Multifocal Osteomyelitic Tuberculosis at Rare Locations with Metastatic Tuberculosis Abscess.

BACKGROUND Multifocal tuberculosis (TB) with more than 1 tuberculous osteoarticular lesion is rare. Furthermore, metastatic tuberculous abscess (MTA) is also a very rare manifestation of cutaneous TB in children. A non-specific, often subtle, early clinical presentation in conjunction with a low prevalence rate constitute obstacles for diagnosis. CASE REPORT A 9-years old female patient was referred to Hasan Sadikin Pediatric Respirology Outpatient clinic from the Orthopedic Department with lumps at the left elbow joint, lateral side of the left hand, and lateral side of the left foot. Fine needle aspiration biopsy of the lumps suggested a chronic inflammation due to TB. The patient was then started with a course of anti-TB drugs consisting of rifampicin, isoniazid, pyrazinamide, and ethambutol. During the treatment course, she experienced anti-TB drug-induced hepatotoxicity (ADIH). We then switched the regimen to streptomycin and ethambutol for 2 weeks, then reintroduced treatment with the modified British Thoracic Society guidelines regimen. The nodules appeared shrunken after 3 months of treatment with anti-TB drugs. CONCLUSIONS Increased awareness of unusual manifestations of TB will likely allow for proper diagnosis and management of this common infection. Accordingly, timely diagnosis and management will prevent further debilitating sequelae.

Coccidioides, cryptococcus, or blastomyces? A diagnostic dilemma encountered during frozen section evaluation.

Intraoperative consultation via frozen section is an important part of modern day surgical pathology. Recognizing fungi in tissues on frozen and permanent sections is not always a simple task, and correctly identifying the agent can be a significant challenge, even for experienced microscopists. We present a case of a 17-year-old boy with chronic osteomyelitis involving the right proximal ulna. During an irrigation and debridement operation, a frozen section was sent to surgical pathology for evaluation. A limited patient history coupled with sparse organisms present in the frozen section led to the diagnosis of fungal osteomyelitis, favor Coccidioides . Follow-up permanent sections with special staining and successful fungal culture clarified the causal agent to be Blastomyces dermatitidis . The role of frozen sections is not to perfectly speciate the fungal pathogen but to describe the morphology and infectious process and provide a differential diagnosis of the candidate fungi. The importance of intraoperative culture in infectious cases cannot be understated, and it is the responsibility of pathologists to inform surgeons that tissue is needed for culture. A brief overview of Blastomyces , including histopathologic features and key microscopic differences from Coccidioides and Cryptococcus , is discussed.

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.

Osteomyelitis of the ulna caused by Porphyromonas gingivalis.

A 41-year-old man was provided with a jacket crown after a root end resection of a molar. Four months later, cortical destruction of the ulnar diaphysis with swelling and pain appeared in his forearm. No microorganism could be grown from an intraoperative tissue specimen, but bacterial 16S rRNA genes were detected by broad-range PCR, revealing Porphyromonas gingivalis as the causative agent of osteomyelitis.

Erysipelas in the critically endangered kakapo (Strigops habroptilus).

This paper describes the effect of a disease outbreak on the success of a translocation for conservation management in a critically endangered species. Three juvenile kakapo from a group of 19 translocated birds died within 72 h of transport between New Zealand offshore islands. Clinical findings, gross necropsy changes, cytology, histopathology and bacterial culture confirmed systemic disease caused by Erysipelothrix rhusiopathiae. On the island from which the kakapo were sourced, positive cultures of E. rhusiopathiae were obtained from the medulla of the ulna from 10 out of 15 seabird carcasses examined, suggesting that this could be the source of infection for the kakapo. Immediately after the diagnosis, all of the translocated birds were re-captured and treated with antibiotics. A vaccination programme has commenced using a commercial killed bacterin developed for turkeys. The disease outbreak has had costly implications for the population and conservation management of the species. This is the first report of erysipelas in wild parrots, and the first report of the management of erysipelas in a critically endangered wild population of birds.

Group A streptococcal osteomyelitis: severe presentation and course.

AIM: To evaluate the course of group A streptococcal osteomyelitis associated with severe disease nowadays. METHODS: Three consecutive cases of severe group A streptococcal disease with osteomyelitis in children that were documented in Beer Sheva, Israel are described in detail. RESULTS: Two of the three cases were postvaricella. Early in the course of the disease, the presentation resembled that of severe cellulitis. All three patients had severe osteomyelitis and required surgery, and one patient developed chronic osteomyelitis. Sepsis was diagnosed in two cases. CONCLUSION: Our cases are distinguishable from typical haematogenous staphylococcal osteomyelitis by the severe course and the extensive involvement of bone and soft tissues. The increase in severity of invasive group A streptococcal infections documented throughout the world could account for the difference between our complex cases and the previous reports.

Aspergillus terreus as a cause of septic olecranon bursitis.

A 72-year-old, non-insulin-dependent diabetic man with a 2-month history of painful right olecranon bursitis was examined after a fall on the sidewalk that resulted in some abrasion of the skin overlying the elbow. Fluid aspirated from the bursa showed growth of Aspergillus terreus, as did tissue from a bursectomy performed 1 week later. Septic bursitis is an uncommon disease that is nearly always caused by Staphylococcus aureus or hemolytic streptococci. Mycotic bursitis is very rare and this is the first reported instance of any Aspergillus species causing septic bursitis.

Osteomyelitis due to Kingella kingae infection.

A case of osteomyelitis due to Kingella kingae is presented to illustrate the insidious onset and indolent course typical of bone infections caused by this organism. The frequently negative result obtained with Gram's stain and the fastidious nature of the organism makes diagnosis difficult. Initial therapy with an aminopenicillin such as ampicillin in addition to antimicrobial drugs for Staphylococcus aureus should be effective in resolving bone and joint infections in children.