koves ut, Budapest, H-1204, Hungary. .,Experimental Rheumatology Research Group, Semmelweis University, Budapest, Hungary.
| | | | | | - Matías de Albert
- Department of Radiology, Vall d'Hebron Hospital, Barcelona, Spain
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Li GQ, Wang YK, Zhou H, Jin LG, Wang CY, Albahde M, Wu Y, Li HY, Zhang WK, Li BH, Ye ZM. Application of Immune Infiltration Signature and Machine Learning Model in the Differential Diagnosis and Prognosis of Bone-Related Malignancies. Front Cell Dev Biol 2021; 9:630355. [PMID: 33937231 PMCID: PMC8082117 DOI: 10.3389/fcell.2021.630355] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 03/15/2021] [Indexed: 01/16/2023] Open
Abstract
Bone-related malignancies, such as osteosarcoma, Ewing's sarcoma, multiple myeloma, and cancer bone metastases have similar histological context, but they are distinct in origin and biological behavior. We hypothesize that a distinct immune infiltrative microenvironment exists in these four most common malignant bone-associated tumors and can be used for tumor diagnosis and patient prognosis. After sample cleaning, data integration, and batch effect removal, we used 22 publicly available datasets to draw out the tumor immune microenvironment using the ssGSEA algorithm. The diagnostic model was developed using the random forest. Further statistical analysis of the immune microenvironment and clinical data of patients with osteosarcoma and Ewing's sarcoma was carried out. The results suggested significant differences in the microenvironment of bone-related tumors, and the diagnostic accuracy of the model was higher than 97%. Also, high infiltration of multiple immune cells in Ewing's sarcoma was suggestive of poor patient prognosis. Meanwhile, increased infiltration of macrophages and B cells suggested a better prognosis for patients with osteosarcoma, and effector memory CD8 T cells and type 2 T helper cells correlated with patients' chemotherapy responsiveness and tumor metastasis. Our study revealed that the random forest diagnostic model based on immune infiltration can accurately perform the differential diagnosis of bone-related malignancies. The immune microenvironment of osteosarcoma and Ewing's sarcoma has an important impact on patient prognosis. Suppressing the highly inflammatory environment of Ewing's sarcoma and promoting macrophage and B cell infiltration may have good potential to be a novel adjuvant treatment option for osteosarcoma and Ewing's sarcoma.
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Affiliation(s)
- Guo-Qi Li
- Department of Orthopedics, Musculoskeletal Tumor Center, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Orthopedics Research Institute of Zhejiang University, Hangzhou, China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Yi-Kai Wang
- Department of Orthopedics, Musculoskeletal Tumor Center, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Orthopedics Research Institute of Zhejiang University, Hangzhou, China
| | - Hao Zhou
- Department of Orthopedics, Musculoskeletal Tumor Center, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Orthopedics Research Institute of Zhejiang University, Hangzhou, China
| | - Lin-Guang Jin
- Department of Orthopedics, Musculoskeletal Tumor Center, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Orthopedics Research Institute of Zhejiang University, Hangzhou, China
| | - Chun-Yu Wang
- Department of Orthopedics, Musculoskeletal Tumor Center, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Orthopedics Research Institute of Zhejiang University, Hangzhou, China
| | - Mugahed Albahde
- Department of Hepatobiliary and Pancreatic Surgery, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Yan Wu
- Department of Orthopedics, Musculoskeletal Tumor Center, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Orthopedics Research Institute of Zhejiang University, Hangzhou, China
| | - Heng-Yuan Li
- Department of Orthopedics, Musculoskeletal Tumor Center, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Orthopedics Research Institute of Zhejiang University, Hangzhou, China
| | - Wen-Kan Zhang
- Department of Orthopedics, Musculoskeletal Tumor Center, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Orthopedics Research Institute of Zhejiang University, Hangzhou, China
| | - Bing-Hao Li
- Department of Orthopedics, Musculoskeletal Tumor Center, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Orthopedics Research Institute of Zhejiang University, Hangzhou, China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
| | - Zhao-Ming Ye
- Department of Orthopedics, Musculoskeletal Tumor Center, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Orthopedics Research Institute of Zhejiang University, Hangzhou, China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
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Abstract
The treatment of musculoskeletal neoplasms and infection is usually based on an initial diagnostic biopsy. Prior to biopsy, a hypothesis should be formed about the most likely diagnosis and a differential diagnosis. These deliberations should consider whether the lesion is a primary benign or malignant tumour, a metastasis, a haematological problem or an infection. A tactical plan should be developed which evaluates the necessity, the risk, the approach and finally defines the technique of biopsy most likely to achieve a representative result in the clinical case. In developing this technical approach, the pitfalls should be anticipated, i.e. inadequate sampling, difficulty of pathological interpretation and contamination. The tactical approach should be developed in conjunction with a multi-disciplinary team together with appropriate pre-biopsy imaging.
Cite this article: EFORT Open Rev 2017;2:51–57. DOI: 10.1302/2058-5241.2.160065
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Affiliation(s)
- G Ulrich Exner
- Orthopaedie Zentrum Zuerich (ozz), Seestrasse 259, CH 8038 Zurich, Switzerland
| | - Michael O Kurrer
- Gemeinschaftspraxis fuer Pathologie, Caecilienstrasse 3, CH 8032 Zurich, Switzerland
| | - Nadja Mamisch-Saupe
- Klinik Hirslanden, Department of Musculoskeletal Radiology, Witellikerstrasse 40, 8032 Zurich, Switzerland
| | - Stephen R Cannon
- BMI The Clementine Churchill Hospital, Sudbury Hill, Harrow, Middlesex HA1 3RX, Great Britain
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McCarville MB, Chen JY, Coleman JL, Li Y, Li X, Adderson EE, Neel MD, Gold RE, Kaufman RA. Distinguishing Osteomyelitis From Ewing Sarcoma on Radiography and MRI. AJR Am J Roentgenol 2015; 205:640-50; quiz 651. [PMID: 26295653 PMCID: PMC5744678 DOI: 10.2214/ajr.15.14341] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The purpose of this study was to determine whether clinical and imaging features can distinguish osteomyelitis from Ewing sarcoma (EWS) and to assess the accuracy of percutaneous biopsy versus open biopsy in the diagnosis of these diseases. MATERIALS AND METHODS Three radiologists reviewed the radiographs and MRI examinations of 32 subjects with osteomyelitis and 31 subjects with EWS to determine the presence of 36 imaging parameters. Information on demographic characteristics, history, physical examination findings, laboratory findings, biopsy type, and biopsy results were recorded. Individual imaging and clinical parameters and combinations of these parameters were tested for correlation with findings from histologic analysis. The diagnostic accuracy of biopsy was also determined. RESULTS On radiography, the presence of joint or metaphyseal involvement, a wide transition zone, a Codman triangle, a periosteal reaction, or a soft-tissue mass, when tested individually, was more likely to be noted in subjects with EWS (p ≤ 0.05) than in subjects with osteomyelitis. On MRI, permeative cortical involvement and soft-tissue mass were more likely in subjects with EWS (p ≤ 0.02), whereas a serpiginous tract was more likely to be seen in subjects with osteomyelitis (p = 0.04). African Americans were more likely to have osteomyelitis than EWS (p = 0). According to the results of multiple regression analysis, only ethnicity and soft-tissue mass remained statistically significant (p ≤ 0.01). The findings from 100% of open biopsies (18/18) and 58% of percutaneous biopsies (7/12) resulted in the diagnosis of osteomyelitis, whereas the findings from 88% of open biopsies (22/25) and 50% of percutaneous biopsies (3/6) resulted in a diagnosis of EWS. CONCLUSION Several imaging features are significantly associated with either EWS or osteomyelitis, but many features are associated with both diseases. Other than ethnicity, no clinical feature improved diagnostic accuracy. Compared with percutaneous biopsy, open biopsy provides a higher diagnostic yield but may be inconclusive, especially for cases of EWS. Our findings underscore the need for better methods of diagnosing these disease processes.
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Affiliation(s)
- M Beth McCarville
- 1 Department of Radiological Sciences (MS220), Division of Diagnostic Imaging, St. Jude Children's Research Hospital, 262 Danny Thomas Pl, Memphis, TN 38105
- 2 Department of Radiology, University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Jim Y Chen
- 3 Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | - Jamie L Coleman
- 1 Department of Radiological Sciences (MS220), Division of Diagnostic Imaging, St. Jude Children's Research Hospital, 262 Danny Thomas Pl, Memphis, TN 38105
| | - Yimei Li
- 4 Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN
| | - Xingyu Li
- 4 Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN
| | - Elisabeth E Adderson
- 5 Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN
- 6 Department of Pediatrics, University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Mike D Neel
- 7 Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN
| | - Robert E Gold
- 1 Department of Radiological Sciences (MS220), Division of Diagnostic Imaging, St. Jude Children's Research Hospital, 262 Danny Thomas Pl, Memphis, TN 38105
- 2 Department of Radiology, University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Robert A Kaufman
- 1 Department of Radiological Sciences (MS220), Division of Diagnostic Imaging, St. Jude Children's Research Hospital, 262 Danny Thomas Pl, Memphis, TN 38105
- 2 Department of Radiology, University of Tennessee Health Science Center College of Medicine, Memphis, TN
- 6 Department of Pediatrics, University of Tennessee Health Science Center College of Medicine, Memphis, TN
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Solmaz D, Onen F, Balci A, Akar S. Pelvic Ewing sarcoma mimicking sacroiliitis. ACTA ACUST UNITED AC 2012; 65:290. [DOI: 10.1002/art.37710] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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10
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Bloem JL, Reidsma II. Bone and soft tissue tumors of hip and pelvis. Eur J Radiol 2011; 81:3793-801. [PMID: 21524868 DOI: 10.1016/j.ejrad.2011.03.101] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Accepted: 03/22/2011] [Indexed: 10/18/2022]
Abstract
Objective is to identify epidemiologic and radiologic criteria allowing specific diagnoses of tumors and tumor-like lesions in the hip region and pelvis, and to optimize pre-operative staging. Patients with pelvic tumors are usually older, and their tumors are larger relative to patients with tumors in extremities. The majority of tumors in the pelvis are malignant (metastases, myeloma, chondrosarcoma, Ewing-, osteo-, and MFH/fibrosarcoma), while those in the proximal femur are in majority benign (fibrous dysplasia, solitary bone cyst, and osteoid osteoma). Soft tissue masses in the thigh in the elderly are typically sarcomas without tumor specific signs. Common tumor-like lesions occurring in the hip and pelvis that can mimic neoplasm are: infections (including tuberculosis), insufficiency/avulsion fractures, cysts, fibrous dysplasia, aneurysmal bone cyst, Langerhans cell histiocytosis, and Paget's disease. Local MR staging is based on the compartmental anatomy. The psoas and gluteal muscles are easily invaded by sarcoma originating in the ileum. The pectineus muscle protects the neurovascular bundle at the level of the hip. The thigh is separated into three compartments, some structures (Sartorius muscle) cross borders between compartments. Immobile joints (SI-joints, osteoarthritic hip) are relatively easily crossed by sarcoma and giant cell tumor.
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Affiliation(s)
- Johan L Bloem
- Leiden University Medical Center, Department of Radiology, PO Box 9600, 2300 RC Leiden, The Netherlands.
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