Osteomyelitis in children

A Case of Hematogenous Osteomyelitis in a 5-Week-Old Male

Pediatric osteomyelitis is a rare diagnosis associated with devastating consequences when treatment is delayed. We report a case of hematogenous osteomyelitis in a 5-week-old male presenting to the emergency department (ED) with a flaccid right upper extremity. In the ED, the patient was evaluated with comprehensive infectious and trauma workups. Initial CT imaging of the head and X-ray imaging of the extremity were unremarkable. C-reactive protein was elevated at 0.8; all other laboratory markers were within normal range. Over the course of the ED evaluation, the extremity weakness spontaneously resolved; however, the infant developed a fever of 100.5 F. Empiric broad spectrum antibiotics were initiated, and the infant was admitted to the pediatric service. At 48 hours following presentation, cultures resulted positive for Staphylococcus aureus and MRI imaging revealed osteomyelitis of the proximal right humeral metadiaphysis. Given the subtle presentation of early hematogenous osteomyelitis, emergency providers should maintain a high index of suspicion for infection as the underlying cause in infants presenting with a flaccid extremity.

Osteomyelitis of the Rib in a Child With Indolent Symptoms

We describe a case of osteomyelitis of the rib caused by methicillin-susceptible Staphylococcus aureus. The patient presented with a subtle, indolent course leading to a suspected 2-year delay in diagnosis. This case highlights that the diagnosis of rib osteomyelitis, which can readily mimic other diagnoses, such as costochondritis, intraabdominal infections, pneumonia, or malignancies warrants a high index of suspicion. Albeit rare, pediatricians should be aware of the possibility of rib osteomyelitis in healthy children to help ensure a prompt diagnosis and appropriate, timely management.

Osteomyelitis in Immunocompromised children and neonates, a case series

BACKGROUND

Osteomyelitis in immunocompromised children can present differently from immunocompetent children and can cause devastating sequelae if treated inadequately. We aim to review the aetiology, clinical profile, treatment and outcomes of immunocompromised children with osteomyelitis.

METHODS

Retrospective review of all immunocompromised children aged < 16 years and neonates admitted with osteomyelitis in our hospital between January 2000 and January 2017, and referred to the Paediatric Infectious Disease Service.

RESULTS

Fourteen patients were identified. There were 10 boys (71%), and the median age at admission was 70.5 months (inter-quartile range: 12.3-135.0 months). Causal organisms included, two were Staphylococcus aureus, two were Mycobacterium bovis (BCG), and one each was Mycobacterium tuberculosis, Pseudomonas aeruginosa, Stenotrophomonas maltophilia, Burkholderia pseudomallei and Rhizopus sp. One patient had both Clostridium tertium and Clostridium difficile isolated. Treatment involved appropriate antimicrobials for a duration ranging from 6 weeks to 1 year, and surgery in 11 patients (79%). Wherever possible, the patients received treatment for their underlying immunodeficiency. For outcomes, only three patients (21%) recovered completely. Five patients (36%) had poor bone growth, one patient had recurrent discharge from the bone and one patient had palliative care for underlying osteosarcoma.

CONCLUSIONS

Although uncommon, osteomyelitis in immunocompromised children and neonates can be caused by unusual pathogens, and can occur with devastating effects. Treatment involves prolonged administration of antibiotics and surgery. Immune recovery also seems to be an important factor in bone healing.

Bone and Joint Infections: The Role of Imaging in Tailoring Diagnosis to Improve Patients' Care

Imaging is needed for the diagnosis of bone and joint infections, determining the severity and extent of disease, planning biopsy, and monitoring the response to treatment. Some radiological features are pathognomonic of bone and joint infections for each modality used. However, imaging diagnosis of these infections is challenging because of several overlaps with non-infectious etiologies. Interventional radiology is generally needed to verify the diagnosis and to identify the microorganism involved in the infectious process through imaging-guided biopsy. This narrative review aims to summarize the radiological features of the commonest orthopedic infections, the indications and the limits of different modalities in the diagnostic strategy as well as to outline recent findings that may facilitate diagnosis.

Late Deep Infections Complicating Percutaneous Pinning of Supracondylar Humerus Fractures

Objectives

Complications following treatment of supracondylar humerus fractures are typically seen shortly postoperatively. Late complications occurring years after percutaneous pinning are rare but can be indolent and have permanent sequelae. We present cases of children presenting with late deep infections to discuss their diagnosis and treatment.

Methods

After institutional review board approval, we retrospectively reviewed records of three children who developed deep infections at least one year after percutaneous pinning of their supracondylar humerus fracture. Patient details and outcomes were analyzed. Radiographs and magnetic resonance imaging were reviewed along with each patient's clinical course and treatment.

Results

We report 3 cases of osteomyelitis and/or septic arthritis presenting at least one year after supracondylar humerus fractures treated with closed reduction and percutaneous pinning. The patients required several irrigation and debridement procedures with placement of antibiotic beads in addition to a prolonged course of antibiotics.

Conclusion

Delayed deep infections can occur after closed reduction and percutaneous pinning of supracondylar humerus fractures in children. Vigilance is required to diagnose and treat such occurrences, and prolonged follow-up is needed to monitor for recurrent or intractable infections.

Clinical Practice Guideline by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America: 2021 Guideline on Diagnosis and Management of Acute Hematogenous Osteomyelitis in Pediatrics

This clinical practice guideline for the diagnosis and treatment of acute hematogenous osteomyelitis (AHO) in children was developed by a multidisciplinary panel representing Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA). This guideline is intended for use by healthcare professionals who care for children with AHO, including specialists in pediatric infectious diseases, orthopedics, emergency care physicians, hospitalists, and any clinicians and healthcare providers caring for these patients. The panel's recommendations for the diagnosis and treatment of AHO are based upon evidence derived from topic-specific systematic literature reviews. Summarized below are the recommendations for the diagnosis and treatment of AHO in children. The panel followed a systematic process used in the development of other IDSA and PIDS clinical practice guidelines, which included a standardized methodology for rating the certainty of the evidence and strength of recommendation using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. A detailed description of background, methods, evidence summary and rationale that support each recommendation, and knowledge gaps can be found online in the full text.

[Acute osteomyelitis caused by community-acquired methicillin-resistant Staphylococcus aureus in children: about 15 cases]

La prise en charge de l´ostéomyélite aiguë devient plus délicate depuis l´émergence du Staphylocoque aureus résistant à la méthicilline d´origine communautaire. Nous avons recueilli les cas d´ostéomyélite aiguë dues à ce germe sur une période de 21 ans (Janvier 1995-Décembre 2016) et nous avons essayé d´analyser les particularités de cette entité pathologique. Notre série comporte 15 enfants, d´âge moyen 9 ans. Le membre inférieur était atteint dans tous les cas. Une notion de traumatisme local a été signalée dans 8 cas et une porte d´entrée cutanée a été trouvée dans 4 cas. Le mode de début était aigu dans 12 cas avec un tableau de pseudo-paralysie du membre atteint. Une staphylococcie pulmonaire avec des signes septico-pyohémiques ont été notés dans un cas. L´hémoculture était positive dans 8 cas. La recherche par PCR de la leucocidine de Panton et Valentine était pratiquée dans 1 cas avec un résultat positif. Tous ces patients ont eu un débridement chirurgical et une antibiothérapie empirique secondairement adaptée. L´évolution était bonne dans 8 cas et mauvaise dans les autres cas avec passage à la chronicité dans 6 cas et un cas de décès. Une fracture pathologique a été signalée dans 3 cas. La survenue d´une ostéomyélite à Staphylocoque aureus résistant à la méthicilline d´origine communautaire est péjorative. Connaitre ces infections en se basant sur des arguments cliniques et paracliniques est un enjeu important pour une prise en charge thérapeutique spécifique et rapide.

Italian consensus on the therapeutic management of uncomplicated acute hematogenous osteomyelitis in children

BACKGROUND

Acute hematogenous osteomyelitis (AHOM) is an insidious infection of the bone that more frequently affects young males. The etiology, mainly bacterial, is often related to the patient's age, but it is frequently missed, owing to the low sensitivity of microbiological cultures. Thus, the evaluation of inflammatory biomarkers and imaging usually guide the diagnosis and follow-up of the infection. The antibiotic treatment of uncomplicated AHOM, on the other hand, heavily relies upon the clinician experience, given the current lack of national guidelines for the management of this infection.

METHODS

A systematic review of the studies on the empirical treatment of uncomplicated AHOM in children published in English or Italian between January 1, 2009, and March 31, 2020, indexed on Pubmed or Embase search engines, was carried out. All guidelines and studies reporting on non-bacterial or complicated or post-traumatic osteomyelitis affecting newborns or children older than 18 years or with comorbidities were excluded from the review. All other works were included in this study.

RESULTS

Out of 4576 articles, 53 were included in the study. Data on different topics was gathered and outlined: bone penetration of antibiotics; choice of intravenous antibiotic therapy according to the isolated or suspected pathogen; choice of oral antibiotic therapy; length of treatment and switch to oral therapy; surgical treatment.

CONCLUSIONS

The therapeutic management of osteomyelitis is still object of controversy. This study reports the first Italian consensus on the management of uncomplicated AHOM in children of pediatric osteomyelitis, based on expert opinions and a vast literature review.

Utility of Inflammatory Markers in Hospitalized Children With Skin Erythema

BACKGROUND

There is overlap in the clinical presentations of superficial skin infections (eg, cellulitis) and deeper infections (eg, osteomyelitis). Inflammatory markers are frequently obtained in hospitalized patients with cellulitis. However, it is unknown whether inflammatory markers discriminate between superficial and deeper infections.

METHODS

We performed a retrospective review of children hospitalized with erythema on the skin and diagnoses of cellulitis, bursitis, myositis, osteomyelitis, and/or tenosynovitis. Patients were grouped into superficial infection (cellulitis and bursitis) and deeper infection (myositis, tenosynovitis, osteomyelitis). We compared C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) values between the two groups and constructed receiver operating characteristic curves to determine optimal cutoff values.

RESULTS

Among 168 children hospitalized with skin erythema, 122 patients had superficial and 46 patients had deeper infections. Mean CRP and ESR were significantly higher in patients with deeper infections (CRP: 8.3 [±9.6] mg/dL versus 2.8 [±3.5] mg/dL; P < .001; ESR: 48.3 [±28.6] mm/h versus 21.8 [±16.0] mm/h; P < .001). Neither WBC nor fever was significantly different between groups. CRP ≥2 mg/dL and ESR ≥30 mm/h were associated with deeper infections (CRP: odds ratio: 4.77; 95% confidence interval: 2.24-10.15; ESR: odds ratio: 7.93; 95% confidence interval: 3.46-17.67). When CRP and ESR were below these cutoffs, the negative predictive value was 89%.

CONCLUSIONS

Among patients presenting with skin erythema, CRP ≥2 mg/dL and ESR ≥30 mm/hr were significantly associated with deeper infection, whereas values below these cutoffs were reassuring against deeper infection. Future study of inflammatory markers in skin and soft tissue infections may help develop tailored testing strategies.

Adolescent with osteomyelitis after intramuscular administration of a vaccine: A case report

OBJECTIVE

To emphasize adverse outcomes associated with applying adult immunization protocols to the pediatric population.

CASE SUMMARY

A 15-year-old female with no past medical history developed severe pain in her left arm and decreased range of motion 11 days after receiving an intramuscular injection of the human papillomavirus vaccine. Over the following month, she was treated with a short course of steroids for frozen shoulder and gabapentin for Parsonage-Turner syndrome. During the third visit to a specialist for severe pain and loss of left arm mobility, she was sent to the emergency department for further workup. An x-ray and magnetic resonance imaging of the left arm were suspicious for osteomyelitis. The diagnosis was confirmed by incision and drainage of the abscess and a bone biopsy. A 6-week course of antibiotic therapy was initiated after the biopsy results. The injury was attributed to overpenetration by the needle during the intramuscular injection she had received in the previous month.

PRACTICE IMPLICATIONS

As the number of states allowing pharmacists to vaccinate patients of all ages grows, pharmacists must be prepared to safely provide vaccinations to patients of varying sizes. Assessing body habitus while balancing the constant responsibilities of a community pharmacy will be a challenge. Introduction of a guidance document with specific needle lengths based on weight, age, and sex can address potential errors before they occur.

Chronic Osteomyelitis Caused by Haemophilus parainfluenzae: A Case Report

CASE

A 14-year-old boy presented with a pathologic fracture of the distal aspect of the tibia and a remote history of a dog bite near the injury site. Imaging studies, biopsy, and presentation corroborated the diagnosis of chronic osteomyelitis. Multiple diagnostic methods were negative until an open biopsy identified Haemophilus parainfluenzae, a fastidious oropharyngeal bacterium, with polymerase chain reaction analysis. The patient underwent extensive debridement, placement of external fixation, and a year-long antibiotic therapy regimen. He subsequently required a tibial-fibular osteotomy at a second site with placement of an intramedullary nail for correction of a leg-length discrepancy.

CONCLUSION

This case report illustrates the complex management of chronic osteomyelitis in pediatric patients, its sequelae, and the importance of considering treatment of atypical pathogens.

Point-of-Care Ultrasound in a Child with Chest Wall Pain and Rib Osteomyelitis

BACKGROUND

Diagnosis of acute osteomyelitis in young children can be challenging due to the lack of specific clinical signs and symptoms. Prompt diagnosis and treatment is essential to prevent complications and to improve long-term prognosis and reduce the need for operative intervention. Point-of-care ultrasound (POCUS) may be a useful tool to detect early changes associated with osteomyelitis.

CASE REPORT

A 26-month-old boy presented with 6 days of fever and 3 days of focal pain over the right anterior lower ribs without swelling, erythema, or bony deformity, and negative chest x-ray study. A POCUS was performed by the ultrasound fellows and revealed deep soft tissue swelling, periosteal elevation, and increased vascular flow with color Doppler. The patient was admitted to the pediatric service with infectious disease consultation and started on antibiotics. Magnetic resonance imaging confirmed the diagnosis of a right seventh anterior rib osteomyelitis, and the patient subsequently improved and was discharged home. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In this case, the use of POCUS in the emergency department heightened the suspicion for acute osteomyelitis in a rare location and guided early diagnosis and treatment.

RIB OSTEOMYELITIS: A RARE COMPLICATION OF VARICELLA

Objective:

To report a case of varicella complicated by acute osteomyelitis in order to remind of a rare and potentially serious complication of a very common pediatric disease.

Case description:

A previously healthy 3-month-old female infant with 10-day history of varicella was admitted to the hospital for fever, groan and prostration. The initial laboratorial evaluation was compatible with bacterial sepsis. By the third day after admission, a swelling of the seventh left rib had developed. The ultrasound and scintigraphy evaluation suggested rib osteomyelitis. Blood cultures were negative. The patient completed six weeks of antibiotics with favorable clinical, laboratorial and imaging evolution.

Comments:

Varicella is one of the most frequent exanthematic diseases of childhood and it is usually self-limited. The most frequent complication is bacterial infection of cutaneous lesions. Osteoarticular complications are rare, and rib osteomyelitis is described in less than 1% of cases. The main route of dissemination is hematogenic, and the most frequent etiological agent is Staphylococcus aureus. The prognosis is generally good and depends on early detection and antibiotic initiation.

Current Approach to the Evaluation and Management of Septic Arthritis

Septic arthritis is an emergent condition caused by bacterial infection of a joint space. The most common etiology is hematogenous spread from bacteremia, but it can also occur from direct inoculation from bites, injection injuries, cellulitis, abscesses, or local trauma. Septic arthritis occurs most frequently in the lower extremities, with the hips and knees serving as the most common locations. The most sensitive findings include pain with motion of the joint, limited range of motion, tenderness of the joint, new joint swelling, and new effusion. Laboratory testing and imaging can support the diagnosis, but the criterion standard is diagnostic arthrocentesis. Treatment involves intravenous antibiotics and joint decompression.

Osteomyelitis of flat bones: A report of 20 cases and review of the literature

OBJECTIVE

Osteomyelitis is frequently localized on the fertile metaphysis of long bones. However, there are other locations such as short or flat bones. The aim of our study was to determine the diagnostic, therapeutic and evolutionary aspects of osteomyelitis of flat bones in our environment.

METHODS

It's was a retrospective study conducted from January 2013 to December 2017; Children from 0 to 16 years admitted for osteomyelitis of a flat bone where included.

RESULTS

We followed 19 patients who presented 20 locations of osteomyelitis on a flat bone. They accounted for 9.1% of all osteomyelitis observed during the study period. The average age was 6.7 years (9 months-14 years). The clinical picture most often associated with fever and local inflammatory swelling related to an abscess. The predominant locations were the sternum with 8 cases and the scapula with 4 cases. Eleven patients were homozygous sickle cell patients. The diagnosis was strengthened with standard radiography in the majority of cases. A micro-organism was isolated in 8 cases (40%) and Staphylococcus aureus was the predominant germ in 7 cases. Nearly all patients were treated with surgical drainage of the abscess, bone curettage and antibiotics. A typical radiographical evolution has been observed with bone reconstruction in 15 cases with a mean follow-up of 3.3 years.

CONCLUSION

Flat bones are relatively rare locations of osteomyelitis. Standard radiography remains the first-line examination. Their treatment obeys the same rules as that of osteomyelitis of long bones. There is a successful outcome when the care is early and adequate.

Late recurrence of an osteoarticular infection caused by Klebsiella pneumoniae in a child

Klebsiella pneumoniae is an opportunistic pathogen in neonates. A 23-day-old newborn developed septic arthritis of the right hip due to an ESBL-producing strain. A recurrence on the knee was observed at 4 years of age. A molecular investigation confirmed the clonal link of the strains responsible for the two infections and allowed us to identify virulence factors.

Managing pulmonary embolism secondary to suppurative deep vein thrombophlebitis due to community-acquired Staphylococcus aureus in a resource-poor setting

Deep vein thrombosis and pulmonary thromboembolism are rare and life threatening emergencies in children. We report an 11-year old female who presented with acute complaints of high grade fever, pain in the left thigh and inability to walk and breathlessness since 6 days. On physical examination, there was a diffuse tender swelling of the left thigh, tachypnea, tachycardia with hyperdynamic precordium and bilateral basal crepitations. Ultrasonography and venous doppler of lower limbs showed mild effusion of left hip joint and thrombus in the left common femoral vein and left external iliac vein suggesting a diagnosis of septic arthritis with thrombophlebitis. The tachypnea and tachycardia which was out of proportion to fever and crepitations on auscultation prompted suspicion of an embolic phenomenon. Radiograph of the chest revealed multiple wedge shaped opacities in the right middle zone and lower zone suggestive of pulmonary embolism and left lower zone consolidation. For corroboration, computed tomography pulmonary angiography and computed tomography of abdomen was performed which showed pulmonary thromboembolism and deep venous thrombosis extending up to infrarenal inferior vena cava. On further workup, magnetic resonance imaging of hips showed left femoral osteomyelitis and multiple intramuscular abscesses in the muscles around the hip joint. Blood culture grew methicillin resistant Staphylococcus aureus. Antibiotics were changed according to culture sensitivity and there was a dramatic response. After four weeks of anticoagulation and antibiotics the child became asymptomatic and thrombus resolved. Thus, it is crucial to consider methicillin resistant Staphylococcus aureus infection as an important infection when we encounter such a clinical scenario. This case report highlights an unusual and potentially life threatening presentation of a virulent strain of a common pathogen, which when diagnosed was completely amenable to treatment.

Septic Arthritis, Osteomyelitis, and Pyomyositis in a Previously Healthy Infant

Septic arthritis of the shoulder is rare in the pediatric population. In younger children and infants, it can be very difficult to diagnose. Septic arthritis of the shoulder is more commonly associated with concurrent osteomyelitis when compared to septic arthritis of the lower extremity. We describe a case of a 9-month-old patient with septic arthritis, osteomyelitis, and pyomyositis of the shoulder, and a discussion of diagnosis and management of pediatric bone and joint infection in the emergency department setting.

[Chronic recurrent multifocal osteomyelitis of the spine : Children and adolescent]

Chronic non-bacterial osteomyelitis (CNO) in childhood and adolescence is a non-infectious autoinflammatory disease of the bone with partial involvement of adjacent joints and soft tissue. The etiology is unknown. The disease can occur singular or recurrent. Individual bones can be affected and multiple lesions can occur. Chronic recurrent multifocal osteomyelitis (CRMO) shows the whole picture of CNO. Accompanying but temporally independent of the bouts of osteomyelitis, some patients show manifestations in the skin, eyes, lungs and the gastrointestinal tract. The article gives an overview of the clinical manifestations, diagnostic procedures, and treatment options for CRMO involvement of the spine based on the current literature and our own cases.

Multifocal rib osteomyelitis in children: a case report and literature review

Rib osteomyelitis is a rare disease, occurring in ~1% or less of all cases of haematogenous osteomyelitis. During the last century, 58 cases of rib osteomyelitis were reported in the literature, of which, multiple ribs were involved in only five patients. Because of its rarity and non-specific clinical signs, diagnostic of rib osteomyelitis may be delayed. We report a case of multifocal rib osteomyelitis revealed by a dorsal mass in a healthy 13-year-old female child.

Bacterial Osteomyelitis or Nonbacterial Osteitis in Children: A Study Involving the German Surveillance Unit for Rare Diseases in Childhood

BACKGROUND

Although bacterial osteomyelitis (BO) is a commonly recognized diagnosis in pediatrics, it is often difficult to distinguish from nonbacterial osteitis (NBO). The goal of our study was to distinguish between the 2 disease entities and better define NBO.

METHODS

Using the German Surveillance Unit for Rare Diseases in Childhood (Erhebungseinheit für Seltene Paediatrische Erkrankungen in Deutschland), this prospective study during a 5-year period captured 657 patients at first diagnosis of either BO (n = 378) or NBO (n = 279) while analyzing epidemiologic, clinical and radiologic data.

RESULTS

BO was reported in 1.2 per 100,000 children with a higher prevalence in younger male patients (58%), and NBO was reported in 0.45 per 100,000 children. BO patients tended to present with fevers (68%), elevated inflammation markers (82%) and local swelling (62%) but a shorter course of symptoms than NBO patients. NBO patients presented in good general health (86%) and were more likely to have multifocal lesions (66%). Staphylococcus aureus was the most prominent pathogen (83%), with only one methicillin-resistant S. aureus reported. Complications ranged from arthritis adjacent to the lesion to hyperostosis and vertebral fractures.

CONCLUSIONS

BO and NBO can be distinguished based on symptoms, associated diseases and inflammation markers. NBO should always be considered in pediatric patients presenting with bone lesions and pain, especially in young female patients presenting with good general health, minimal inflammation markers and multifocal lesions in the vertebrae, clavicle and sternum.

Oral Ambulatory Treatment of Acute Osteomyelitis in Children: A Case-Control Study

The treatment of acute hematogenous osteomyelitis has evolved in recent years to a shorter parenteral treatment with an early switch to the oral route. Current publications recommend a 2- to 4-day parenteral treatment before the oral switch. We retrospectively analyzed a series of 45 children aged 1 to 11 years and treated in our department for acute osteomyelitis without severity criterion. Nineteen of 45 patients were treated by an exclusive ambulatory oral treatment by amoxicillin and clavulanic acid. Twenty six of 45 patients had a 2- to 4-day parenteral treatment before the oral switch. The minimum follow-up was 6 months. The primary endpoint was a clinical, radiographic, and biologic healing, 6 months after the beginning of the treatment. The secondary endpoints evaluated were the length of hospitalization, the total duration of treatment, and the type of antibiotic used. On the primary endpoint, we did not find any significant difference between the 2 treatments (P = 0.38). On the duration of treatment, we found a significant difference (P = 0.049) in favor of oral treatment. The ambulatory oral treatment by amoxicillin and clavulanic acid seems to be a valid alternative to the classical parenteral then oral sequence in the treatment of acute hematogenous osteomyelitis in children without severity criterion.

Bone Scintigraphic Findings in MRSA Osteomyelitis

Methicillin-resistant Staphylococcus aureus osteomyelitis is a severe form of infection characterized by multifocal or multiple segmental osseous involvement and subperiosteal abscess formation with increased frequency of extraosseous complications including pyomyositis, septic thrombus, and septic arthritis. Bone scan showed long segment and/or multifocal involvement in 4 of 5 patients with areas of abnormal increased and decreased uptake. The clinical presentations included limp and/or pain. Joint involvement was seen in 4 cases. Bone scan abnormalities correlated well with MRI findings of severe and extensive bone disease, abscess formation, muscle, as well as joint and soft tissue involvement.

Successful Daptomycin Use in a Pediatric Patient With Acute, Bilateral Osteomyelitis Caused by Methicillin-Resistant Staphylococcus aureus

Staphylococcus aureus is the most common bacteria associated with the development of osteomyelitis in pediatric patients. Osteomyelitis caused by methicillin-resistant Staphylococcus aureus (MRSA) can be difficult to safely and effectively treat. Vancomycin, linezolid, and clindamycin are commonly used to treat osteomyelitis caused by MRSA. While adult studies suggest intravenous (IV) daptomycin may by beneficial for the treatment of MRSA osteomyelitis, it is not Food and Drug Administration approved for use in pediatrics, and minimal data are available related to its use in this population. This case report describes the successful use of daptomycin (8 mg/kg/dose IV daily) combined with rifampin for 5 weeks, followed by 5 weeks of oral sulfamethoxazole/trimethoprim, for treatment of acute bilateral osteomyelitis caused by MRSA in an 8-year-old male. The patient did not initially respond to the combination of vancomycin plus rifampin and gentamicin, nor did he respond to ceftaroline treatment. After initiation of daptomycin, his fevers quickly subsided, his pain rapidly improved, and his inflammatory markers significantly decreased. While daptomycin was effective in this patient, additional research is needed to determine the true safety and efficacy of this drug for treatment of osteomyelitis caused by MRSA in pediatric patients.

Subperiosteal abscess in a child. Trueta's osteomyelitis hypothesis undermined?

Subperiosteal abscess formation is almost exclusively seen secondary to underlying hematogenous infected osteomyelitis or secondary as a result of a contagious focus. We present an unusual case of a 9-year-old girl with progressive ankle pain due to an isolated subperiosteal abscess of the distal fibula without concomitant osteomyelitis. The subperiosteal abscess was most likely caused by hematogenous spread to the periosteal region of the distal fibula located above the highly vascularized metaphysis. Remarkably, there were no signs of osteomyelitis on either MRI or during surgical inspection. She was successfully treated with debridement and antibiotic therapy. We hypothesize that subperiosteal abscess formation near the metaphysis originates in the periosteal region and not from outward extension from the sinusoidal veins in the intrametaphyseal area to the cortex and subperiosteal region.

Ultrasound-Guided Diagnosis of Femoral Osteomyelitis and Abscess

Skin and soft tissue infections are common disease presentations to the pediatric emergency department, and rapid and accurate identification of potentially serious skin and soft tissue infections is critical. In cases of atraumatic musculoskeletal pain with systemic complaints, a bacterial etiology must be ruled out. Point-of-care ultrasonography is increasingly common in the pediatric emergency department and assists in rapid and accurate identification of a variety of disease processes. We present a case of a 14-year-old adolescent boy with atraumatic right knee pain to illustrate the benefits of point-of-care ultrasonography in the timely diagnosis of musculoskeletal and soft tissue pathology. Moreover, we describe the use of ultrasound in procedural guidance of deep-space fluid aspiration, with an eventual diagnosis of femoral osteomyelitis. Ultrasonographic techniques and the emergent work-up and management of osteomyelitis are reviewed.

Salmonella osteomyelitis of the calcaneum bone in an immunocompetent child

Salmonella osteomyelitis occurs infrequently in healthy children and can manifest in the subacute form. This condition has only been reported in few cases previously. We report the first case of primary subacute haematogenous osteomyelitis of the calcaneum in a healthy 12-year-old child. The patient made uneventful recovery following surgical drainage and antibiotic therapy. Histology of the tissue biopsy confirmed a diagnosis of Salmonella livingstone infection. Although the diagnosis of Salmonella osteomyelitis of the calcaneum can be difficult to establish, it should be considered as an aetiological factor even in healthy children.

Magnetic resonance imaging of the immature skeleton

Magnetic resonance (MR) is unique in its ability to allow assessment of bone marrow, epiphyseal, physeal, and articular cartilage as well as tendons and ligaments. An understanding of skeletal maturation and the accompanying changes on MR is of utmost importance in pediatric radiology. In particular, it is important to recognize the normal spectrum related to ossification and marrow transformation. This review will include a brief description of main indications and common pitfalls in musculoskeletal MR in children. Also, we will focus on the MR appearance of the growing pediatric skeleton on the most commonly used sequences.

Reconstruction of the distal humerus and elbow joint using a pedicled scapular flap: case report

Loss of elbow function resulting from major bone loss negatively affects quality of life and leaves limited options for reconstruction and restoration of function. To overcome this disabling problem, we reconstructed the distal humerus of a child in a single stage using a scapular flap based on the angular branch of the thoracodorsal artery as a pedicled flap. We also reconstructed the proximal ulna using an iliac crest bone graft with dermal graft interposition arthroplasty, which enabled the restoration of useful elbow function.

Paediatric bone and joint infections are more common in boys and toddlers: a national epidemiology study

AIM

Little is known about bone and joint infections (BJIs) in children, despite the risk of growth disturbance. This study examined BJIs epidemiology using the French National Hospital Discharge Database (HD).

METHODS

Any child <15 years hospitalized with an HD diagnosis of BJI, alone or in combination with sepsis or orthopaedic procedure, was included. The majority of BJIs (96%) were haematogenic infections. We conducted descriptive analyses to evaluate epidemiological and economic outcomes of paediatric haematogenic BJIs.

RESULTS

There were 2592 paediatric patients with 2911 BJI hospitalizations and an overall incidence of 22 per 100 000. BJIs occurred more frequently in boys than girls (24 vs 19 per 100 000) and in toddlers. Septic arthritis (52%) and osteomyelitis (44%) were the most frequent infections, 16.6% of patients had a micro-organism coded (61% were Staphylococci) and 13% of had comorbidities. The mean hospital stay was 8.6 days, costing approximately €5200 per BJI stay.

CONCLUSION

This national study of paediatric BJIs in France showed a higher prevalence in toddlers and boys and demonstrated that the HD database can be used to study BJIs. However, the number of BJI cases was maybe overestimated by coding reactive arthritis as septic arthritis in the absence of bacterial evidence.

Rib osteomyelitis in a pediatric patient case report and literature review

Rib osteomyelitis is a very rare form of childhood osteomyelitis. We describe a case of a 9-year-old child with an osteomyelitis of the rib due to Staphylococcus aureus and review 57 cases reported in the literature. This case demonstrates that the diagnosis of this uncommon disease requires a high index of suspicion due to its rarity and nonspecific signs.

Osteomielite hematogênica aguda em Pediatria: análise de casos atendidos em hospital universitário

OBJETIVO: Descrever a ocorrência, a evolução e o desfecho de pacientes com osteomielite hematogênica aguda na faixa etária pediátrica. MÉTODOS: Estudo descritivo de 21 casos de pacientes de zero a 14 anos com diagnóstico de osteomielite hematogênica aguda, em acompanhamento no Ambulatório de Infectologia Pediátrica da Escola Paulista de Medicina entre 2005 e 2009. A coleta de dados ocorreu pelo levantamento de prontuários. Realizaram-se a análise descritiva e o teste de correlação de Spearman, com intervalo de confiança de 95%. RESULTADOS: Foi identificada maior incidência no sexo masculino e em crianças maiores de cinco anos. Febre e dor foram os sintomas mais frequentes. Os ossos longos foram os mais acometidos. O principal agente etiológico identificado foi o Staphylococcus aureus. Em média, o tempo de sintomatologia até o diagnóstico foi de 9,7 dias, o de internação, 24,7 dias, e o total de antibioticoterapia foi de 71,7 dias. A resolução completa do quadro ocorreu em 71,4% dos casos, com permanência de sequelas em 28,6% deles, sendo a evolução para osteomielite crônica a principal delas. CONCLUSÕES: As características dos pacientes e da doença referentes a sexo, idade, etiologia e evolução mostram-se concordantes com o descrito na literatura. O tempo de tratamento foi de aproximadamente dez semanas, valor acima do habitualmente encontrado nos diferentes estudos. Não foram encontradas correlações significantes entre o tempo de sintomatologia até o diagnóstico, o tempo de internação e o tempo total de antibioticoterapia, havendo a limitação do tamanho da amostra.

Characterization of nasal and blood culture isolates of methicillin-resistant Staphylococcus aureus from patients in United States Hospitals

A total of 299 nares and 194 blood isolates of methicillin-resistant Staphylococcus aureus (MRSA), each recovered from a unique patient, were collected from 23 U.S. hospitals from May 2009 to March 2010. All isolates underwent spa and staphylococcal cassette chromosome mec element (SCCmec) typing and antimicrobial susceptibility testing; a subset of 84 isolates was typed by pulsed-field gel electrophoresis (PFGE) using SmaI. Seventy-six spa types were observed among the isolates. Overall, for nasal isolates, spa type t002-SCCmec type II (USA100) was the most common strain type (37% of isolates), while among blood isolates, spa type t008-SCCmec type IV (USA300) was the most common (39%). However, the proportion of all USA100 and USA300 isolates varied by United States census region. Nasal isolates were more resistant to tobramycin and clindamycin than blood isolates (55.9% and 48.8% of isolates versus 36.6% and 39.7%, respectively; for both, P < 0.05). The USA300 isolates were largely resistant to fluoroquinolones. High-level mupirocin resistance was low among all spa types (<5%). SCCmec types III and VIII, which are rare in the United States, were observed along with several unusual PFGE types, including CMRSA9, EMRSA15, and the PFGE profile associated with sequence type 239 (ST239) isolates. Typing data from this convenience sample suggest that in U.S. hospitalized patients, USA100 isolates of multiple spa types, while still common in the nares, have been replaced by USA300 isolates as the predominant MRSA strain type in positive blood cultures.

Osteoblastic and fibroblastic multicentric osteosarcoma

Bone sarcomas are uncommon tumours, of which osteosarcoma is the least rare, as well as the third most common malignant tumour in childhood, appearing usually between the 10 and 20 years of age. The case the authors present in this work is of a patient suffering from a long-standing condition encompassing skin and soft tissue lesions. After multiple medical treatments, the patient was diagnosed with squamous osteosarcoma, which required aggressive surgical management and chemotherapy.

Case of idiopathic loss of deciduous teeth and associated alveolus

We describe exfoliation of the lower left deciduous canine and deciduous first molar (CD) and associated alveolus of unknown cause in a 5-year-old healthy boy. Extraction of the teeth and removal of local bone led to healing without complication.

Nonbacterial osteitis in children: data of a German Incidence Surveillance Study

AIM

To analyse the incidence, clinical presentation, laboratory and radiological findings, as well as diagnostic approaches and therapeutic procedures in paediatric patients suffering from nonbacterial osteitis.

METHODS

A nationwide incidence survey was conducted from 2006 to 2008 through monthly contacts with all German paediatric and paediatric-orthopaedic hospitals. Children with osteomyelitic bone lesions newly diagnosed as suffering from nonbacterial osteitis were identified. Cases were assessed using a questionnaire to be filled in by the treating physician containing information on time since first symptoms, associated diseases, diagnostic procedures, localization of lesions, complications, laboratory and histological results, and treatment.

RESULTS

Nonbacterial osteitis was newly reported in 148 children. The annual incidence was estimated at 0.4 per 100,000 children. Mean manifestation age was 11.4 years (SD 3.2); 99 children (67%) were girls. Palmoplantar pustulosis was observed in 8 (6%). Unifocal manifestations were seen in 50 (34%) patients. Of all patients with vertebral involvement (15%), 9% suffered from vertebral fractures. Bone biopsies were taken in 79 (53%) patients.

CONCLUSIONS

Nonbacterial osteitis is an auto-inflammatory disorder resulting in at least 60 new paediatric cases/year in Germany. Spinal lesions and complications are frequently observed, even at first diagnosis.

Follow-up of acute osteomyelitis in children: the possible role of PET/CT in selected cases

BACKGROUND

Magnetic resonance imaging (MRI) and/or scintigraphy are commonly used for follow-up in children after treatment of acute osteomyelitis. Regularly, post-treatment imaging reveals pathological findings even if serum inflammatory parameters and clinical presentation are normal. We analyzed combined positron emission tomography and multislice computed tomography (PET/CT) for this condition.

METHODS

Six children received PET/CT after treatment of acute osteomyelitis. Post-treatment MRI had revealed suspicious residual and/or additional findings. All patients had physiological serum infection parameters and no clinical symptoms.

RESULTS

Median patient age was 59.5 months (range, 48-156). No increased 18-Fluor-2-deoxy-D-glucose uptake was observed in 3 patients. In 3 patients, there was minimal activity at the site of infection, which, however, did not reach the presumed range of osteomyelitis. All children were taken off antibiotic medication. No clinical symptoms reoccurred in any of them, and repeatedly controlled serum infection parameters were all normal. Median follow-up was 33 months (range, 4-65).

CONCLUSIONS

The PET/CT was superior to MRI in distinguishing between infection and reparative activity within the musculoskeletal system in selected children after acute osteomyelitis. The termination of antibiotic treatment for children after acute osteomyelitis seems justified when laboratory parameters as well as clinical presentation are normal, and PET/CT scan is unsuspicious.

Isolation and characterization of Streptococcus mitis from blood of child with osteomyelitis

OBJECTIVES

Osteomyelitis is an inflammatory process accompanied by bone destruction that is caused by bacterial infection, with most child cases showing a haematogenous origin and metaphysis of the long bones. The aim of the present study was to characterize streptococcal strains isolated from the blood of a child diagnosed with osteomyelitis in a long bone and investigate the biological properties related to virulence of strains associated with osteomyelitis.

METHODS

Blood isolate species were determined based on the 16S rRNA sequence. Next, the blood isolates were analysed for phagocytosis susceptibility by polymorphonuclear leukocytes, platelet aggregation, inhibitory effects on osteoblastic cells, and their properties of adhesion with cells, and compared to the reference strain Streptococcus mitis ATCC49456.

RESULTS

The blood isolates were found to be a single clone (named SA1101), which was determined to be S. mitis. The phagocytosis susceptibility of SA1101 was significantly lower than that of ATCC49456, while its platelet aggregation rate was higher. Furthermore, SA1101 showed an inhibitory effect toward the growth of osteoblastic cells and had greater properties of adhesion to those cells as compared to ATCC49456.

CONCLUSIONS

These results suggest that S. mitis SA1101 is a possible etiological agent and caused osteomyelitis in the present case.

Microbiological profile of haematogenous osteoarticular infections in children

INTRODUCTION

Staphylococcus aureus, Kingella kingae and β-hemolytic streptococcus are presently the most frequently identified bacteria in child haematogenous osteoarticular infection.

OBJECTIVE

To determine the microbiological profile (bacteria and antibiotic susceptibility) of osteoarticular infections in a paediatric hospital, so as to adapt treatment protocols to the ecology of the bacteria isolated.

PATIENTS AND METHODS

Prospective descriptive study, including children admitted for acute osteomyelitis or septic arthritis. A series of blood cultures was performed systematically on admission. In case of surgery, local samples were taken for bacteriology. Antibiotherapy was initiated and subsequently adapted to the bacteriological findings.

RESULTS

One hundred and six children were included. Thirty-five were under (Group 1) and 71 over 3 years of age (Group 2). Ninety-five underwent surgery. Peroperative samples were positive in 61 cases and blood culture in 23. Bacteria were isolated in 22 patients in G1. Extended-spectrum β-lactamase-producing Klebsiella pneumoniae was isolated in five neonates who had passed through intensive care. Staphylococcus aureus was the most frequently isolated bacterium in G2 (n=40), and was methicillin-resistant (MRSA) in six children.

DISCUSSION

Methicillin-susceptible Staphylococcus aureus was the most frequently isolated microorganism. Other than neonates who had passed through intensive care and the six patients with community-acquired MRSA infection, all isolated bacteria were susceptible to second-generation cephalosporins.

LEVEL OF EVIDENCE

II, prospective descriptive prognostic study.

Magnetic resonance imaging findings in hematogenous osteomyelitis of the hip in adults

Hematogenous hip infections are rare in adults and the extent of infection into the bone or adjacent soft tissues may be underestimated, leading to inadequate surgical débridement. Using MRI, we sought to determine the extent of bone involvement and the presence of adjacent soft tissue abscesses in adults with hip osteomyelitis. We reviewed the records and MRIs in 11 adult patients (12 hips) with hematogenous osteomyelitis of the femoral head in 12 hips. Ten of 11 patients had one or more comorbidities. All patients underwent surgical débridement and received antibiotic therapy for 6 weeks. MRI revealed osteomyelitis distal to the femoral head in seven of 12 hips with extension into the medullary canal in three of these seven. Femoral head erosions were present in 10 hips, acetabulum osteomyelitis in 11, and acetabular erosions in six hips. Infection extended into adjacent soft tissues in eight of 12 hips. MRI demonstrated that the infection may extend distal to the femoral head or into the adjacent soft tissues. MRI may be useful for preoperative planning so that all regions affected by the infection can be treated.

LEVEL OF EVIDENCE

Level III, diagnostic study.