Tuberculosis of radius diaphysis: Case report and review of literature.

Diaphyseal tuberculosis (TB) is a rare case of the skeletal TB. The following report documents the case of a 52-year-old Moroccan woman with a swelling over the right forearm followed by pulmonary TB under treatment for 3 months. The radiographs of the forearm show a lytic image located at the radius mid-diaphysis. The histopathology confirmed the diagnosis. The patient received surgical drainage with trepanation of the bone. The antibacillary chemotherapy was administered for 6 months. It is, therefore, indispensable to bear in mind the possibility of such atypical presentations of TB when making a rapid and pertinent diagnosis and prescribing the appropriate treatment.

Osteitis of the radius following Bacillus Calmette-Guérin vaccination at birth: a case report.

BACKGROUND: The Bacillus Calmette-Guérin vaccine, which is used for the prevention of tuberculosis, is considered protective against the severe forms of childhood tuberculosis. However, some serious adverse reactions including osteitis of the long bones can occur. CASE PRESENTATION: We report a case of an 18-month-old Sudanese girl who presented at the age of 3 months with swelling of her left forearm following Bacillus Calmette-Guérin vaccination administered at birth. Radiological and histological investigations confirmed tuberculous osteitis of the distal radius. She responded very well to antituberculous treatment with complete healing at follow-up visits. To the best of our knowledge this is the first case report of osteitis of the radius following Bacillus Calmette-Guérin vaccination described from Sudan. CONCLUSIONS: Bacillus Calmette-Guérin osteitis, although rare, should be considered a possible complication of the Bacillus Calmette-Guérin vaccination, and early diagnosis and treatment are essential.

Local gentamicin delivery from resorbable viscous hydrogels is therapeutically effective.

BACKGROUND: Local delivery can achieve the high antimicrobial concentrations necessary to kill biofilm-related microbes. Degradation times for resorbable carriers are too long. Hydrogels (gels of hydrophilic polymer in water) can degrade faster but release antimicrobials too quickly. We previously developed hydrogels based on the copolymer poly(N-isopropylacrylamide-co-dimethyl-γ-butyrolactone acrylate-co-Jeffamine® M-1000 acrylamide) (PNDJ) with delivery times of several days with complete degradation in less than 6 weeks. QUESTIONS/PURPOSES: We asked: (1) What is the elution profile of gentamicin from PNDJ hydrogels? (2) Is gentamicin released from gentamicin-loaded PNDJ (G-PNDJ) hydrogel effective for treatment of orthopaedic infection? (3) Does local gentamicin delivery from G-PNDJ hydrogel cause renal dysfunction? METHODS: (1) Two formulations of G-PNDJ, lower dose (1.61 wt%) and higher dose (3.14 wt%), five samples each, were eluted in buffered saline under infinite sink conditions. (2) Infections were induced in 16 New Zealand White rabbits by inserting a Kirschner wire in a devascularized radius segment and inoculating with 7.5×10(6) colony-forming units Staphylococcus aureus. At 3 weeks, débridement was performed and a new Kirschner wire was placed in the dead space. Treatment was randomized to higher-dose G-PNDJ or no hydrogel. No systemic antimicrobials were used. Positive culture and acute inflammation on histology were used to determine the presence of infection 4 weeks postdébridement. (3) 3.14 wt% G-PNDJ, 0.75, 1.5, or 3.0 mL, was injected subcutaneously in nine Sprague-Dawley rats, three of each dose. Serum gentamicin, blood urea nitrogen, and creatinine were measured on Days 1, 3, 7, 14, and 28. RESULTS: (1) Gentamicin release was sustained over 7 days with the higher-dose formulation release profile similar to release from high-dose antimicrobial-loaded bone cement. (2) Four weeks postdébridement, infection was present in eight of eight no-hydrogel rabbits but zero of eight rabbits treated with G-PNDJ hydrogel (p<0.001). (3) Blood urea nitrogen and creatinine were transiently elevated (p<0.05) only for the two of three rats receiving the 3.0-mL dose on Days 3 and 7. CONCLUSIONS: Gentamicin is delivered from PNDJ hydrogel with low systemic exposure and decreased treatment failure for orthopaedic infection. Transient renal dysfunction occurs at high doses. Biodistribution and toxicity testing are needed for G-PNDJ to be clinically usable. CLINICAL RELEVANCE: Resorbable viscous hydrogels for local antimicrobial delivery may improve outcomes for one-stage management of implant infections when uncemented reconstructions are performed.

Evaluation of dynamic [18F]-FDG-PET imaging for the detection of acute post-surgical bone infection.

Diagnosing bone infection in its acute early stage is of utmost clinical importance as the failure to do so results in a therapeutically recalcitrant chronic infection that can only be resolved with extensive surgical intervention, the end result often being a structurally unstable defect requiring reconstructive procedures. [(18)F]-FDG-PET has been extensively investigated for this purpose, but the results have been mixed in that, while highly sensitive, its specificity with respect to distinguishing between acute infection and sterile inflammatory processes, including normal recuperative post-surgical healing, is limited. This study investigated the possibility that alternative means of acquiring and analyzing FDG-PET data could be used to overcome this lack of specificity without an unacceptable loss of sensitivity. This was done in the context of an experimental rabbit model of post-surgical osteomyelitis with the objective of distinguishing between acute infection and sterile post-surgical inflammation. Imaging was done 7 and 14 days after surgery with continuous data acquisition for a 90-minute period after administration of tracer. Results were evaluated based on both single and dual time point data analysis. The results suggest that the diagnostic utility of FDG-PET is likely limited to well-defined clinical circumstances. We conclude that, in the complicated clinical context of acute post-surgical or post-traumatic infection, the diagnostic utility accuracy of FDG-PET is severely limited based on its focus on the increased glucose utilization that is generally characteristic of inflammatory processes.

A non-traumatic Staphylococcus aureus osteomyelitis model in pigs.

BACKGROUND: The propensity for bacterial localization within bones of juvenile pigs is similar to the situation in humans, where haematogenously based osteomyelitis most commonly occurs in infants and children. In both pigs and humans, Staphylococcus aureus is a dominant cause of pyaemic lesions including osteomyelitis. The aim of the present study was to evaluate the pig as a model for the development of osteomyelitis following haematogenous spread of S. aureus. MATERIALS AND METHODS: Twelve animals were challenged intravenously once or twice with 1x10(8) bacteria/kg body weight and euthanased consecutively from 6 h to 48 h after challenge. Following euthanasia, tissues were sampled from the lungs and bones for histology and immunohistochemical staining of vessels, different inflammatiory cells, apoptosis cells, and S. aureus. RESULTS: Disseminated microabscesses developed within the lungs by 6 h but had disappeared at 48 h. Within the metaphyseal area of bones, microabscesses developed after 12 h and progressed until 48 h after challenge. Within bones, lesions were localized in separate foci from where the infection progressed towards the growth plate, which was in some cases bypassed due to bacterial spread through transphyseal vascular channels. Often, bone lesions resulted in trabecular osteosis, in which apoptotic cells were sometimes present. CONCLUSION: The model revealed a pattern of development and presence of lesions similar to the frequently occurring osteomyelitic lesions, especially in pre-pubertal children following haematogenous spread of S. aureus. Therefore, this model can be reliably applied in studies of this disease with respect to pathophysiology, pathomorphology, impact of strain virulence, and therapy.

Comparison of arthroscopic and open treatment of septic arthritis of the wrist. Surgical technique.

BACKGROUND: Open irrigation and débridement is the standard of treatment for septic arthritis of the wrist. Although isolated cases of arthroscopic irrigation and débridement have been reported, a comparison of arthroscopic and open techniques has not been performed, to our knowledge. The purpose of this study was to compare the two methods of management. METHODS: A retrospective comparison of patients with septic arthritis of the wrist initially treated, over an eleven-year period, with open or arthroscopic irrigation and débridement was undertaken at a single institution. The clinical presentation, laboratory and microbiological findings, hospital course, complications, and outcomes were compared between the two groups. RESULTS: Between 1997 and 2007, thirty-six patients with septic arthritis involving a total of forty wrists were identified. Nineteen wrists (seventeen patients) were initially treated with open irrigation and débridement, and twenty-one wrists (nineteen patients) were initially treated arthroscopically. Eleven wrists in the open-treatment cohort required repeat irrigation and débridement, and eight wrists in the arthroscopy cohort required a repeat procedure. If a repeat irrigation and débridement was required, it was performed in an open fashion in all but two cases. When the comparison included all of the patients in the series, no difference between the two cohorts was found with regard to the number of irrigation and débridement procedures required or the length of the hospital stay. However, when the comparison was limited to the patients with isolated septic arthritis of the wrist, it was found that only one of seven wrists in the open-treatment cohort but all eight wrists in the arthroscopy cohort had been successfully managed with a single irrigation and débridement procedure (p = 0.001). No patient in whom isolated septic arthritis of the wrist had been treated with arthroscopic irrigation and débridement required a second operation. The patients in whom isolated septic arthritis of the wrist was treated with the open method stayed in the hospital for an average of sixteen days compared with a six-day stay for those in whom isolated septic arthritis of the wrist was treated with the arthroscopic method (p = 0.04). The ninety-day perioperative mortality rate in the series was substantial (18% [three patients] in the open-treatment cohort and 21% [four patients] in the arthroscopy cohort). CONCLUSIONS: Arthroscopic irrigation and débridement is an effective treatment for patients with isolated septic arthritis of the wrist; these patients had fewer operations and a shorter hospital stay than did patients who had received open treatment. However, these benefits were not seen in patients with multiple sites of infection.

Tuberculosis of the elbow joint in children: a review of ten patients who were managed nonoperatively.

BACKGROUND: There is scarce information regarding osteoarticular tuberculosis of the elbow in children, even in countries where tuberculosis is endemic. We report our experience with ten patients who were managed nonoperatively. METHODS: We retrospectively assessed ten children with elbow tuberculosis with regard to their presentation, diagnosis, management, response to standard antitubercular drugs, and outcome at the completion of antitubercular therapy. All patients were managed nonoperatively with splinting for as long as six weeks, followed by mobilization along with multidrug antitubercular medication for twelve months. RESULTS: Swelling of the elbow that did not respond to initial treatment was the most common cause for referral to our clinic. The proximal ulnar metaphysis was most commonly involved. The average duration of follow-up was twenty-six months. The average time for healing of draining sinuses was twelve weeks (range, four to fourteen weeks). Lytic lesions, including coke-like sequestrum, healed radiographically at an average of 7.4 months (range, six to nine months). Range of motion improved with treatment, but some motion restriction always persisted, depending on the extent of joint destruction. CONCLUSIONS: In the Indian subcontinent, the presentation of elbow tuberculosis is usually exudative with abscess formation, and the disease is fairly advanced at the time of diagnosis. An "ice cream scoop" appearance of the proximal part of the ulna in children should raise suspicion for tuberculosis. Elbow tuberculosis in children can be treated adequately with use of nonoperative means, regardless of the extent of osseous destruction, with a good outcome.

A case of traumatic osteomyelitis in a victim of child abuse.

A premature black female infant born at 31 weeks gestation with history of 4 weeks in the newborn intensive care unit was discharged healthy to the care of her mother and was lost to follow-up. At age 4 months the infant was found dead in bed. There was no history of trauma and no external injuries were noted. There was no attempt at resuscitation. Coroner's autopsy showed acute bronchopneumonia, 3 partially healed skull fractures, a chronic subdural hematoma, chronic intracerebral hemorrhage, retinal hemorrhages, multiple healing rib fractures, a fractured fibula, and a partially healed fracture of the distal right radius. The fracture of the right radius showed a medullary abscess of the bone surrounded by scar tissue and containing pus and granulation tissue. We believe this inflicted fracture became secondarily infected by a hematogenous route. The final diagnosis of the cause of death was pneumonia secondary to multiple blunt force trauma, and the manner of death was diagnosed as homicidal. This is believed to be the first reported case of osteomyelitis in a context of child abuse.

Blastomycosis of long bones.

The presentation of blastomycosis clinically and radiographically is nonspecific and often mistaken for a neoplasm. Delay in diagnosis is common. Patients with osseous blastomycosis present with pain and swelling. Radiographs usually show an eccentric lucency in the distal ends of long bones. These patients frequently are referred for a neoplastic workup and a diagnosis is made only after biopsy. We review the cases of five patients diagnosed with a bone tumor who had blastomycosis osteomyelitis. The time to diagnosis from original symptoms was 4.7 months (range, 3-8 months). The average age of the patients was 45.6 years (range, 20-59 years). A Musculoskeletal Tumor Society functional assessment was done. Early radiographs of the current patients ranged from normal to showing faint osteopenia in the involved location. As the disease progressed, the area of lucency appeared with either diffuse or well-marginated borders. Treatment included surgical debridement with antifungals. The mean functional score was 93.3%. All patients are disease-free. Blastomycosis, similar to tuberculosis, often is mistaken for a neoplasm. Blastomycosis osteomyelitis can be treated with excellent results. The key is diagnosis and including endemic fungal infections in the differential diagnosis of bone tumors. In addition, every potential neoplasm should include cultures of specimens obtained at biopsy.

Effective treatment of osteomyelitis with biodegradable microspheres in a rabbit model.

Biodegradable microspheres were manufactured from a high molecular weight copolymer of 50% lactic and 50% glycolic acid and the antibiotic tobramycin. It was hypothesized that the microspheres would be more effective than polymethylmethacrylate beads in the local delivery of tobramycin and that the microspheres would not inhibit bone healing. Osteomyelitis was established in 40 New Zealand White rabbits using Staphylococcus aureus. All animals had irrigation and debridement of the infected radii four weeks after inoculation and were divided into five treatment groups: debridement alone, microspheres alone, microspheres containing tobramycin plus parenteral treatment with cefazolin, polymethylmethacrylate beads containing tobramycin plus parenteral cefazolin, and parenteral cefazolin. All animals were sacrificed after 4 weeks of treatment. The group treated with microspheres plus parenteral antibiotics was the only group to have a significantly higher percentage of animals without bacteria after 4 weeks of treatment when compared with the control group. Additionally, the animals treated with microspheres had a higher degree of bone healing in the defect than the animals treated with bone cement. The most effective treatment was biodegradable microspheres combined with parenteral antibiotic in this rabbit osteomyelitis model.

Disseminated infection with Phialemonium obovatum in a German shepherd dog.

A 4-year-old spayed female German Shepherd Dog was evaluated because of left forelimb lameness. A fungal granuloma on the distal portion of the radius was determined to be the cause of the lameness; the infecting organism was identified as Phialemonium obovatum. Despite aggressive treatment with amphotericin B, itraconazole, and ketoconazole and curettage of the local area, the dog developed systemic disease and was euthanatized 5 months after initial evaluation. Immune dysfunction may have played a role in development of disseminated disease, because although serum concentrations of total IgG, IgA, and IgM were within or greater than reference ranges, results of lymphocyte proliferation assays were abnormal, which indicated cellular immune dysfunction. Infection with Phialemonium obovatum should be considered as a differential diagnosis when branching fungal organisms are detected during histologic, cytologic, or microbiologic evaluation of tissue specimens.

Tuberculosis of the distal end of the radius mimicking a giant-cell tumour.

We report a case of a lady presenting with a lesion in the distal radius with classical radiological features of a giant-cell tumour. These tumours are often resected without preliminary histological confirmation. A biopsy done in this patient showed it to be tuberculosis.

[Recurrent osteitis and Coxiella burnetii: the relation to chronic recurrent multifocal osteomyelitis]. / Ostéites récidivantes et Coxiella burnetti: relation avec l'ostéomyélite chronique récurrente multifocale.

UNLABELLED: Chronic recurrent multifocal osteomyelitis (CRMO) is a disorder of suspected--but unproved-infectious etiology. OBSERVATION: A girl presented with a typical CRMO involving successively the left fibula, radius, humerus and the right carpus. A Coxiella burnetii infection was indicated during the first attack. Two recurrences occurred in spite of suitable antibiotic treatment and with negative infectious investigation. Two months after stopping antibiotic treatment, a new recurrence associated with antibodies increase and positive bone culture occurred. CONCLUSION: Coxiella burnetii can initiate a CRMO. The mechanism involved is probably a delayed hypersensitivity. CRMO would therefore be the first type of reactive osteitis.

Mycoplasma-mediated bone resorption in bone organ cultures.

Mycoplasmas have been identified as one of many aetiological factors associated with experimental or human joint disease. Mycoplasma hyorhinis and M. arthritidis, but not M. pulmonis were found to cause significant release of calcium from murine long bone explants. The resorption process is inhibited by calcitonin, acetazolamide and by indomethacin. Mycoplasma-derived bone resorbing activity (M-BRA) is not an endotoxin as its effect is equally potent in cultures of bones obtained from endotoxin-responsive and -unresponsive mice. M-BRA is a high molecular weight compound resistant to proteases and heat but sensitive to hyaluronidase, lipase, detergents and in part to alkali and acid conditions. The active component is associated with the particulate fraction of the mycoplasma and its yield is enhanced by sonication. The damage to the subchondral bone in arthritis associated with a mycoplasma infection may be caused by a potent bone resorption inducing agent of mycoplasma origin.