Musculoskeletal Infections in the Emergency Department

A Case Report of Hematogenous Osteomyelitis of the Manubrium Caused by Seeding from a Colovesicular Fistula

Introduction

Osteomyelitis can occur at various osseous locations and commonly presents in the emergency department (ED). The incidence of osteomyelitis is 21.8 cases per 100,000 persons annually.1 Hematogenous osteomyelitis typically occurs in the vertebrae; however, it may seldomly occur in the manubrium. Hematogenous osteomyelitis can be seen in patients with complicated thoracic surgery, radiation, fracture, diabetes, immunosuppression, steroid therapy, and malnutrition.2 Because signs and symptoms of osteomyelitis may be nonspecific, clinicians must have high suspicion based on history and physical. Workup should include identifying the source, imaging, and surgical cultures.

Case Report

A 60-year-old male with hypertension and diabetes presented with atraumatic right shoulder and chest pain. The patient presented twice to the ED for clavicle pain five days prior. Computed tomography (CT) of the chest detected osseous infection of the manubrium and upper sternum, right clavicle, and mediastinal phlegmon. A CT of the abdomen and pelvis revealed osteomyelitis and discitis of the 12th thoracic and first lumbar vertebral body with gas at the psoas muscle, as well as sigmoid diverticulitis with colovesicular fistula. The patient was started on broad spectrum antibiotics and 1,500 milliliters of lactated Ringer's in the ED. After evaluation by cardiothoracic surgery, the patient was taken to the operating room for neck exploration, incision/drainage, manubriectomy, and right sternoclavicular joint resection. Surgical, blood, urine, and respiratory cultures grew Klebsiella pneumoniae. After a 34-day hospital course, the patient was discharged on two weeks of oral levofloxacin and follow-up appointments with cardiothoracic surgery and infectious disease. The patient had good prognosis and recovery.

Conclusion

Hematogenous osteomyelitis to the manubrium is rare and may present with only chest pain. It is important to consider other sources that seed in the manubrium and imaging to evaluate multisite infection. Treatment should include intravenous antibiotics and/or surgical intervention for debridement with washout or manubriectomy.

Musculoskeletal infections through direct inoculation

Musculoskeletal infections consist of different clinical conditions that are commonly encountered in daily clinical settings. As clinical findings and even laboratory tests cannot always be specific, imaging plays a crucial role in the diagnosis and treatment of these cases. Musculoskeletal infections most commonly occur secondary to direct inoculation into the skin involuntarily affected by trauma, microorganism, foreign bodies, or in diabetic ulcers; direct infections can also occur from voluntary causes due to surgery, vaccinations, or other iatrogenic procedures. Hematogenous spread of infection from a remote focus can also be a cause for musculoskeletal infections. Risk factors for soft tissue and bone infections include immunosuppression, old age, corticosteroid use, systemic illnesses, malnutrition, obesity, and burns. Most literature discusses musculoskeletal infections according to the diagnostic tools or forms of infection seen in different soft tissue anatomical planes or bones. This review article aims to evaluate musculoskeletal infections that occur due to direct inoculation to the musculoskeletal tissues, by focusing on the traumatic mechanism with emphasis on the radiological findings.

Imaging of MSK infections in the ER

Musculoskeletal infections in the ER are not an uncommon presentation. The clinical context is critical in determining the suspicion for infection and degree of tissue involvement which can involve all layers from the skin to bones. The location, extent, and severity of clinically suspected infection directly relate to the type of imaging performed. Uncomplicated cellulitis typically does not require any imaging. Localized and superficial infections can mostly be evaluated with ultrasound. If there is a diffuse site (an entire extremity) or suspected deeper involvement (muscle/deep fascia), then CT is accurate in diagnosing, widely available, and performed quickly. With potential osseous involvement, MRI is the gold standard for diagnosing acute osteomyelitis; however, it has the drawbacks of longer scan times, artifacts including patient motion, and limited availability.

Spontaneous spinal epidural abscess in an adolescent patient: A case report and literature review

INTRODUCTION

Spinal epidural abscess (SEA), particularly the spontaneous variant, is a severe and rare condition often associated with vertebral osteomyelitis, hematogenous infections, and spinal interventions, leading to severe neurological damage and disabilities. Although more common in adults, spontaneous SEA (SSEA) in adolescents is extremely rare but represents a significant risk, as presented here.

PRESENTATION OF CASE

A 16-year-old boy presented with progressive back pain, uncontrolled fever, and paresthesia in the right lower extremity. Despite the absence of common risk factors, SEA was diagnosed at the L4-L5 level. Laboratory results revealed leukocytosis and elevated levels of inflammatory markers. Magnetic resonance imaging (MRI) confirmed the diagnosis of SEA, and surgery revealed Group A Streptococcus in the abscess. The patient showed significant improvement after laminectomy and a six-week course of intravenous cefazolin.

DISCUSSION

SSEA often presents with nonspecific symptoms, leading to delayed diagnosis and treatment. The gold standard for diagnosis is MRI, and typical treatment involves antibiotic administration and surgical decompression. The importance of maintaining a high index of suspicion for SEA in adolescent patients presenting with back pain and fever, even in the absence of common risk factors or sources, is highlighted.

CONCLUSION

We report the infrequent manifestation of SEA in an adolescent patient, and the difficulties in the diagnosis and treatment thereof. Despite these common risk factors, SEA should be considered as a differential diagnosis in adolescents with back pain and uncontrolled fever. Prompt diagnosis, early surgical intervention, and appropriate antimicrobial therapy are vital to improve patient outcomes and prognosis.

Post-COVID-19 Spondylodiscitis: A Case Study and Review of the Literature

COVID-19 is currently a major health problem, leading to respiratory, cardiovascular and neurological complications, with additional morbidity and mortality. Spinal infections are rare, representing around 1% of all bone infections and comprising less than 2 per 10,000 of all hospitalizations in tertiary care centers. Spondylodiscitis is a complex disease, with challenging diagnosis and management. We report the case of a 45-year-old man, non-smoker hospitalized for severe COVID-19 disease with respiratory failure. Post-COVID-19, in the 8th week after discharge, he was diagnosed by magnetic resonance imaging with spondylodiscitis, but etiology was not confirmed by microbiological investigations. Antibiotics were used, considering the identification of MRSA from cultures of pleural fluid and nasal swab, but surgical intervention was not provided. Clinic, biologic and imagistic were improved, but rehabilitation and long term follow up are necessary. We concluded that spondylodiscitis with spinal abscess is a rare but severe complication post-COVID-19 disease, due to dysbalanced immune response related to the respiratory viral infection, endothelial lesions, hypercoagulation and bacterial superinfection.

Spinal epidural abscess in COVID-19 patients

Objective

To report the peculiarity of spinal epidural abscess in COVID-19 patients, as we have observed an unusually high number of these patients following the outbreak of SARS-Corona Virus-2.

Methods

We reviewed the clinical documentation of six consecutive COVID-19 patients with primary spinal epidural abscess that we surgically managed over a 2-month period. These cases were analyzed for what concerns both the viral infection and the spinal abscess.

Results

The abscesses were primary in all cases indicating that no evident infective source was found. A primary abscess represents the rarest form of spinal epidural abscess, which is usually secondary to invasive procedures or spread from adjacent infective sites, such as spondylodiscitis, generally occurring in patients with diabetes, obesity, cancer, or other chronic diseases.

In all cases, there was mild lymphopenia but the spinal abscess occurred regardless of the severity of the viral disease, immunologic state, or presence of bacteremia. Obesity was the only risk factor and was reported in two patients. All patients but one were hypertensive. The preferred localizations were cervical and thoracic, whereas classic abscess generally occur at the lumbar level. No patient had a history of pyogenic infection, even though previous asymptomatic bacterial contaminations were reported in three cases.

Conclusion

We wonder about the concentration of this uncommon disease in such a short period. To our knowledge, cases of spinal epidural abscess in COVID-19 patients have not been reported to date. We hypothesize that, in our patients, the spinal infection could have depended on the coexistence of an initially asymptomatic bacterial contamination. The well-known COVID-19-related endotheliitis might have created the conditions for retrograde bacterial invasion to the correspondent spinal epidural space.

Furthermore, spinal epidural abscess carries a significantly high morbidity and mortality. It is difficult to diagnose, especially in compromised COVID-19 patients but should be kept in mind as early diagnosis and treatment are crucial.

Roseomonas species infections in humans: a systematic review

Roseomonas species have been recognized to cause infections in immunocompromised individuals. The purpose of this study was to systemically review all published cases of Roseomonas infections in humans and describe the epidemiology, microbiology, antimicrobial susceptibility, treatment and outcomes of these infections in humans. We performed a systematic review of PubMed (through 20th Octrober 2019) for studies providing epidemiological, clinical, microbiological as well as treatment data and outcomes of Roseomonas species infections. A total of 37 studies, containing data of 99 patients, were included in the analysis. The most common Roseomonas infections were those of the bloodstream in 74.7% (74 patients), musculoskeletal infections in 8.1% (8 patients), skin and soft tissue infections (SSTIs) and peritoneal dialysis-associated peritonitis in 6.1% (6 patients) each. Epidemiology of these infections differed, with bacteremias being more prevalent in patients with malignancy and central venous lines, musculoskeletal infections being more prevalent after orthopedic surgery, and SSTIs occurring without any reported underlying cause. Resistance to beta-lactams was very high with penicillin, piperacillin/tazobactam resistance and cephalosporin resistance at 96.6%, 90.7% and 77.8% respectively, while quinolone resistance was 9.1%. Quinolones, carbapenems and cephalosporins are the most common agents used for treatment, irrespectively of the infection site. Overall mortality was 3% (3 patients), with the mortality attributed to Roseomonas being at 1% (1 patient).

Red flags of low back pain

Low back pain is a frequent complaint of patients seeking care at private offices, ambulatory clinics, and EDs. Key signs and symptoms can guide clinicians in differentiating acute and persistent mechanical low back pain from back pain resulting from a specific cause. Awareness of these findings can reduce the number of missed or incorrect diagnoses that lead to poor patient outcomes. The ability to recognize the red flag findings of serious causes of low back pain ensures prompt diagnosis and initiation of appropriate treatment. This article highlights the history and physical examination findings that will improve identification of red flags associated with emergency or serious causes.

Prosthetic joint infections: diagnosis, management, and complications of the two-stage replacement arthroplasty

Despite improved strategies to prevent prosthetic joint infection, as the total number of joint replacements increases, so does the absolute number of infections. Radiography serves as the first-line imaging modality for the assessment of a suspected prosthetic joint infection. Additionally, serial radiographs acquired after a surgery to eradicate a prosthetic joint infection are an important clinical tool. Prosthetic joint infections are often treated with a 2-stage replacement arthroplasty utilizing a prosthesis with antibiotic-loaded acrylic cement. While complications are uncommon with this procedure, imaging may demonstrate periprosthetic fractures, as well as spacer migration, joint dislocation, and spacer fracture. We describe the classification of prosthetic joint infections, the clinical and imaging diagnosis, and treatment strategies. Familiarity with the hardware utilized in the management of the prosthetic joint infection, and its potential complications is fundamental to accurate imaging interpretation.