Osteomyelitis in infancy and childhood: A clinical and diagnostic overview M. Mearadji

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2 Osteomyelitis in infancy and childhood: A clinical and diagnostic overview M. Mearadji International Foundation for Pediatric Imaging Aid

3 Introduction Osteomyelitis is a relative common disease in infancy and childhood. Higher incidence in early life (In USA 1 : 1000 younger than 1 year. 1 : 5000 older). Clinical symptoms are different depending on location, extension and the type of osteomyelitis. With exception of neonates fever is a frequent finding. Other symptoms are pain, soft tissue swelling, tenderness and immobility. Some laboratory findings could be specific and some non specific.

4 Classification of osteomyelitis number of cases studied for this presentation Pyogenic hematogeneous osteomyelitis: 71 a) Neonatal osteomyelitis: 29 b) Acute osteomyelitis in infancy and childhood: 41 c) Sequelae of infantile meningococcemia: 3 Subacute osteomyelitis (Brodie abscess): 33 Chronic osteomyelitis: 49 a) Sclerosing osteomyelitis: 2 b) Epiphyseal osteomyelitis: 2

5 Classification of osteomyelitis number of cases studied for this presentation Exogenous osteomyelitis caused by direct implantation (surgery, trauma or foreign bodies): 11 Chronic recurrent multifocal osteomyelitis: 3 Adjacent joint or soft tissue infection: 1 Osteomyelitis resulting from unusual organisms: 4

6 Diagnostic priorities of imaging modalities Plain films are the first step in diagnosis of osteomyelitis. Ultrasound is useful in recognition of arthritis and soft tissue abscesses. Nuclear scanning is valuable to search for multifocal location of osteomyelitis. CT is a proper modality in detection of bone sequestration. MRI is an adequate modality for early diagnosis and complication of osteomyelitis especially in difficult locations (spine and pelvis).

7 Pathway of pyogenic hematogenous osteomyelitis. Hematogeneous osteomyelitis usually involves the highly vasculated metaphysis. Organisms lodge mostly in the terminal capillary loops of metaphysis. Early initial affection of epiphysis or cortex is rare. Septic arthritis is frequently an early complication.

8 Clinical sign and symptoms of acute hematogenous osteomyelitis Fever (rarely in neonatal period) Local pain Soft tissue swelling Warmth Sepsis with positive blood cultures Reluctance to use the limbs

9 Clinical and radiological data of 29 neonates with hematogenous osteomyelitis nr % Age 0 4 weeks Male Female Isolated micro organisms -Staphylococcus aureus -Streptococcus pneumonia -Proteus ,5 3,5 Monolocular affection Multilocular afffection Septic arthritis 17 59

10 Clinical and radiological data of 29 neonates with hematogenous osteomyelitis Affected bone nr % Femur Tibia 9 31 Humerus 6 21 Ulna 2 7 Fibula 1 3 Proximal phalanx 1 3 Used diagnostic modalities nr % Plain films Ultrasound CT 0 0 MRI 0 0 Nuclear scanning 2 6

11 April 2005 May 2005 January 2006 July 2005 A neonate with a multilocular osteomyelitis of the left femur. Note the shortening of the femur.

12 March 2006 May 2006 November 2006 Neonate with monolocular osteomyelitis of tibia.

13 Neonate with osteo-arthritis located in distal tibia.

14 Osteomyelitis of severely affected humerus with abscess.

15 Osteomyelitis of proximal humerus visuable on chest x-ray. Note the sonographic finding and the second location in distal femur.

16 Clinical and radiological data of 41 cases with postneonatal acute osteomyelitis nr % Age 1 15 years Average: 6.2 years Male Female Isolated micro organisms Staphylococcus aureus Others 2 5 Arthritis 9 22

17 Clinical and radiological data of 41 cases with postneonatal acute osteomyelitis Affected bone nr % Used diagnostic modalities nr % Plain films Ultrasound CT 7 37 MRI 6 15 Nuclear scanning 6 15 Femur Tibia 3 7 Fibula 3 7 Humerus 7 17 Radius 1 2 Pelvis 3 7 Sternum 2 5 Spine 1 2 Os frontale 3 7 Foot 4 10

18 A case of postneonatal acute right-sided cox arthritis. Note the normal x-ray film.

19 September 2005 October 2005 Acute osteomyelitis of distal humerus with an abscess visible on sonogram.

20 Osteomyelitis of frontal bone with an subdural abscess (Pott s Puffy tumor).

21 Multilocular osteomyelitis following meningococcal meningitis. Note the shortening and destruction of right femur and tibia.

22 Late complication of hemogenous osteomyelitis Premature and asymmetric epiphyseal plate closure. Growth disturbance and limb deformities. Limb length discrepancy (shortening and lengthening). Joint destruction. Pathologic fracture.

23 Case A. Shortening of tibia following multilocular osteomyelitis. Note the premature physial closure. Case B. Shortening of lower limb following multilocular osteomyelitis. Foot amputation complicated with osteomyelitis of stump.

24 Low grade osteomyelitis Subacute osteomyelitis (Brodie abscess) is likely the result of an organism of low virulence contained by a partial host response. The initial purulent exsudate is replaced by granulation tissue. Mild clinical manifestation with pain. Radiological characterised by a variable areas of sclerosis.

25 Clinical and radiological data of 33 cases with low grade osteomyelitis nr % Age: 2 weeks 19 years Average: 6.8 years Male Female Isolated micro organisms 0 0 Biopsy 8 24

26 Clinical and radiological data of 33 cases with low grade osteomyelitis Diagnostic modalities nr % Plain films Ultrasound CT 2 6 MRI Nuclear scanning 4 12 Affected location nr % Femur Tibia 5 15 Pelvis 6 18 Humerus 3 9 Foot 4 12 Radius 1 3

27 Low grade osteomyelitis located in right-sided distal metaphysis (Brodie abscess).

28

29 Brodie abscess located in the right acetabulum. The muscle atrophy and persisting joint effusion shown on sonography were the initial sign of severe pathology.

30 Brodie abscess located on the femur metaphysis. Also visible by ultrasonography.

31 Clinical signs and symptoms of chronic osteomyelitis The patient`s history of chronic osteomyelitis is usually longer than 2 weeks. Pain is a predominant sign of chronic osteomyelitis. Fever however is not obligatory in cases with chronic osteomyelitis. Immobility and muscle atrophy are a frequent clinical finding in chronic osteomyelitis. The laboratory data could be specific or less specific. In contrast to acute osteomyelitis the less vasculated diaphysis is affected more frequent by chronic osteomyelitis.

32 Clinical and radiological data of 47 cases with chronic osteomyelitis nr % Age 1 18 years Average: 8.4 years Male Female Isolated micro organisms 11 23,5 -Staphylococcus aureus Streptococcus epidermis 3 6 -Stomatococcus mucilaginosus 1 2 Biopsy 17 36

33 Clinical and radiological data of 47 cases with chronic osteomyelitis Used diagnostic modalities nr % Plain films Ultrasound CT 3 6 MRI 6 13 Nuclear scanning Affected bone nr % Femur Tibia Foot 5 11 Humerus 3 6 Pelvis 2 4 Spine 2 4 Sternum 2 4 Hand 1 2 Rib 1 2

34 Right-sided chronic osteomyelitis of os pubis

35 Left-sided chronic osteomyelitis of os ilium.

36 July 2005 December 2005 December 2005 Right-sided chronic osteomyelitis of diaphysis of tibia.

37 A B A Left-sided chronic osteomyelitis of femur with a sequestrum. Before (A) and after (B) resection.

38 February 2001 June 2002 June 2003 Follow up of sclerosing osteomyelitis of left clavicle

39 January 2007 April 2007 April 2008 Right-sided chronic epiphyseal osteomyelitis.

40 Exogenous osteomyelitis left calcaneus caused by ulceration (decubitus) of the heel.

41 Exogenic coccygeal osteomyelitis following decubitus in a child with spina bifida.

42 Chronic recurrent multifocal osteomyelitis The bone lesions are multifocal with a prolonged course with varying activity of the disease. Lack of response to antibiotics. Typical radiographic lytic regions surrounded by sclerosis. No identifiable organism found. Not complicated with abscesses.

43 January 2008 February 2008 A case of multifocal recurrent osteomyelitis affecting the fifth metatarsal bone of both sides.

44 Multifocal recurrent osteomyelitis with a history of back pain of more than 6 months. Left ilium affected.

45

46 An infant with right-sided primary purulent coxitis complicated with destruction of the epiphysis later on.

47 BCG osteomyelitis of right femur.

48 Salmonella osteomyelitis of distal humerus with soft tissue abscess.

49 Conclusion I The highly vasculated metaphysis is the most common affected site by hematogenous osteomyelitis, specially in infancy. The femur is the most frequently affected bone in osteomyelitis. Staphylococcus aureus is the most common causative organism in all types of osteomyelitis. A history of osteomyelitis longer than 2 weeks should be considered as subacute or chronic. Septic arthritis is an early and limb shortening is a late complication of osteomyelitis.

50 Conclusion II Biopsy is indicated incidentally to confirm the diagnosis of a subacute or chronic osteomyelitis. Ultrasound additionally to plain film is a useful modality in recognition of septic arthritis and soft tissue abscesses. Nuclear scanning should be performed when multifocal involvement is expected. MRI is a useful method to assess the extention of inflammatory process as well as in differential diagnosis with other bone disorders. CT is the modality of choice in diagnosis of sequestration by chronic osteomyelitis.

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