Diagnosis and treatment of cryptococcal osteomyelitis in a pediatric lung transplant patient.

BACKGROUND: Asymptomatic pulmonary nodules may appear at any point after lung transplantation. The differential diagnosis is broad and includes serious life-threatening disease entities. METHODS: A retrospective case report of a single patient who developed a pulmonary nodule after lung transplantation. RESULTS: At 2 years post-transplant, an 11-year-old with cystic fibrosis was asymptomatic and had normal lung function. A single nodule was noted on surveillance chest CT scan. Initial evaluation was negative, but subsequently, he was diagnosed with cryptococcal osteomyelitis in a thoracic rib. He responded well to an extended course of antifungal therapy without loss of allograft function or infectious complications. CONCLUSION: Pulmonary nodules after lung transplantation may be a harbinger of serious complications. A systematic approach to evaluation and follow-up is recommended.

An unusual cause for rib osteomyelitis in the tropics: Cryptococcal osteomyelitis.

The more common manifestations of cryptococcal infections are restricted to the central nervous system and lungs. We report an unusual case of fungal osteomyelitis due to Cryptococcus. The patient was a young man who had been adequately treated for pulmonary tuberculosis three years prior. Three months before, he sustained a minor road-traffic accident with only minor abrasions. He presented with subacute chest pain of 15 days' duration and was found to have radiological evidence of a lytic lesion of the fifth rib. Given prior tuberculosis, he was thought to have a relapse of disease with tuberculous osteomyelitis. Surprisingly, a biopsy revealed evidence of fungal osteomyelitis with Cryptococcus. An evaluation for primary immunodeficiency revealed low CD4 cell counts with undetectable serum IgA and IgM levels. Genetic sequencing proved a genetic mutation consistent with primary T-cell immunodeficiency. The patient responded well to treatment and is asymptomatic on follow-up.

Metagenomic Next-Generation Sequencing Technique Helps Identify Cryptococcal Infection in the Rib: A Report of 2 Cases and Review of the Literature.

CASE: Two patients presented with pathological lytic bone lesions in the rib and associated soft tissue mass believed initially to represent soft tissue neoplasm. However, further consideration of infectious etiologies led to the identification of cryptococcal osteomyelitis. In one case, the microbiological culture was negative, but Cryptococcus neoformans was identified with the help of the metagenomic next-generation sequencing (mNGS) technique. Both patients received oral fluconazole-only treatment, and the infections were successfully eradicated. CONCLUSIONS: The mNGS technique helps identify cryptococcal infection in the rib.

Indolent Rib Osteomyelitis Following Breast Implant Reconstruction: An Unusual Case and Review of the Literature.

Rib osteomyelitis is an infrequently occurring but important complication of breast implant surgery. Although prosthetic or surgical site infection (SSI) and rib osteomyelitis as separate entities are well described in the literature, only five cases of rib or sternal osteomyelitis related to implant placement have been reported globally. Historically patients who experience this complication have not demonstrated an identifiable prevalence of the traditional risk factors associated with SSI or rib osteomyelitis. This report describes the sequence of clinical manifestations of an unusual case of breast implants complicated by rib osteomyelitis. A 56-year-old female underwent mastectomy and insertion of tissue expanders for bilateral invasive ductal carcinoma following which the tissue expanders became infected in the early postoperative period and were subsequently removed. The patient underwent successful expander insertion and subsequent implant exchange surgery several years later and enjoyed an uncomplicated recovery from this. Following nipple reconstruction more than 12 months after successful implant placement, she presented with Staphylococcus epidermidis bacteremia and a left-sided clinical peri-implant infection. Upon removal of her implant, an intraoperative discovery of rib necrosis/osteomyelitis was made for which she was treated. To provide context, the literature was reviewed for other reported cases of rib osteomyelitis following breast implant surgery. This patient, in combination with others reported in the literature, emphasises the diagnostic difficulties posed by this condition as a result of its low incidence and variable or absent clinical features. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Salmonella Osteomyelitis Of Ribs.

A 45-year-old diabetic male who was a farmer by profession, presented to Khyber Teaching Hospital with swelling and redness on the right side of the chest at the level of 8th rib for the past 5 months which was accompanied by fever and pain. He went to a local hospital where he was given broad spectrum antibiotics. He presented again with yellowish discharge from the wound. Dressing of the wound was done and he was referred to Khyber Teaching Hospital. On presentation, there was an open wound of about 4 cm on the right side of the chest wall at the level of 8th rib near the midclavicular line. X-ray revealed a lytic bone lesion near the costo-chondral junction of the 8th rib. CT scan also showed erosive changes at the above mention site. His fasting blood sugar was well above the normal range and his Alkaline Phosphatase was slightly raised. He was started on Insulin. Debridement and dressing were done and samples were taken for investigations. Bone tissue biopsy revealed inflammatory non-caseating tissue. Culture report was positive for Salmonella Typhi which was resistant to Ciprofloxacin. The patient was given antibiotic (co-amoxiclave) treatment to which he responded leading to a satisfactory recovery.

Candida albicans osteomyelitis as a cause of chest pain and visual loss.

Candida albicans osteomyelitis is a rare disease that occurs in immunocompromised individuals, sometimes with a late diagnosis related to the mismatch between symptoms and candidemia. This case refers to a 36-year-old male patient with a history of oesophageal surgery for achalasia with multiple subsequent surgeries and hospitalisation in the intensive care unit for oesophageal fistula complication. Four months after discharge, the patient was admitted to the infectious diseases department with pain in the 10th-12th left ribs, swelling of the 4th-6th costal cartilage and decreased visual acuity. An MRI study showed thickening and diffuse enhancement, with no defined borders in the cartilage and ribs, compatible with infection. After performing a CT-guided bone biopsy, isolated C. albicans sensitive to antifungal agents was detected. The patient started therapy with liposomal amphotericin B and maintenance fluconazole for 6 months and showed clinical and radiological improvement within this time.

[Evaluation of biological properties of Pseudomonas aeruginosa strains isolated from patients with sternum and rib osteomyelitis].

AIM: Study of the role of P. aeruginosa in the development of osteomyelitis of sternum and ribs in cardio-surgery patients, and analysis of the main biological properties of the isolated bacterial strains. MATERIALS AND METHODS: 132 bacterial cultures were isolated from 83 hospital patients as a result of bacteriological examination during 2007-2013. Wound discharge was the study mate- rial. Sampling, seeding and identification of the isolated cultures was carried out by using the respective test-systems; antibiotic sensitivity was studied by disc-diffusion method. RESULTS: The proportion of P. aeruginosa was 10.6% (n = 14) that is comparable with data on wound infections of general surgery hospitals. A direct and strong correlation (R = 0.846, p = 0.000132) between hemolytic and phospholipase activity was established during evaluation of virulence properties of the isolated-strains. The degree of film-forming ability varied significantly from 0.122 to 1.412 OD; 64.3% ofthe studied cultures were highly film-forming variants. Statistically significant association between biofilm formation and other studied properties was not found. 4 strains produced VIM2-type metallo-betalactamase and had identical RAPD profiles. CONCLUSION: Considering that earlier the similar cultures were not detected and all of them were isolated at a short interval of time, we have made a conclusion, that their short-term circulation is probably associated with introduction, which was the reason for patient infection. P. aeruginosa could be the etio-pathogen of both early and later complications of cardio-surgical interventions.

Costal BCG osteomyelitis developing 1 year after BCG vaccination.

Reported here is the case of a 15-month-old boy with costal osteomyelitis due to the bacillus Calmette-Guérin (BCG) vaccine against tuberculosis. Mild complications of this vaccine, such as localized abscess and regional lymphadenitis, are occasionally recognized, but its association with osteomyelitis is extremely rare.

Bone-destroying candida infection following left ventricular assist device explant.

Infections associated with left ventricular assist devices (LVADs) constitute an important clinical issue because they are difficult to completely eradicate without removal of the LVAD itself and can sometimes be fatal. We encountered a case of extracorporeal LVAD-related candida infection in a patient who was successfully weaned from LVAD support. Although the patient appeared to have recovered from the infection, the patient was readmitted to our institute due to a relapse of candida infection 9 months after LVAD removal. Although the patient did not demonstrate any systemic sign of infection on admission, computed tomography images clearly showed that the residual apical cuff of the LVAD inflow cannula, which was infected with Candida albicans during the initial admission, resulted in re-infection that involved the chest wall with destruction of the adjacent rib.

Management of pleural empyema with a vacuum-assisted closure device and reconstruction of open thoracic window in a patient with liver cirrhosis.

The patient is a 21-year-old female, diagnosed with cryptogenic cirrhosis at the age of 9. She presented with left post-pneumonic empyema that did not remit with conventional medical management and evolved with fistulization to the skin in the 7th intercostal space in the left subscapular region. We performed an open thoracic window procedure, and on the 6th day the patient was sent home with a portable vacuum-assisted closure device, with changes of the material every 4 days until the cavity was completed obliterated (92 days). Imaging tests showed full expansion of the lung, and chest wall reconstruction was performed with titanium rods. The high mortality of empyema in patients with liver disease requires both implementing and searching for new adjuvant therapies, like the use of vacuum-assisted closure systems and reconstruction with titanium rods. Controlled studies with a wide range of cases are needed for proper evaluation.

Salmonella osteomyelitis of multiple ribs and thoracic vertebra with large psoas muscle abscesses.

BACKGROUND CONTEXT: Salmonella vertebral osteomyelitis is a well-known complication of sickle cell disease. However, it has been infrequently reported in immunologically normal people or diabetic patients. PURPOSE: To report a case of Salmonella vertebral osteomyelitis in a diabetic patient with multiple rib infections, large bilateral psoas muscle abscesses, and pleural effusion. STUDY DESIGN/SETTING: Case report. METHODS: A case of Salmonella vertebral osteomyelitis is reported in a 42-year-old man with diabetes. The patient had multiple rib and T12 vertebral infections with pleural effusion and large bilateral psoas muscle abscesses. The adjacent discs were intact. RESULTS: Diagnosis was made by computed tomography-guided psoas muscle abscess drainage and aspirate culture. Appropriate antibiotic treatment resulted in a favorable outcome. The patient had mild back pain with a 38 degrees residual kyphosis at his thoracolumbar junction after treatment. CONCLUSIONS: Vertebral osteomyelitis caused by Salmonella is uncommon in diabetic patients. Salmonella can cause multiple bone infections and large abscesses of psoas muscles in patients without sickle cell disease. Correct diagnosis can be confirmed by blood, biopsy, or abscess culture. Appropriate antibiotic treatment was effective.

Osteomyelitis of the rib caused by Aspergillus flavus following cardiac surgery.

Deep sternal wound infections are a rare but severe complication of coronary artery bypass graft (CABG) surgery, with an estimated prevalence of 1%-4%. We report a case of osteomyelitis of the rib and chest wall abscess caused by Aspergillus flavus in a CABG patient, which was treated successfully with voriconazole.

Tuberculotic osteomyelitis of rib--a surgical entity.

Primary tuberculotic osteomyelitis (TBOM) of the rib is rare. We report our experience of seven patients presenting with primary TBOM of rib. Over a period of eight years, otherwise healthy patients presenting with discharging sinus on the chest wall were managed. Patients included four males and three females, aged between 4 and 18 years. Following history and examination, radiological and histological investigations were performed. After confirming osteomyelitis of rib, excision of the sinus tract along with subperiosteal resection of the affected part of the rib was done. Tuberculosis was confirmed on histological examination of the resected specimens. Oral anti-tubercular therapy (ATT) was given for a period of one year. Patients were followed for 5-8 years. The lesion was demonstrable in all the patients on plain X-ray. Histological confirmation of tuberculosis (TB) before surgery could be done in one patient. The anterio-lateral part of the rib was most commonly affected. Mean operative time was 35 min. Mean postoperative hospital stay was four days. There were no wound complications. No recurrence or relapse was seen. Resection of affected part of the rib with the sinus tract followed by oral ATT for one year is an effective modality of treatment for TBOM of rib.

[Subcutaneous nodules with malignant presentation, but caused by infection]. / Een subcutane zwelling met een maligne presentatie, maar met een infectieuze oorzaak.

Three patients, a woman aged 32, a boy aged 6.5 and a man aged 56 years, presented with a subcutaneous mass suggesting a malignancy: respectively a rubbery swelling, painful to the touch below the left scapula, a partly massive, partly soft swelling on the inside of the left upper leg, and a non-fluctuating mass near the right eighth rib, parasternally. Additional diagnostic investigation revealed an infectious cause: respectively Mycobacterium tuberculosis, Bartonella henselae and Salmonella typhi. Antimicrobial therapy was successful. Subcutaneous masses suspected of being a benign or malignant tumour are sometimes caused by an infection. The differential diagnosis is extensive. Sometimes the travel anamnesis yields helpful information. It is concluded that besides histopathological examination, microbiological investigation can play a major role in the evaluation of subcutaneous masses.

Successful treatment of invasive aspergillosis in chronic granulomatous disease by granulocyte transfusions followed by peripheral blood stem cell transplantation.

Chronic granulomatous disease (CGD) is a primary immunodeficiency disorder characterized by impaired microbial killing and susceptibility to bacterial and fungal infections. Cure of the disease can be achieved by stem cell transplantation when performed early in its course, and before severe infections have developed. Invasive aspergillosis constitutes a very high risk for transplantation. We report a 4-year-old boy with X-linked CGD who underwent successful HLA-identical peripheral blood stem cell (PBSC) transplantation during invasive pulmonary aspergillosis and osteomyelitis of the left fourth rib, which was unresponsive to antifungal treatment. During the 2 months prior to the transplant he received G-CSF-mobilized granulocyte transfusions (GTX) from unrelated donors three times a week in addition to the antifungal treatment. This resulted in clinical improvement in his respiratory status. He also received GTX during the aplastic period after the conditioning regimen, until he had engrafted. Post-transplant superoxide generation test revealed that neutrophil function was within normal range. One year post transplant the CT scan showed almost complete clearance of the pulmonary infiltrates and a marked improvement in the osteomyelitic process. Based on other reports and our own experience, GTX can serve as important treatment in patients with CGD who have failed conventional anti-fungal treatment and for whom stem cell transplantation is the only chance for cure.

Autologous bone grafting in staged scoliosis surgery. The patient as bone bank.

STUDY DESIGN: A prospective clinical study in which autologous rib graft, harvested during the thoracotomy in staged scoliosis correction, is stored within the patient for use during the second stage (posterior intrumentation and fusion). OBJECTIVE: To determine whether the bone stored by this technique is biologically viable and microbiologically safe. SUMMARY OF BACKGROUND DATA: To the authors' knowledge, this method of storage of bone has never been described previously. METHODS: During the first operation, the excised rib was divided into 3-5 cm fragments and stored in a sub-muscular plane adjacent to the posterior elements of the spine before closure. The graft was then retrieved at the second stage. Samples were sent for histologic and microbiologic examination before implantation. RESULTS: On histologic examination, more than 50% of the osteocytes retained their basophilic staining, indicating that they were viable. In addition, osteoclastic activity was notably absent. There was no significant bacterial contamination of the samples. Clinically, all patients achieved satisfactory bone fusion. CONCLUSION: Homeostatic equilibrium in humans provides the ideal environment in which bone graft can be stored. There is no increased risk of infection, and the osteogenic potential of the graft is retained.