Osteomyelitis and Complications in Pediatric Patients: Case and Literature Review

Transcription

1 Osteomyelitis and Complications in Pediatric Patients: Case and Literature Review Matthew Martin, D.O.; Matthew Carlson,D.O.; Michelle Mark, D.O.; Glenn Barnes, D.O.; Michelle Lin, D.O. Presented by: Michelle Mark, D.O.; Glenn Barnes, D.O.; Michelle Lin, D.O. NOMA May 3, 2018

2 Introduction - Goals and Objectives Osteomyelitis Pediatric case of osteomyelitis Highlighting common findings and differences between pediatric and adult cases Discuss complications of osteomyelitis Discuss ways to improve outcomes

3 Introduction Osteomyelitis Infection localized to the bones generally via hematogenous pathway Early symptoms: back pain Pediatric cases: may be nonspecific Complications: Sepsis Long bone fractures Early diagnosis and treatment to prevent complications

4 Presenting Signs & Symptoms of Osteomyelitis Pain* Malaise Fever Localized symptoms Swelling Tenderness to palpation of spine with stiffness Decreased range of motion Decreased ability to bear weight

5 Signs and Symptoms in Pediatric Population *Back pain Nonspecific musculoskeletal pain Decreased appetite Fever

6 Initial Presentation: Outpatient Office 11 year old female presenting with back pain for 5 days Possible injury playing soccer Pain described as tingling in mid-low back 48 hours after: severe pain awakening from sleep Symptoms: Fever (101 F), fatigue, nausea, decreased appetite Relieving factors: Laying down, not moving Precipitating factors: Any movement

7 Initial Presentation: Outpatient Office Past Medical History Hx of several MRSA skin infections since 8 years old Past Surgical History None Past Social History Lives with family In school Medications None Immunizations Up to date

8 Initial Presentation: Vital Signs Temperature F Blood pressure 100/61 Pulse tachycardic Height: 86%ile Weight: 56%ile

9 Initial Presentation: Physical Exam General: mild to moderate distress, generalized malaise, decreased talkativeness, antalagic movements Cardiovascular: tachycardia, global systolic murmur Abdomen: infraumbilical tenderness to palpation, moderate abdominal distention Skin: 0.5cm hyperpigmented lesion around T10-11 spinous process Musculoskeletal: bilateral tenderness to palpation T10-L5, innominates, reproducible back pain at T10-11 with passive flexion of hips and neck

10 Initial Presentation: Outpatient Office Based on the previous findings, patient and family were directed to ER for further evaluation

11 Initial ER Evaluation Additional symptoms: No bowel movements x 5 days Decreased oral intake Diagnostic findings WBC normal, neutrophil 81.6%, ESR 41 (elevated), Sodium 130, glucose 120, CRP 15.3 Imaging (elevated) Blood cultures: pending MRI Lumbar spine w/o contrast: normal XR Abdomen: gaseous colonic dilatation with moderate fecal loading suggestive of functional colonic motility disorder XR of Lumbar Spine: normal XR of Sacrum/Coccyx: normal

12 Initial ER Evaluation Treatment: Morphine and Tramadol in ER Discharge Plan Home Rx of Norco, Motrin, Miralax

13 Results of Blood Cultures Available 6 days later Positive for MRSA Sensitive to Clindamycin and Bactrim Patient and family were notified and recommended to return to ER

14 Pathology Epidemiology Microbiology Diagnosis Treatment Prognosis

15 Pathogenesis of Pediatric Osteomyelitis Hematogenous deposition of bacteria into metaphysis of long bones or vertebral disk is most common path to infection. Less common is direct extension of soft tissue infections or direct inoculation Resultant cellulitis on bone marrow creates increased marrow pressure forcing exudate through cortex, periosteum and eventually joint space in up to ⅓ of cases resulting in septic arthritis. (1) Younger patients have thinner cortices and increased metaphyseal nutrient arteries that can carry the infection into the diaphysis and epiphysis resulting in septic joints. (5)

16 Epidemiology Geographic distribution of incidence - Developed countries 1:7700 and undeveloped countries 1: Of note in USA, incidence of MRSA pediatric osteomyelitis is increasing 2,3 Risk Factors are based on patient age (4)(5)(6) - Neonates (<30 days): complicated delivery, maternal infection, skin infections, central lines, urinary tract abnormalities - Infants and Children: Sickle Cell, Immunodeficiency, sepsis, indwelling catheters, minor trauma with coincident bacteremia

17 Microbiology Most are caused by single organism (4 most common listed below) 1. Staphylococcus aureus - ⅔ of all cases a. MRSA associated with PVL mutation involved in all complications 1 2. Group A and B Streptococcus a. Group A in older infants and children as complication of VZV infection 2 b. Group B in infants < 3 months but usually 2-4 weeks. Commonly with no preceding infection 3 3. Streptococcus pneumoniae a. More common in at pneumococcal at risk patients (i.e. heart/lung disease, diabetes, sickle cell, splenic dysfunction) 4 4. Kingella kingae a. More commonly affects non-tubular bone 5. Increasingly being identified as causative organism 6

18 Microbiology Cont Other rare causative organisms (44-50) - E. Coli, H. Flu Type B, Bartonella henselae, Pseudomonas aeruginosa, Brucella, Mycobacterium tuberculosis, Actinomyces, Fusobacterium, Coccidiomycosis, Aspergillus Polymicrobial osteomyelitis typically occurs due to contiguous spread of soft tissue/articular infection. (56)

19 Diagnosis of Pediatric Osteomyelitis Begins with clinical suspicion based on signs of bone infection such as focal bone tenderness, limitation of bone function, and elevated inflammatory markers along with constitutional symptoms. Ways to confirm diagnosis 1 1. Bone biopsy, marrow aspirate showing + culture or histopathologic evidence of inflammation. GOLD STANDARD. Requires specialists. 2. Infection is likely with symptoms plus clinical, laboratory or imaging evidence of bone infection. Also likely if cultures negative but good response to empiric antibiotics 3. Unlikely if MRI is normal.

20 Empiric and Targeted Treatment Treatment delay with empiric therapy most dangerous with S. aureus. - Blood culture and focal infection cultures should be performed first.* Considerations for antibiotic selection include age, clinical features, and prevalent organisms. (1, 2, 3, 4) All therapy should be parenteral! months - Vancomycin and 3rd gen Cephalosporin (Cefotaxime preferred) - > 3 months - Nafcillin/Oxacillin if community resistance <10%. If >10%, vancomycin or clindamycin Targeted therapy should be started immediately once cultures and sensitivities become available.

21 Prognosis With prompt treatment before bone necrosis cure rate ~ 95% (1, 2) Factors portending worse prognosis (3) 1. MRSA with PVL mutation 2. Septic arthritis, pyomyositis, or abscess 3. Hip, ankle, knee involvment 4. Positive culture 5. Young age 6. Delay in treatment *

22 Hospital Course Vitals: tachycardia, tachypnea, hypotension, fever Difficulty with ambulation Treatment: IV fluids Supplemental oxygen Admitted to: Pediatric ICU Antibiotics: IV Ceftriaxone, Vancomycin, Acyclovir

23 Hospital Course: Labs/Diagnostics Thrombocytopenia Hyponatremia Hypocarbia INR 1.5 Elevated alkaline phosphatase Hypoalbuminemia Increased creatinine Decreased level of ADAMTS13 Possible acquired TTP CXR: reticulonodular pattern

24 Hospital Course: Procedures Bronchoscopy Hemorrhagic secretions throughout lungs Several mucus plugs removed Bronchoalveolar lavage of bilateral lower lobes Strong growth of MRSA Echocardiogram Dilated IVC and large atrial sided tricuspid valve vegetation Posterior and septal leaflets with mild insufficiency CT abdomen/pelvis with IV contrast Fecal loading, ascites, anasarca

25 Hospital Course: Complications Septic shock secondary to MRSA Required intubation and vasopressor support via PICC line Supraventricular tachycardia Spontaneously resolved Multisystem organ failure DIC Septic endocarditis with likely septic pulmonary emboli

26 Hospital Course: Treatment Infectious disease consulted Ceftriaxone Later switched to Gentamicin after review of sensitivities Transferred to facility for pediatric cardiac surgery Vegetation and septic emboli removal

27 Outcome/follow up Discharge summary 1 month after transfer to surgery Final dx: R fibula osteomyelitis complicated by flexion contractures 8 week course of linezolid, steroid taper, pain medication Walker for ambulation Follow up with cardiology, endocrinology, infectious disease Patient was lost to follow up.

28 Complications Varies with age Site of involvement Pathogen Duration if infection

29 Complications: Musculoskeletal New born + CA-MRSA: Abnormal bone growth at physis and epiphysis Multifocal infection Young infants: extension into soft tissue Septic arthritis if involving proximal humerus and femur or hematogenous delivery Subperiosteal abscess/ Brodie abscess

30 Complications: Musculoskeletal cont d CA- MRSA: Pathologic fractures Osteonecrosis of femoral head Vertebral body destruction w/ assoc kyphosis or spinal cord compression Devitalized bone and cutaneous fistulae Chronic osteomyelitis Devitalized bone on radiograph + 2 weeks of bone inflammation Inadequate duration of therapy

31 Complications: Venous thrombosis/septic emboli Children Age 8 and adolescents At sites adjacent to osteomyelitis S. aureus, MRSA Coagulation abnormalities Disseminated infection CRP >6mg/dl at presentation Increased severity of infection

32 Final Comments Be aware of atypical presentation of osteomyelitis Aggressive diagnostics Labs (CRP, Cultures), Radiographs, MRI Empirical parenteral antibiotics Be aware of the complications Considering further diagnostics in context of symptoms Consider preemptive education for parents for children with MRSA infections

33 References 1. Gonzalez BE, Teruya J, Mahoney DH Jr, Hulten KG, Edwards R, Lamberth LB, Hammerman WA, Mason EO Jr, Kaplan SL. Venous thrombosis associated with staphylococcal osteomyelitis in children. Pediatrics. 2006;117(5): Gorenstein A, Gross E, Houri S, Gewirts G, Katz S. The pivotal role of deep vein thrombophlebitis in the development of acute disseminated staphylococcal disease in children. Pediatrics. 2000;106(6):E Hollmig ST, Copley LA, Browne RH, Grande LM, Wilson PL. Deep venous thrombosis associated with osteomyelitis in children. J Bone Joint Surg Am. 2007;89(7): Goergens ED, McEvoy A, Watson M, Barrett IR. Acute osteomyelitis and septic arthritis in children. J Paediatr Child Health. 2005;41(1-2): Krogstad P. Hematogenous osteomyelitis in children: Clinical features and complications. UpToDate. Topic 6064 Version Available: [Accessed on April14, 2016.] 6. Emslie KR, Nade S. Pathogenesis and treatment of acute hematogenous osteomyelitis: evaluation of current views with reference to an animal model. Rev Infect Dis. 1986;8(6); Yagupsky P, Bar-Ziv Y, Howard CB, Dagan R. Epidemiology, etiology, and clinical features of septic arthritis in children younger than 24 months. Arch Pediatr Adolesc Med. 1995;149(5): Dartnell J, Ramachandran M, Katchburian M. Haematogenous acute and subacute paediatric osteomyelitis: a systematic review of the literature. J Bone Joint Surg Br. 2012;94(5): Arnold SR, Elias D, Buckingham SC, Thomas ED, Novais E, Arkader A, Howard C. Changing patterns of acute hematogenous osteomyelitis and septic arthritis: emergence of community-associated methicillin-resistant Staphylococcus aureus. J Pediatr Orthop. 2006;26(6): Krogstad P. Hematogenous osteomyelitis in children: Epidemiology, pathogenesis, and microbiology. UpToDate. Topic 6063 Version Available: [Accessed on May 3, 2017] 11. Faust SN, Clark J, Pallett A, Clarke NM. Managing bone and joint infection in children. Arch Dis Child Jun;97(6): Epub 2012 Mar Krogstad P. Hematogenous osteomyelitis in children: Evaluation and diagnosis. UpToDate. Topic 6067 Version Available: [Accessed on May 3, 2017] 13. Browne LP, Mason EO, Kaplan SL, Cassady CI, Krishnamurthy R, Guillerman RP. Osteomyelitis and septic arthritis in children: appropriate use of imaging to guide treatment. AJR Am J Roentgenol. 1995;165(2): Krogstad P. Hematogenous osteomyelitis in children: Management. UpToDate. Topic 5958 Version Available: [Accessed May 20, 2017] 15. Karwowska A, Davies HD, Jadavji T. Epidemiology and outcome of osteomyelitis in the era of sequential intravenous-oral therapy. Pediatr Infect Dis J. 1998;17(11): Belthur MV, Birchansky SB, Verdugo AA, Mason EO Jr, Hulten KG, Kaplan SL, Smith EO, Phillips WA, Weinberg J. Pathologic fractures in children with acute Staphylococcus aureus osteomyelitis. J Bone Joint Surg Am. 2012;94(1): Speechly-Dick ME, Swanton RH. Osteomyelitis and infective endocarditis.postgrad Med J Dec; 70(830):

34 Questions?