Updated: 1/31/2019

Osteomyelitis

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  • A 53-year-old man presents to the emergency department for fever, chills, and pain in the left foot. His symptoms began several weeks ago and have progressively worsened since. The pain is present with and without movement; he denies any recent trauma to the area. He feels feverish and experiences rigors at night. Medical history is significant for poorly controlled type II diabetes mellitus and peripheral vascular disease. On physical exam, there is a tender and erythematous ulcer on the pedal surface of the left foot. A probe-to-bone test is performed and demonstrates a hard and gritty surface. Laboratory testing is significant for an elevated erythrocyte sedimentation rate and C-reactive protein and leukocytosis. A plain radiograph demonstrates periosteal thickening and soft tissue swelling. Microbial cultures are obtained and he is started on empiric antibiotics.
Introduction
  • Clinical definition
    • inflammation of the bone and bone marrow most commonly due secondarily to infection that can be categorized as
      • acute osteomyelitis
        • more common in children
        • typically symptom onset is within 2 weeks postinfection
      • chronic osteomyelitis
        • more common in adults
        • typically symptoms persists months or years postinfection
  • Epidemiology
    • risk factors
      • diabetes
      • peripheral vascular disease
      • open fracture
      • intravenous drug use
      • catheter use
      • surgery
  • Etiology
    • note that infection can be due to bacteria, fungi, and mycobacteria
    • microbiology
      • Staphylococcus auerus
        • most common cause overall
          • may be seen in
            • sickle cell disease
            • prosthetic joint replacement
            • vertebral involvement
            • intravenous drug use
      • Neisseria gonorrhoeae
        • rare
      • Staphylococcus epidermidis
        • can also be seen in prosthetic joint involvement
      • Salmonella species
        • may be seen in hemoglobinathies such as sickle cell disease or thalassemia
      • Mycobacterium tuberculosis
        • can also be seen in cases of vertebral involvement (Pott disease)
      • Pasteurella multocida
        • seen in cases caused by cat and dog bites
      • Pseudomonas and Candida
        • can also be seen in cases caused by intravenous drug abuse
  • Pathogenesis
    • hematogenous seeding of bone
    • contiguous spread of infection from adjacent structures (e.g., soft tissues and joints)
    • direct inoculation
      • e.g., penetrating trauma and contaminated surgical tools
  • Prognosis
    • mortality has significantly decreased since the use of antibiotics
Presentation
  • Symptoms
    • acute osteomyelitis
      • lethargy
      • acute pain in affected site
      • erythema and
    • chronic osteomyelitis
      • chronic pain
  • Physical exam
    • swelling
    • erythema
    • tenderness
    • reduced range of motion
    • bone tenderness
    • ulcers
    • exposed bone may be seen
    • sinus tract
      • pathognomonic for chronic osteomyelitis
    • must perform a neurovascular exam
Imaging
  • Radiographs
    • indication
      • preferred initial test in evaluating for osteomyelitis
        • note that it takes 10-14 days postinfection for findings to appear
    • findings
      • periosteal thickening and elevation "Codman triangle"
  • Magnetic resonance imaging
    • indication
      • considered when radiography is unrevealing
    • findigs
      • may reveal bone necrosis, abscess, and sinus tracts
Studies
  • Labs
    • C-reactive protein 
    • erythrocyte sedimentation rate
    • leukocytosis
      • present in acute osteomyelitis
      • unlikely to be found in chronic osteomyelitis
  • Biopsy and culture
    • confirms the diagnosis
Differential
  • Septic arthritis
  • Gout
  • Cellulitis
  • Osteosarcoma
Treatment
  • Medical
    • empiric antibiotics
      • indication
        • considered the mainstay of treatment
          • eventually tailored to organism after culture sensitivities return
  • Operative
    • debridement
      • indication
        • to remove necrotic tissue
Complications
  • Bone necrosis
  • Sepsis
  • Squamous cell carcinoma
    • most common tumor associated with osteomyelitis

 

 

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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

(M1.MK.159) A 7-year-old Caucasian male presents with a temperature of 38°C. During the physical exam, the patient complains of pain when his femur is palpated. The patient's parents state that the fever started a few days after they noticed a honey-colored crusting on the left upper lip of the child's face. Culture of the bacteria reveals a catalase-positive, gram-positive cocci. Which of the following bacteria is most likely to be found in a biopsy of the child's left femur? Review Topic

QID: 101618
1

Staphylococcus aureus

64%

(7/11)

2

Staphylococcus saprophyticus

9%

(1/11)

3

Streptococcus pyogenes

18%

(2/11)

4

Clostridium perfingens

0%

(0/11)

5

Escherichia coli

9%

(1/11)

M1

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