When surgical option is not provided: a successful multidisciplinary approach to a refractory case of sternal osteomyelitis following coronary surgery.

PURPOSE: Sternal osteomyelitis is a major complication of cardiac operations performed through median sternotomy. The surgical treatment, which involves the debridement and removal of whole infected and necrotic tissue is the standard of care, although it is sometimes unachievable. This may occur, for instance, when the infectious-inflammatory process invades the anterior mediastinum and tenaciously incorporates one or more of vital anatomical structures. METHODS AND RESULTS: An inoperable case of postoperative sternal osteomyelitis that involved the right ventricle and the right coronary artery, and that was successfully treated using a nonsurgical multidisciplinary approach, is reported here. CONCLUSION: For highly selected patients with sternal osteomyelitis for whom surgery is a too risky option, an approach including the contribution of various specialists might be a viable way out.

Microbiological study of sternal osteomyelitis after median thoracotomy - a retrospective cohort study.

INTRODUCTION: Deep sternal wound infection is a rare but feared complication of median thoracotomies and is usually caused by microorganisms from the patient's skin or mucous membranes, the external environment, or iatrogenic procedures. The most common involved pathogens are Staphylococcus aureus, Staphylococcus epidermidis and gram-negative bacteria. We aimed to evaluate the microbiological spectrum of deep sternal wound infections in our institution and to establish diagnostic and treatment algorithms. METHODS: We retrospectively evaluated the patients with deep sternal wound infections at our institution between March 2018 and December 2021. The inclusion criteria were the presence of deep sternal wound infection and complete sternal osteomyelitis. Eighty-seven patients could be included in the study. All patients received a radical sternectomy, with complete microbiological and histopathological analysis. RESULTS: In 20 patients (23%) the infection was caused by S. epidermidis, in 17 patients (19.54%) by S. aureus, in 3 patients (3.45%) by Enterococcus spp., in 14 patients (16.09%) by gram-negative bacteria, while in 14 patients (16.09%) no pathogen could be identified. In 19 patients (21,84%) the infection was polymicrobial. Two patients had a superimposed Candida spp. INFECTION: Methicillin-resistant S. epidermidis was found in 25 cases (28,74%), while methicillin-resistant S. aureus was isolated in only three cases (3,45%). The average hospital stay for monomicrobial infections was 29.93 ± 13.69 days and for polymicrobial infections was 37.47 ± 19.18 (p = 0.03). Wound swabs and tissue biopsies were routinely harvested for microbiological examination. The increasing number of biopsies was associated with the isolation of a pathogen (4.24 ± 2.22 vs. 2.18 ± 1.6, p < 0,001). Likewise, the increasing number of wound swabs was also associated with the isolation of a pathogen (4.22 ± 3.34 vs. 2.40 ± 1.45, p = 0.011). The median duration of antibiotic treatment was 24.62 (4-90) days intravenous and 23.54 (4-70) days orally. The length of antibiotic treatment for monomicrobial infections was 22.68 ± 14.27 days intravenous and 44.75 ± 25.87 days in total and for polymicrobial infections was 31.65 ± 22.29 days intravenous (p = 0.05) and 61.29 ± 41.45 in total (p = 0.07). The antibiotic treatment duration in patients with methicillin-resistant Staphylococci as well as in patients who developed an infection relapse was not significantly longer. CONCLUSION: S. epidermidis and S. aureus remain the main pathogen in deep sternal wound infections. The number of wound swabs and tissue biopsies correlates with accurate pathogen isolation. With radical surgical treatment, the role of prolonged antibiotic treatment remains unclear and should be evaluated in future prospective randomized studies.

Pathological study of sternal osteomyelitis after median thoracotomy-a prospective cohort study.

PURPOSE: Osteomyelitis of the sternum may arise either as a primary condition or secondary to median thoracotomy after cardiac surgery, with the latter being decidedly more frequent. Deep sternal wound infections appear as a complication of median thoracotomy in 0.2 to 4.4% of cases and may encompass the infection of the sternal bone. To date, there are no exhaustive histopathological studies of the sternal osteomyelitis. METHODS: Our work group developed a surgical technique to remove the complete infected sternal bone in deep sternal wound infections. We therefore prospectively examined the en bloc resected sternal specimens. Seven standard histological sections were made from the two hemisternums. RESULTS: Forty-seven sternums could be investigated. The median age of the patients in the cohort was 66 (45-81) years and there were 10 females and 37 males. Two methods were developed to examine the histological findings, with one model dividing the results in inflammatory and non-inflammatory, while the second method using a score from 0 to 5 to describe more precisely the intensity of the bone inflammation. The results showed the presence of inflammation in 76.6 to 93.6% of the specimens, depending on the section. The left manubrial sections were more prone to inflammation, especially when the left mammary artery was harvested. No further risk factors proved to have a statistical significance. CONCLUSION: Our study proved that the deep sternal wound infection may cause a ubiquitous inflammation of the sternal bone. The harvest of the left mammary artery may worsen the extent and intensity of infection.

[Surgical treatment of sternal osteomyelitis and sternomediastinitis following cardiac surgery]. / Khirurgicheskoe lechenie osteomielita grudiny i sternomediastinita vsledstvie kardiokhirurgicheskikh operatsii.

OBJECTIVE: To analyze the incidence of cardiac surgeries and postoperative sternal osteomyelitis/sternomediastinitis, as well as treatment outcomes in these patients. MATERIAL AND METHODS: We summarized 171 patients with postoperative sternal osteomyelitis and sternomediastinitis. RESULTS: Organization of the Khabarovsk center for cardiovascular surgery in the Far Eastern Federal District was followed by 7.9- and 24.9-fold increase of the number of cardiac surgeries and CABG in 2005-2019, respectively. As a result, the number of patients with sternal osteomyelitis and sternomediastinitis after cardiac surgery increased from 0.50±0.10 to 1.59±0.17 cases per 100.000 (t=3.01; p<0.01). CPB and aortic clamping time (t=3.97; p<0.01), as well as surgery time (t=2.4; p<0.05) were significant risk factors of early postoperative complications. Two-stage surgical treatment of postoperative sternal osteomyelitis and sternomediastinitis (removal of ligatures and foreign bodies, sternal curettage with removal of sequesters at the first stage; resection of sternum with chest wall repair at the second stage) reduced hospital-stay from 31.9±13.4 to 29.2±10.8 days.

[Treatment of postoperative anterior mediastinitis, sternal osteomyelitis in a patient with a novel coronavirus infection]. / Lechenie posleoperatsionnogo perednego mediastinita, osteomielita grudiny u patsientki s novoi koronavirusnoi infektsiei (COVID-19).

The incidence of mediastinitis after median sternotomy makes up 1-3%. This complication results prolonged hospital-stay, significant increase in treatment cost and high mortality (up to 75%). Severe COVID-19 pneumonia is often manifested by coughing, that impairs sternum stability after osteosynthesis. Moreover, concomitant leukopenia increases the risk of mediastinitis. Viral pneumonia and mediastinitis are complicated by respiratory failure and mutually potentiate the negative effect. Negative pressure wound therapy (NPWT) with combined antibiotic therapy ensures a favorable outcome even in patients with postoperative mediastinitis and osteomyelitis combined with viral pneumonia.

Successful treatment of Aspergillus fumigatus sternal osteomyelitis with isavuconazole in a heart transplant recipient.

A 65-year-old man was diagnosed with an invasive Aspergillus fumigatus infection with sternal osteomyelitis 4 months after heart transplantation. Unfortunately, after 8 weeks patient developed severe cutaneous and neurological toxicities induced by voriconazole leading to drug discontinuation. Therefore, isavuconazole was chosen as second-line therapy. The patient presented a favorable outcome and tolerance was excellent after ten months monotherapy. Here, we report for a first time, an successful isavuconazole-based treatment of sternal osteomyelitis aspergillosis in a cardiac recipient.

Candida auris Sternal Osteomyelitis in a Man from Kenya Visiting Australia, 2015.

In Australia in 2015, Candida auris sternal osteomyelitis was diagnosed in a 65-year-old man with a history of intensive care treatment in Kenya in 2012 and without a history of cardiac surgery. The isolate was South Africa clade III. Clinicians should note that C. auris can cause low-grade disease years after colonization.

[Combined thoracoplasty using titanium mesh implant in patients with total sternal instability following postoperative sternomediastinitis]. / Kombinirovannaia torakoplastika setchatym titanovym éndoprotezom u patsientov s total'noi nestabil'nost'iu grudiny v iskhode khronicheskogo posleoperatsionnogo sternomediastinita.

OBJECTIVE: To analyze the results of chest wall reconstruction with titanium mesh implant in patients with total sternal instability following postoperative sternomediastinitis. MATERIAL AND METHODS: There were 100 patients with total sternal instability for the period from January 2016 to December 2018. Median of age was 62 (58; 68) years. Male/female ratio was 82/18. All patients were treated in accordance with standardized protocol. Postoperative complications were assessed using Clavien-Dindo scale. Staged surgical treatment including one or more debridement procedures before the final thoracoplasty was performed in 62 (62%) out of 100 patients. Aseptic sternal instability was observed in 38 patients. RESULTS: Follow-up period ranged from 3 weeks to 35 months after the final thoracoplasty. Complicated postoperative period occurred in 15 (15%) out of 100 patients (95% CI 9.3-23.3). One patient died in 9 days after surgery from acute heart failure. Complications without need for redo surgery, postoperative wound suppuration and seroma were noted in 3 patients. Redo surgery was required in 11 patients due to postoperative wound suppuration, eventration after thoracoomentoplasty, intermuscular hematoma and delayed divergence of major pectoral muscles. Removal of mesh implant was performed in 1 out of 100 patient (95% CI 0.2-5.5) in 7 days after surgery due to suppuration. There was no recurrent sternal instability within 30 days. CONCLUSION: Anterior chest wall reconstruction using titanium mesh implant is an effective and safe procedure in patients with postoperative sternal instability following postoperative sternomediastinitis.

Recurrent skin opening induced by chronic sternal osteomyelitis caused by a bite wound in a cat: A case report.

BACKGROUND: Chronic sternal osteomyelitis is a rare condition in felines, with limited reported cases to date. OBJECTIVES: We report the case of a 2-year-old castrated male, domestic shorthair cat, weighing 4.68 kg, that presented with skin openings every 3-4 months, despite skin debridement and reconstruction. METHODS: A subcutaneous dead space larger than the skin defect was detected. Haematological analysis revealed elevated levels of inflammatory markers. Thoracic radiography revealed sternal deformation and suspected osteomyelitis. Computed tomography revealed a fistula extending from the third to the fourth sternebrae. RESULTS: Bone and soft tissue debridement and abscess flushing were performed along with long-term antibiotic therapy. The cat remained recurrence-free throughout an 18-month post-surgery follow-up period. CONCLUSION: To the best of our knowledge, this is the first report of chronic osteomyelitis occurring in a cat's sternebrae and represents the first successful case of its treatment. This case showcases the potential for improved treatment outcomes in similar cases. Understanding and successful treatment of such cases can pave the way for better management of feline osteomyelitis.

Multidisciplinary Management of Sternal Osteomyelitis Due to Klebsiella aerogenes after Open Heart Surgery in a Patient with Multiple Myeloma: A Case Report and Discussion of the Literature.

Sternal wound complications following cardiac surgery, including sternal dehiscence, mediastinitis, and osteomyelitis, pose significant challenges in terms of management and patient outcomes. We present a case report highlighting the complex management of a patient who underwent open heart surgery for severe aortic valve stenosis, followed by sternal wound dehiscence and sternum osteomyelitis due to extended spectrum beta lactamase (ESBL) producing Klebsiella aerogenes. A multiple myeloma diagnosis was also suspected at the positron emission tomography (PET) scan and confirmed with bone marrow biopsy. Multidisciplinary evaluation of the case led to a comprehensive treatment plan. To control the sternal osteomyelitis, total sternectomy was performed followed by immediate reconstruction with a bone (tibia) graft from the tissue bank and fixation with the minimal hardware possible. A microsurgical latissimus dorsi free flap was required to reconstruct the soft tissue defect. After 6 weeks of antibiotic treatment with ertapenem and fosfomycin based on a culture of intraoperative material, no clinical, imaging, or laboratory signs of infection were seen. Multiple myeloma treatment was then started. At 1 year of follow up, no recurrence of infection occurred, and the reconstruction was stable and closed. Multiple myeloma is under chronic treatment with novel agent combination, with an excellent haematological response.

Culture-negative primary sternal osteomyelitis in a patient with uncontrolled type 2 diabetes mellitus.

Primary sternal osteomyelitis (PSO) is a rare condition defined as an infection of the sternal bone marrow with no contiguous source of infection. The overlap in symptoms of PSO with other cutaneous and malignant pathologies often leads to misdiagnosis and delay of appropriate care. In this case report, we outline the presentation of PSO in a 30 year-old male patient who was newly diagnosed with type 2 diabetes mellitus. The patient was successfully treated with antibiotic therapy alone, without need for surgical intervention. Interestingly, the patient's workup returned with negative microbial cultures. To our knowledge, this patient represents the first reported case of a spontaneously presenting, culture-negative PSO.

Sternal osteomyelitis caused by Gordonia bronchialis in an immunocompetent patient following coronary artery bypass surgery.

Skin commensals, especially gram-positive cocci, are the usual microbial organisms that cause post-operative sternal wound infections. Rarely, environmental bacteria such as Gordonia spp. have been implicated as etiological agents in post-cardiac procedure surgical site infections. We report a case of a patient who presented with post-coronary artery bypass sternal osteomyelitis caused by this uncommon pathogen, and review relevant medical literature to identify commonalities in presentation, diagnosis and management. Repeat isolation of Gordonia bronchialis in the setting of post-procedure wound infection should raise suspicion for a real pathogenicity. Definitive identification requires a broad range of bacterial PCR DNA amplification and sequencing followed by susceptibility testing as treatment may require a prolonged course of antibiotics.

A case of sternal osteomyelitis during treatment with everolimus for recurrent breast cancer.

BACKGROUND: Everolimus is a mechanistic-target-of-rapamycin (mTOR) inhibitor bearing a potent antitumor effect against hormone receptor-positive breast cancer. Here, we report the case of a patient with recurrent breast cancer who developed osteomyelitis during the treatment with everolimus plus exemestane. CASE PRESENTATION: A 56-year-old woman with early-stage breast cancer underwent right mastectomy and axillary lymph node dissection at the age of 45. Four years after the surgery, she experienced relapse at the chest wall. Radiotherapy was performed on the chest wall, including the sternum, and denosumab was administered. After several regimens of hormonal therapies, everolimus in combination with exemestane was administered. Three months later, the patient visited our clinic because of continuous fever. A computed tomography scan showed an osteolytic change in the sternal bone with pneumomediastinum, which indicated sternal osteomyelitis. Extensive debridement followed by secondary reconstruction of the chest wall was successfully performed. CONCLUSIONS: Everolimus may cause osteomyelitis of the affected bone as a result of tumor necrosis. Everolimus-induced osteomyelitis may be manageable by extensive debridement performed without delay.

Aspergillus fumigatus sternal osteomyelitis following cardiac surgery: Case report and literature review.

BACKGROUND: Sternal osteomyelitis caused by Aspergillus spp is uncommon in cardiac surgery patients requiring sternotomy. CASE PRESENTATION: We report a 77-year-old male with a history of poorly controlled diabetes who was diagnosed with Aspergillus sternal osteomyelitis, three months following an uneventful coronary artery bypass surgery. He underwent multiple debridement surgeries and was treated with voriconazole. Despite a complicated post-operative course, the patient responded well to voriconazole with clinical and biochemical evidence of remission. Unfortunately, he died of an unrelated cause due to decompensated heart failure. DISCUSSION: Though uncommon, Aspergillus sternal osteomyelitis should be considered in the differential diagnosis of immunocompetent patients with post-operative sternal wound infections and negative bacterial tissue cultures. Management should include a combination of medical and surgical therapy.

HISTORIQUE: L'ostéomyélite sternale causée par des espèces d'Aspergillus est rare chez les patients en chirurgie cardiaque qui ont besoin d'une sternotomie. PRÉSENTATION DE CAS: Les chercheurs présentent le cas d'un homme de 77 ans ayant des antécédents de diabète mal contrôlé qui a obtenu un diagnostic d'ostéomyélite sternale à Aspergillus trois mois après un pontage aortocoronarien sans histoire. Il a subi de multiples opérations de débridement et a reçu un traitement au voriconazole. Malgré une évolution postopératoire complexe, il a bien répondu au voriconazole et a obtenu des résultats cliniques et biochimiques de rémission. Malheureusement, il est décédé d'une décompensation cardiaque non apparentée. DISCUSSION: Bien qu'elle soit rare, l'ostéomyélite sternale à Aspergillus devrait faire partie du diagnostic différentiel des patients immunocompétents présentant une infection postopératoire de la plaie sternale et des cultures tissulaires bactériennes négatives. La prise en charge doit inclure un traitement médical et chirurgical associé.

Incidence and risk factors for sternal osteomyelitis after median sternotomy.

Background: Sternal osteomyelitis (OM) after median sternotomy is the rarest form of deep sternal wound infections (DSWIs). A retrospective study was implemented to evaluate the incidence and potential risk factors of sternal OM after median sternotomy. Methods: We analyzed 3,410 consecutive patients who underwent cardiothoracic surgery via median sternotomy from January 2005 to December 2019 at our institution. A sternal OM and control group without any sign of wound infections after median sternotomy were selected. Comparisons of the variables between the two groups were performed using the Student's t-test and Fisher's exact tests. The association of potential risk factors with sternal OM was tested by logistic regression analysis. Results: A total of 16 patients (0.47%) had sternal OM after median sternotomy. None of the variables were different between the sternal OM patients and the control group including body mass index (BMI), diabetes mellitus (DM), hypertension (HTN), left ventricle (LV) function, transfusion, operation time, cardiopulmonary bypass (CPB) time and intensive care unit and ventilator days. By univariate analysis, none of the variables were associated with an increased risk of sternal OM. Conclusions: The incidence of sternal OM after median sternotomy in our institution was 0.47% and there was no correlation between the known risk factors of DSWI and sternal OM in our study.

Breast tuberculosis presenting with intractable mastitis: a case report.

BACKGROUND: Breast tuberculosis, also known as tuberculous mastitis, is an extremely rare form of tuberculosis. It accounts for <0.1% of all breast diseases and <2% of all cases of tuberculosis. It is often misdiagnosed as breast cancer, which can potentially lead to a delayed diagnosis. CASE PRESENTATION: A 69-year-old Japanese woman presented with a tumor-mimicking lesion in her right breast, followed by intractable mastitis with a fistula formation. The time until the correct diagnosis of tuberculosis of the breast and sternal bone was 14 months. CONCLUSIONS: Although rare, it is important to recognize that tuberculous mastitis can present as refractory abscesses/mastitis or mass lesions that mimic carcinomas in women of reproductive age and elderly people. Breast tuberculosis should always be considered in the differential diagnoses, particularly in patients with a history of tuberculosis and those living in areas where tuberculosis is endemic.

Primary Sternal Osteomyelitis Caused by Methicillin-Sensitive Staphylococcus aureus: A Diagnosis Rare in Healthy Adults.

Primary sternal osteomyelitis (PSO) is a rare clinical entity, and usually, it is associated with predisposing factors such as intravenous drug use, diabetes mellitus, or human deficiency virus infection. In an otherwise healthy adult, it becomes an even rarer entity. Early diagnosis and treatment minimize associated morbidity, like the need for surgical debridement, longer courses of medication, and length of in-hospital stay. We describe the case of a 54-year-old man without any predisposing risk factors for PSO, who presented with chest pain, erythema, tenderness, and warmth at the right parasternal region. A non-enhanced thoracic tomography showed a 33 mm suspicious pulmonary nodule and no signs of sternum abnormalities. To better evaluate this finding, a positron emission tomography with fluorine-18 fluorodeoxyglucose was performed, showing abnormal uptake of the radionuclide at the sternomanubrial synchondrosis and no abnormal uptake at the lung parenchyma. The presence of Staphylococcus aureus in blood cultures, in conjunction with these results, supported the diagnosis of PSO. The patient completed six weeks of microbiologically oriented antibacterial therapy with complete recovery.

Role of ultrasound and CT in the early diagnosis and surgical treatment of primary sternal osteomyelitis caused by Salmonella: Case reports.

Primary sternal osteomyelitis (PSO) caused by Salmonella is a rare condition and most commonly associated with sickle cell disease. Only one such case has been previously reported in an infant (age, <1 year) worldwide. The present study reported on two infantile cases of PSO caused by Salmonella in the absence of any hematological diseases. A total of two male infants (age, ≤1 year) were referred to our hospital for fever and rapid breathing accompanied by a chest wall mass involving the lower end of the sternum. Imaging findings on CT and ultrasound, which included sternal segment dislocation, lytic destruction and periosteal elevation, confirmed the diagnosis of PSO. Blood and purulent material cultures confirmed that the causative pathogen was Salmonella. The infants were completely cured by sequential intravenous and oral antibiotics followed by surgical debridement. The infants remained symptom-free and local recurrence of PSO was not detected at follow-up. PSO caused by Salmonella in the absence of any hematological diseases is a rare condition. Unfamiliarity with this disease may lead to a delay in diagnosis and serious complications. The current case report presents two cases of PSO along with a brief overview of the characteristics and management modalities for this condition, and it provides a comprehensive reference for pediatricians regarding this rare disease, particularly in infants.

Ulnar infected pseudoaneurysm in the course of extended-spectrum beta-lactamase Escherichia coli septicemia.

We describe the first case of proximal ulnar pseudoaneurysm due to extended-spectrum beta-lactamase-producing Escherichia coli. We performed an open ligation of the ulnar artery and partial excision of the aneurysmal sac. This article discusses the etiology and surgical management of ulnar-infected pseudoaneurysms according to the literature data.