Multifocal bilateral metatarsal tuberculosis: a rare presentation.

Tuberculosis, or phthisis (consumption) as it was popularly known in the Greek era, has been endemic in Southeast Asia and Sub-Saharan Africa; however, the human immunodeficiency virus epidemic has seen the re-emergence of this disease in the areas in which it was not very commonly reported. With this, the need for understanding and treatment of rare presentations of tuberculosis has become of paramount importance to achieve the World Health Organization millennium goal of a "reversal of incidence by 2015." Foot involvement has been reported in 0.1% to 0.3% of extrapulmonary cases. Multifocal lesions have an incidence of <10% in osteoarticular tuberculosis. Bilateral feet involvement in multifocal tuberculosis has not yet been reported in either children or adults in published studies. We report a case of tuberculosis with lesions in the bilateral metatarsals, the occurrence of which is very rare. The diagnosis was mainly histopathologic owing to the paucibacillary nature of the disease. Early identification and treatment with antitubercular drugs will normally result in a good cosmetic and functional result.

Burkholderia pseudomallei osteomyelitis of the metatarsal in an infant.

Burkoholderia pseudomallei is an emerging cause of localized musculoskeletal infections. We report the case of a 9-month-old infant with isolated primary chronic osteomyelitis of the fifth metatarsal. Radiographs showed expansion and thickening of the cortex. The metatarsal had lytic lesions with scalloped margins; no periosteal reaction or sequestration was seen. Surgical debridement provided removal of infected material and adequate drainage by saucerization. B. pseudomallei was isolated from purulent material, and histologic examination revealed granulomatous inflammation. The child responded rapidly to a 2-week intravenous course of ceftazidime. The present case highlights the need for an awareness of melioidosis as a new differential diagnosis for a nontuberculous, granulomatous inflammation in those living in or visiting tropical regions.

Tubercular osteomyelitis of the second metatarsal: a case report.

A number of studies have described the osteoarticular involvement of tuberculosis, but very few cases of tubercular osteomyelitis of the foot have been reported. We describe a case of spina ventosa affecting the second metatarsal, with a review of the literature and description of the clinical manifestations, diagnostic images, and treatment of skeletal tuberculosis.

One stage resection and pin stabilization of first metatarsophalangeal joint for chronic plantar ulcer with osteomyelitis.

BACKGROUND: Standard treatment of plantar first metatarsal head neuropathic ulceration with underlying osteomyelitis consists of extensive debridement of infected soft tissues and bone and often first ray amputation. The purpose of this study was to present a previously unreported, one stage, alternative to first ray amputation in patients with chronic first metatarsal head ulceration and associated chronic osteomyelitis. MATERIALS AND METHODS: A retrospective review was conducted of all patients that underwent one stage resection of the first metatarsophalangeal joint with pin stabilization for treatment of chronic plantar first metatarsal head ulceration with associated chronic osteomyelitis. The study included 15 patients (18 feet) who underwent 18 resections and stabilizations. All patients had a diagnosis of diabetic peripheral neuropathy, chronic plantar first metatarsal head ulceration of at least 3 months duration with exposed bone, and no gross purulence or acute cellulitis. Nine patients (60%) (11 feet) were available for followup telephone interviews. Four of the 15 (27%) (four feet) were deceased so they had medical record review only. The average followup was 48.8 months. RESULTS: All ulcers healed with the exception of one foot (5%) who required a transmetatarsal amputation for worsening infection and wound complications. Three feet (17%) developed recurrent ulcerations. No foot had amputation of only the hallux or first ray. CONCLUSION: This study presents a previously unreported, relatively simple, one stage treatment option for chronic first metatarsal head ulceration with underlying chronic osteomyelitis. This procedure allowed for successful healing of the ulcer while retaining the first ray.

Nocardia arthritidis infection in the distal metaphysis of the metatarsal III and IV bone of a heifer.

CASE DESCRIPTION: A 19-month-old 536.4-kg (1,180-lb) Brown Swiss heifer was referred for evaluation of a firm swelling over the distal aspect of the right metatarsal region and chronic lameness in the right hind limb. CLINICAL FINDINGS: Examination of radiographs of the right metatarsophalangeal joints revealed an expansile, smoothly marginated, cyst-like lesion within the distal metaphysis of the metatarsal III and IV bone. Differential diagnoses included bone abscess, bone cyst, aneurysmal bone cyst, neoplasia, osteomyelitis, and metabolic bone disease. Aerobic microbial culture of the aspirate yielded moderate growth of branching, gram-positive, rod-shaped bacteria, which were presumptively identified as Nocardia spp. The isolate was subsequently identified as Nocardia arthritidis by 16S rRNA gene sequence analysis. TREATMENT AND OUTCOME: The lesion was surgically debrided, lavaged, and bandaged. Exercise was restricted, and systemic and local administration of antimicrobials was instituted. After a communication between the abscess and the metatarsophalangeal joints was iatrogenically created, the extralabel use of aminoglycosides was initiated. The heifer had noticeable clinical improvement within 2 weeks after initial evaluation and reportedly had no evidence of lameness and minimal external blemishes 3 months after the second evaluation. CLINICAL RELEVANCE: To our knowledge, this is the first report on the diagnosis and management of a long-bone abscess attributable to N arthritidis infection in cattle. Complications encountered during treatment and the decision to engage in extralabel use of antimicrobial agents in the heifer described here may serve as a guide for food animal practitioners faced with the treatment of valuable cattle.

Metatarsal Salmonella enteritidis osteomyelitis in a healthy child.

Non-typhoidal Salmonella osteomyelitis in healthy children is a very rare condition. A previously healthy 7-year-old boy presented with foot pain following a small injury. Local inflammatory signs of the foot were observed, with a normal radiograph. Two weeks before, he had had gastroenteritis. Assuming cellulitis, flucloxacillin was began. Early during admission, surgical subcutaneous abscess drainage was performed and Salmonella enteritidis was identified. According to bacterial susceptibility, antibiotherapy was changed to ceftriaxone. A foot radiograph and an MRI scan, performed on the 9th and the 12th days, revealed findings suggestive of osteomyelitis of the metaphysis of the fifth metatarsal. Clinical worsening persisted and surgical extensive debridement was needed. A 6-week antibiotic treatment was completed, with a good outcome. Osteomyelitis with a poor evolution in children with risk factors (prior gastrointestinal illness, warm weather and previous exposure to antibiotics) can raise the possibility of a non-typhoidal Salmonella infection.

Cryptococcal Osteomyelitis of the First Metatarsal Head in an Immunocompetent Patient.

Most fungal infections primarily occur in immunocompromised patients. We describe a case of osteomyelitis involving the first metatarsal head due to Cryptococcus neoformans in a previously healthy immunocompetent patient. She was treated with surgical debridement combined with antifungal drug therapy for 6 months. At 5-year follow-up, she remained symptom free with full range of motion of the first metatarsophalangeal joint. Fungal osteomyelitis should be considered as a possible cause in osteolytic lesions in the metatarsal bone.

Oral antimicrobial therapy for diabetic foot osteomyelitis.

BACKGROUND: Osteomyelitis in the foot of a diabetic individual is a common complication of peripheral neuropathy, peripheral vascular disease, and infection. Operative facilities and home intravenous antibiotic therapy programs may not be available in remote or rural communities. Limited data are available regarding the treatment results of oral antimicrobial therapy, with or without limited office debridement for diabetic foot osteomyelitis. METHODS: This retrospective medical record review of 325 consecutive diabetic patients who were evaluated at a multidisciplinary foot clinic identified 94 (29%) patients with 117 episodes of osteomyelitis. The most common group of organisms isolated were aerobic gram-positive cocci, and the single most frequent organism was Staphylococcus aureus. A mean of 1.6 +/- 0.8 (range 1 to 4) pathogens were recovered per episode of osteomyelitis. Therapy was guided by culture results. There were 93 episodes of osteomyelitis (79 patients) that were treated with a mean of 3 +/- 1 oral antimicrobial agents (with or without an initial short course of intravenous antimicrobial agents) and had adequate followup to evaluate outcome of treatment; office treatment included bone debridement in 26 (28%) and toe amputation in nine (10%) of the 93 episodes (79 patients). RESULTS: Of the 93 episodes treated with oral antimicrobial agents (with or without an initial short course of intravenous antimicrobial agents), 75 (80.5%) episodes were put into remission. Mean duration of oral antimicrobial therapy was 40 +/- 30 weeks. Mean relapse-free followup duration was 50 +/- 50 weeks. CONCLUSIONS: Diabetic foot osteomyelitis was effectively managed with oral antimicrobial therapy with or without limited office debridement in most patients. This regimen may be especially useful in communities where infectious disease specialists and operative resources are limited.

Tubercular osteomyelitis of the first metatarsal bone as a cause of forefoot pain.

The reporting of isolated metatarsal tuberculosis in the available literature is sparse, herein we report a case of 26-year-old female who presented with insidious onset pain and swelling in her forefoot. Radiograph showed osteolysis of the first metatarsal. Magnetic resonance imaging showed osseous erosion with marrow oedema. Diagnosis was ascertained by fine needle aspiration cytology of the lesion. The patient received anti-tubercular therapy and showed good clinical outcome. This case is reported because of its rarity of involving isolated metatarsal bone as a cause of forefoot pain.

Osteological, biomolecular and geochemical examination of an early anglo-saxon case of lepromatous leprosy.

We have examined a 5th to 6th century inhumation from Great Chesterford, Essex, UK. The incomplete remains are those of a young male, aged around 21-35 years at death. The remains show osteological evidence of lepromatous leprosy (LL) and this was confirmed by lipid biomarker analysis and ancient DNA (aDNA) analysis, which provided evidence for both multi-copy and single copy loci from the Mycobacterium leprae genome. Genotyping showed the strain belonged to the 3I lineage, but the Great Chesterford isolate appeared to be ancestral to 3I strains found in later medieval cases in southern Britain and also continental Europe. While a number of contemporaneous cases exist, at present, this case of leprosy is the earliest radiocarbon dated case in Britain confirmed by both aDNA and lipid biomarkers. Importantly, Strontium and Oxygen isotope analysis suggest that the individual is likely to have originated from outside Britain. This potentially sheds light on the origins of the strain in Britain and its subsequent spread to other parts of the world, including the Americas where the 3I lineage of M. leprae is still found in some southern states of America.

Cancellous bone grafting in the treatment of bovine septic physitis.

Eleven young cattle (8-24 months of age) were treated for septic physitis of the metacarpal or metatarsal bones. Two new elements were added to the traditional treatment. Firstly, homologous cancellous bone grafts were used for their osteoinductive properties even in an infected surrounding. (Actinomyces pyogenes was recovered most commonly.) Secondly, a walking cast was applied for better immobilization of the lower limb with minimal discomfort to the animal. After surgery, the 11 bovine patients needed an average walking cast period of 4.5 weeks and 1 to 2 weeks' treatment with antibiotics. The new treatment regime expedites the healing process and shows a success rate of 100%. Follow-up after 6 months revealed that all animals were completely sound without recurrence of the physitis.

Tuberculosis of the foot and ankle in children.

PURPOSE: To report manifestations and management of tuberculosis of the foot and ankle in 21 children. METHODS: Records of 12 girls and 9 boys aged 3 to 14 (mean, 7) years with tuberculosis of the foot and ankle were reviewed. The mean delay in presentation was 4.7 (range, 0.5-14) months. All the patients had local swelling, tenderness, and antalgic gait; 16 were limping; 5 had an antecedent trauma; 11 had an abscess; and 6 had a discharging sinus. The diagnosis was based on a smear positive for acid-fast bacilli (n=2), histopathology (n=15), or clinicoradiological findings (n=4). Nine patients had osteoarticular tuberculosis in other parts of the body. None had evidence of pulmonary tuberculosis. Lesions were classified into synovial (articular) and osseous. All 3 synovial lesions occurred in the ankle, 2 of which were at an advanced stage. Osseous lesions occurred in the calcaneus (n=5), metatarsal (n=5), talus (n=3), cuboid (n=3), medial cuneiform (n=1), and phalanx (n=1), and were sub-classified into stages 1 (n=3), 2 (n=5), and 3 (n=10) according to disease progression. All the patients were treated conservatively with splintage and chemotherapy. RESULTS: The mean follow-up period was 21 (range, 7-51) months. All the 3 patients with stage 1 osseous lesions showed healing within 6 weeks and had complete recovery of function. Four of the 5 patients with stage 2 lesions also showed complete recovery of function and reformation of bony trabeculations; radiological incorporation of sequestrum was obvious by 6 months in most patients. In patients with stage 3 lesions, healing was delayed and there was residual alteration in bony architecture and joint changes. Sclerotic changes and joint involvement also increased the likelihood of poor outcomes. However, none of our patients had any residual tenderness or foot deformity at the final follow-up. CONCLUSION: Outcome after non-operative treatment is good, provided the lesions are treated early.

An elderly lady with sudden blindness and a sore foot.

We report the case of an elderly woman presenting with group G streptococcal septicaemia associated with osteomyelitis and endophthalmitis.