IS Case 216: Osteomyelitis
Imaging Sciences URMC 2008
Publication Date: 2009-05-22
Patient is a 4-year-old child, recently immigrated from Asia, presenting with fever and fall on her left elbow. Although initial radiographs were normal, a splint was placed for concern a supracondylar fracture because she had two blisters on antecubital fossa and wrist. Patient was to follow-up with orthopedics as an outpatient. A week later her primary care physician sent her back to the emergency room because of dehydration and fever. Initial concern was for malaria as she comes from an area where it is endemic. However, she complained of left forearm pain so her splint was removed and fluctuance was found around the left elbow with MRI confirming a large abscess. Patient was taken to the operating room where a large amount of pus was removed.
Osteomyelitis has a tendency to occur in metaphyses or metaphyseal equivalents (bone next to cartilage, e.g., calcaneal apophysis and acetabulum). Etiology: Staphylococcus aureus commonest (43%), then β-hemolytic streptococcus (10%) and S. pneumoniae (10%). In penetrating trauma, P. aeruginosa is often causative. In patients with sickle cell disease, salmonella is the likely organism. SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, osteitis) presents with recurrent multifocal osteomyelitis of long-bone metaphyses and medial clavicles. CRMO (chronic recurrent multifocal osteomyelitis) is non-pyogenic and has an unknown cause, as well as prolonged or recurrent course in children and adolescents. Epidemiology: 1/5,000 children < 13 years in the US. Neonates are at highest risk because of an immature host-defense system, especially newborn intensive care babies (umbilical catheter an added risk factor). Neonates usually are infected by S. aureus, β-streptococcus, and Candida (C) albicans.
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