[Acute haematogenous osteomyelitis of the pelvis with multifocal pyogenic abscesses in an adult]. / Ostryi gematogennyi osteomielit taza u vzroslogo s mnozhestvennymi gnoinymi metastazami.

Acute hematogenous osteomyelitis (AHO) in adults is a rare disease complicating timely diagnosis. Even greater difficulties are observed in case of pelvic bone lesion. The authors report AHO of the pelvis an adult. Osteomyelitis was complicated by generalized infection and multiple pyogenic abscesses in subcutaneous adipose tissue of the upper and lower extremities. Detection of primary infectious focus was complicated by extreme severity of the patient's condition and low informative value of X-ray and ultrasound at the early stage of disease. Staphylococcus aureus was obtained from blood culture and infectious foci. Surgical debridement along with complex intensive care ensured a positive outcome.

Oxygen embolism after hydrogen peroxide irrigation during hip arthroscopy: a case report.

BACKGROUND: Hydrogen peroxide has been widely used in Orthopaedics including Orthopaedic oncology, trauma and joint surgeries. However, we encountered an oxygen embolism and myoglobinuria after hydrogen peroxide was used to irrigate a septic hip arthroscopically. CASE PRESENTATION: A 61-year-old male patient with right hip septic arthritis underwent an arthroscopic hip washout and debridement. During the operation, the surgeon used 100 ml of 3% hydrogen peroxide to irrigate the joint cavity. Two minutes after irrigation, there was a transient decrease in oxygen saturation, heart rate and blood pressure, with significant subcutaneous emphysema around the wound. Concentrated urine was drained out 8 h after operation which resolved the following day. Post-operatively, the patient was managed in the intensive care unit for a pulmonary embolism and discharged without further complications. CONCLUSION: Medical staff should be aware of the risk of oxygen embolism and be extremely careful when using hydrogen peroxide in patient care. Oxygen embolism following hydrogen peroxide use is rare, however, once encountered, it may bring serious consequences. Therefore, the use of hydrogen peroxide in closed spaces or arthroscopic procedures should be discontinued.

Catch Me If You Can.

Nocardia is a genus of anaerobic gram-positive bacteria that most commonly infect persons with compromised immunity. Pneumonia and soft tissue infections are seen most frequently; osteomyelitis is an uncommonly reported manifestation of nocardiosis. We report a case of pelvic osteomyelitis due to Nocardia asteroides in a patient with unrecognized acquired immune deficiency syndrome (AIDS) without evidence of concomitant pulmonary or skin infection.

Two cases of Osteoarticular Mucor menace: A diagnostic and management conundrum.

Mucormycosis is an uncommon aggressive fungal infection usually seen in immunocompromised hosts or patients with burns and trauma. The common presentations include rhino-orbital-cerebral and pulmonary involvement. Osteoarticular involvement is a rare presentation of this disease. We present two cases of osteoarticular mucormycosis of pelvis and long bones of the lower limb, one in a patient with burn injury and other one in a patient with chronic granulomatous disease, hitherto a rarely reported association. Delayed diagnosis in a setting where tuberculosis is a common cause of chronic osteomyelitis, challenges in medical and surgical management of these patients are discussed in this report.

Key role of magnetic resonance imaging in the diagnosis of infections around the hip and pelvic girdle mimicking septic arthritis of the hip in children.

Infections around the hip and the pelvic girdle mimicking septic hip arthritis are rare conditions in the pediatric population requiring urgent treatment. They are not readily diagnosed because of rarity, resemblance to septic hip, and unclear pathophysiology, which often results in misdiagnosis, delayed diagnosis, and delayed treatment. The aim of this study was to prove the key role of magnetic resonance imaging (MRI) as the first-line modality in making a early definite diagnosis of an uncommon perihip infection in children. We retrospectively reviewed 20 children with a provisional diagnosis of unilateral septic hip who were confirmed finally to have perihip infections and combined with concomitant osteomyeltis using MRI. All patients were treated with intravenous antibiotics with or without abscess aspiration until normalization of clinical symptoms and laboratory tests including serum C-reactive protein and erythrocyte sedimentation rate. All infections healed successfully and the final C-reactive protein was recovered to a mean of 0.37 mg/dl (range 0.01-0.78 mg/dl) without recurrence or complication. Although the MRI is costly and limited in practical application, it was found to be effective as a primary diagnostic tool for an early, accurate diagnosis of infections around the hip and the pelvic girdle in children to correctly guide the decision and the approach for treatment.

Diagnosing pelvic osteomyelitis beneath pressure ulcers in spinal cord injured patients: a prospective study.

There is no consensus on a diagnostic strategy for osteomyelitis underlying pressure ulcers. We conducted a prospective study to assess the accuracy of multiple bone biopsies and imaging to diagnose pelvic osteomyelitis. Patients with clinically suspected osteomyelitis beneath pelvic pressure ulcers were enrolled. Bone magnetic resonance imaging (MRI) and surgical bone biopsies (three or more for microbiology and one for histology per ulcer) were performed. Bacterial osteomyelitis diagnosis relied upon the association of positive histology and microbiology (at least one positive culture for non-commensal microorganisms or three or more for commensal microorganisms of the skin). From 2011 to 2014, 34 patients with 44 pressure ulcers were included. Bacterial osteomyelitis was diagnosed for 28 (82.3%) patients and 35 (79.5%) ulcers according to the composite criterion. Discrepancy was observed between histology and microbiology for 5 (11.4%) ulcers. Most common isolates were Staphylococcus aureus (77.1%), Peptostreptococcus (48.6%) and Bacteroides (40%), cultured in three or more samples in 42.9% of ulcers for S. aureus and ≥20% for anaerobes. Only 2.8% of ulcers had three or more positive specimens with coagulase-negative staphylococci, group B Streptococcus, and nil with enterococci and Pseudomonas aeruginosa. Staphylococcus aureus, Proteus and group milleri Streptococcus were recovered from one sample in 22.8%, 11.4% and 11.4% of ulcers, respectively. Agreement was poor between biopsies and MRI (κ 0.2). Sensitivity of MRI was 94.3% and specificity was 22.2%. The diagnosis of pelvic osteomyelitis relies on multiple surgical bone biopsies with microbiological and histological analyses. At least three bone samples allows the detection of pathogens and exclusion of contaminants. MRI is not routinely useful for diagnosis.

Osteomyelitis of the iliac crest: a rare complication following perforated appendicitis.

BACKGROUND: Appendicitis is a common surgical emergency with numerous postoperative infective complications. We report an unusual case of iliac crest osteomyelitis as a late complication following emergency appendectomy for perforated gangrenous appendicitis. METHODS: Review of the pertinent English language literature. RESULTS: To the best of our knowledge, this is the first report in the English literature to describe iliac crest osteomyelitis as an infective complication of perforated gangrenous appendicitis. The diagnosis was made with the aid of magnetic resonance imaging and radioisotope bone scans. The complication was treated successfully with broad-spectrum intravenous antibiotics and physiotherapy. CONCLUSION: Iliac crest osteomyelitis is indeed a rare complication of appendicitis. A heightened awareness and better understanding of this complication would necessitate early diagnosis and treatment.

Pelvic osteomyelitis: a diagnostic challenge in children.

BACKGROUND: Acute hematogenous osteomyelitis (AHOM) in children usually occurs in tubular bones. Acute hematogenous osteomyelitis of the pelvis is rare and is often not recognized primarily. METHODS: To review the experience with pelvic AHOM at our institution, we analyzed records from children diagnosed with pelvic AHOM (1984-2003) and compared with those reported in the literature. RESULTS: Among 220 children with AHOM (median age, 6.4 years), those 19 (9%) with pelvic AHOM were significantly older (median age, 9.0 years; range, 0.04-15.6). All children presented with limping or refused to walk. Twelve of 19 patients were febrile, 16 of 18 had elevated C-reactive protein (>20 mg/L), and 6 of 19 had leukocytes greater than 12 G/L. Staphylococcus aureus was isolated from blood or bone aspirates in 9 of 17 patients, and Streptococcus pneumoniae was isolated in 1. Scintigraphy was diagnostic in 15 of 15 children, and magnetic resonance imaging in 7 of 7 children. The mean time between initial symptoms and diagnosis was 3 days (range, 1-8 days). Infection resolved completely in all children after antibiotic therapy. CONCLUSION: Pelvic AHOM should be considered in children with limping and pain referred to the hip, thigh, or abdomen. Diagnosis by scintigraphy or magnetic resonance imaging followed by local puncture and microbiological workup allows for specific antibiotic treatment and results in an excellent outcome of pelvic AHOM.

[Recurring disseminated Mycobacterium avium infections in an HIV-negative patient]. / Rezidivierende disseminierte Mycobacterium-avium-Infektionen bei einem HIV-negativen Patienten.

HISTORY AND ADMISSION FINDINGS: A 64 year old man complained about progressive pain in his right upper leg and pelvis since 4 weeks without any history of trauma. He noticed a reduced general health status for several months with weight loss and subfebrile temperatures. The patient's medical history revealed several malignant tumours and recurrent infections with atypical mycobacteria and herpes viruses. INVESTIGATIONS: Laboratory findings showed signs of chronic inflammation. Multiple disseminated osteolytic bone lesions, hepatosplenomegaly, lymphadenopathy and multiple splenic lesions were detected by CT scan. Mycobacterium avium was isolated from an osteolytic lesion of the pelvic bone. Malignant disease and acquired immunodeficiency syndrome were excluded. Lymphocyte counts showed lymphocytopenia with reduced T cells, B cells and a reduced CD4-/CD8-ratio. Interferon-gamma-pathway defects as described in patients with susceptibility to atypical mycobacteria could not be identified. TREATMENT AND COURSE: Clinical and immunologic findings indicated a link between recurrent Mycobacterium avium infections and an idiopathic CD-4 T-cell lymphopenia (low CD4 syndrome). Antimycobacterial treatment at standard doses was started according to the resistance test obtained from microbiological culture. Medical and radiological checkup after 3 months of therapy showed signs of progressive disease. CONCLUSIONS: Osteolytic lesions can be caused by mycobacterium avium infection. Disseminated atypical mycobacteriosis is an opportunistic disease in patients with congenital or acquired immunodeficiency syndrome.

Pseudomonas aeruginosa sacroiliitis and osteomyelitis of pelvic bones after radical prostatectomy.

A 66-year-old diabetic man presented with acute incapacitating pelvic pain 6 weeks after radical prostatectomy. Symphysis pubis biopsy showed chronic osteomyelitis, and culture grew Pseudomonas aeruginosa. Despite a 7-week course of intravenous piperacillin and ceftazidime, he returned 6 months later with the same symptoms. Imaging studies and biopsy indicated right sacroiliitis and persistent pseudomonas osteomyelitis of the pelvic bones. He refused surgical debridement and was successfully treated with the same antibiotics for 8 more weeks. We emphasize the importance of bone biopsy and culture to expedite effective intravenous antibiotic therapy.

Imaging of low-grade bone infection with a technetium-99m labelled monoclonal anti-NCA-90 Fab' fragment in patients with previous joint surgery.

Low-grade bone infection represents a serious clinical problem. Diagnostic options are often insufficient, yet the therapeutic implications of proven disease are important, especially in patients with prosthetic joint replacement. Technetium-99m labelled monoclonal anti-NCA-90 granulocyte antibody Fab' fragment (MN3 Fab') has been shown to be useful in bone and joint infection, but there are no data specifically referring to low-grade bone infection. We therefore analysed 38 scans in 30 consecutive patients (age range, 30-85 years; median age, 62 years) referred for suspected low-grade bone infection. There were 17 patients (21 scans) with total hip arthroplasty (THA), six with total knee arthroplasty (TKA), three who had undergone hip or knee surgery for trauma and five (seven scans) with resected hips and no endoprostheses (Girdlestone situations); one of these five patients had been investigated before with THA in situ and another prior to surgery for low-grade coxitis. There were no patients with rheumatoid arthritis as the underlying disease. Results were verified by means of bacteriological cultures, histopathological findings and/or follow-up and compared with the respective Zimmerli scores, which were used for clinical assessment of inflammatory activity. In one patient, the final diagnosis could not be established. One, 5 and 24 h after intravenous injection of up to 1.1 GBq of MN3 Fab', whole-body and planar scans were performed using a dual-head gamma camera. Scans were analysed visually and semiquantitatively adopting an arbitrary score ranging from 0 to 3. There were 13 true positive, 14 true negative and 10 false positive outcomes, yielding an overall sensitivity of 100%, an overall specificity of 58%, an accuracy of 73% and positive and negative predictive values of 57% and 100%, respectively. In patients with THA or TKA, accuracy was 81% and 80%, respectively, while it dropped to 43% in patients with Girdlestone situations owing to a high proportion of false positive findings (4/7) in this subgroup. Scintigraphic score was 1 in all of the false positive and in 11/13 true positive findings. The two remaining true positive findings displayed scintigraphic scores of 2 and 3, respectively. Scintigraphic and Zimmerli scores were loosely correlated (Spearman rho=0.38, P<0.05). Infection was excluded in 22/24 investigations with Zimmerli scores of <6. In this group, there were 13 scintigraphically true negative, nine false positive outcomes, and just two true positive outcomes. In 11/12 investigations with Zimmerli scores of 6 or 7, infection was verified and scintigraphic outcome was accordingly true positive, while the remaining patient was true negative. In conclusion, MN3 Fab' scintigraphy proved to be highly sensitive but not specific in diagnosing low-grade infections of the hip and knee regions in patients with previous joint surgery. The method seems reliable in excluding but not in proving the presence of infection. MN3 Fab' scintigraphy should not be applied in patients with Girdlestone situations. Assessment of infection using the Zimmerli score was more reliable than MN3 Fab' scintigraphy in this group of patients without rheumatoid arthritis as the underlying disease. Considering results from the literature concerning leucocyte scintigraphy, MN3 Fab' scintigraphy may be clinically useful in evaluating low-grade bone infection in THA and TKA patients with Zimmerli scores above 5 and concomitant rheumatoid arthritis or other inflammatory diseases.

[Tuberculosis of the bone]. / Gruzlicze zapalenie kosci.

We describe a 75 year old patient treated because of arthrosis and recurrent pneumonia for a year. In hospital acid-fast bacilli were found in sputum. Chest x-ray revealed massive inflammatory and fibrous lesions. Pelvis x-ray revealed lesions estimated as tuberculosis. Tuberculosis of lungs and pelvis bones was recognised. After 3 months of antituberculous treatment patient was referred to outpatient department for further therapy.

[Intra-osseus gas formation in osteomyelitis of vertebrae and pelvis by Klebsiella pneumoniae]. / Intra-ossale gasvorming bij osteomyelitis van wervels en bekken door Klebsiella pneumoniae.

A 59-year-old woman had persistent sepsis after abdominal operations because of a volvulus and subsequently a retroperitoneal abscess, in spite of antibiotic treatment against Klebsiella pneumoniae, which grew in blood cultures. During abscess drainage, a haemorrhage from the infrarenal part of the aorta had occurred; in view of a presumed aortitis this part had been replaced by a bifemoral bypass. Computer tomography revealed intraosseous formation of gas in vertebrae and pelvis. At operation, abscesses were drained and necrotomy and sequestrotomy of the bone were performed. Cultures of the pus from the iliac crests showed K. pneumoniae. The antibiotic management was changed; the wounds were flushed regularly. After exposure of the wounds still draining after 6 months and vascular surgery because of occlusion of the bypass after 7 months, the patient recovered well. She died 2 years later from a cerebral haemorrhage.

Osteomyelitis of the pelvis/hips in paralyzed patients: accuracy and clinical utility of MRI.

PURPOSE: The goal of our study was to determine the accuracy and clinical utility of MRI in the diagnosis of osteomyelitis of the pelvis/hips in paralyzed patients. METHOD: In 44 paralyzed patients, 59 consecutive MR examinations of the pelvis/hips were evaluated prospectively. Criteria for diagnosis of osteomyelitis were based on those established in previous studies of complex, nonhematogenous osteomyelitis (diabetic foot). Average follow-up was 3 years. The standard of reference for the diagnosis of osteomyelitis was histologic/microbiologic results of surgical biopsy specimens or clinical follow-up. Note was made if decubitus ulcers, sinus tract, fistula, fluid collection, abscess, septic arthritis, joint effusion, bursitis, or heterotopic ossification was present on MRI. Comparison of the extent of infection by MRI and surgical margins was performed. Effect on surgical treatment was defined by absence of recurrent infection at the surgical site within 6 weeks of limited resection. RESULTS: The criteria for diagnosis of osteomyelitis were fulfilled in 49 of 57 MR studies for an overall accuracy of 97%. There was one false-negative MR study. MRI for the diagnosis of osteomyelitis yielded a sensitivity of 98% and a specificity of 89%. There were 41 decubitus ulcers, 28 sinus tracts, 2 fistulae, 14 fluid collections, 15 abscesses, 9 hips with septic arthritis, 10 "bland" hip effusions, 5 cases of trochanteric bursitis, and 30 patients with heterotopic ossification. Twenty-one patients underwent limited surgical resection guided by MR findings in which only the enhancing area was resected. There was only one recurrence of osteomyelitis at the surgical margins. CONCLUSION: MRI is accurate in the diagnosis of osteomyelitis and associated soft tissue abnormalities in spinal cord-injured patients. MRI can delineate the extent of infection in guiding limited surgical resection and preserving viable tissue.