Patellar Osteomyelitis in a 9-Year-Old Patient with Chronic Granulomatous Disease: A Case Report

Hematogenous osteomyelitis is commonly reported in long tubular bones in the pediatric population. Acute osteomyelitis involving the patella is extremely uncommon in children, and its diagnosis is frequently delayed due to its rarity and variable clinical manifestations. Chronic granulomatous disease (CGD) is a rare genetic immunodeficiency disorder characterized by severe recurrent bacterial and fungal infections. The most commonly affected sites of infection are the lungs, lymph nodes, skin, liver, and gastrointestinal tract. Acute hematogenous osteomyelitis of the patella associated with CGD has never been reported. Our report describes the first case of acute hematogenous patellar osteomyelitis in a pediatric patient with CGD. Her clinical manifestations were similar to other possible differentials such as septic arthritis; however, use of advanced imaging confirmed the diagnosis, and the patient was successfully managed surgically. Since hematogenous osteomyelitis in children is uncommon, a high index of suspicion and advanced imaging may help with its diagnosis, and in cases where antibiotic treatment proves to be insufficient, prompt surgical management is imperative.

choice of surgical tactics for the treatment of children with destructive pathological dislocation of the hip after hematogenous osteomyelitis

A surgical approach to the treatment of destructive pathological dislocation of the hip in children has been substantiated, depending on age, the severity of destruction of the proximal femur and acetabulum. Reconstructive - restorative operations in most patients ensure the stability of the hip joint and thereby improve the patient's gait and statics, reduce the pelvic misalignment and eliminate the Trendelenburg symptom. The experience of surgical treatment of patients with pathological hip dislocations has shown that the most favorable outcomes are achieved with the use of open reduction of the stump of the head or neck of the femur with intertrochanteric detorsion shortening and varizing osteotomy with rotational pelvic osteotomy according to Salter and acetabular plasty according to Pemberton.

1160. Predictive Factors to Guide Empiric Antimicrobial Therapy of Acute Hematogenous Osteomyelitis in Children

Background Acute hematogenous osteomyelitis (AHO) is a serious infection in children. ESPID guidelines recommend empiric therapy with antistaphylococcal β-lactams in regions with a low methicillin-resistant S. aureus (MRSA) prevalence. In areas with a moderate-high prevalence of MRSA, selection of empiric therapy can be more challenging. We sought to examine factors present at the time of admission which may predict etiology and guide treatment in pediatric AHO in a region with endemic MRSA. Methods We reviewed admissions with ICD9/10 codes for AHO from 2011-2020 in otherwise healthy children. Patients with chronic infection, open or penetrating trauma, orthopedic hardware in situ, or disease secondary to a contiguous focus were excluded. Medical records were reviewed for clinical and laboratory parameters present on the day of admission. Results 586 cases were included. An etiology was identified in 76.8% of cases and S. aureus was most commonly identified (66.2%, 19% MRSA, Figure 1). Infection due to Kingella kingae (0.7%) occurred in younger children (p=0.01). Significant differences in presenting features were noted across pathogens, although S. aureus dominated in all sub-groups (Figure 2). Among children with respiratory symptoms at presentation, Group A Streptococcus (GAS, 10.7%), and S. pneumoniae (2.6%, p=0.01) were identified twice as frequently. Among children with reptiles exposure, Salmonella was identified in 10.8% (p=0.04). Multifocal infections and those requiring ICU admission were due to S. aureus in 88% and 97% of cases, respectively; these cases were disproportionately MRSA (36.4%, p=0.01 and 54%, p< 0.001). Both ESR and CRP were higher among MRSA compared to any other pathogen (Figure 3, p< 0.01). A CRP at presentation > 7 mg/dl had a 79.6% sensitivity for MRSA infection with a negative predictive value of 91.5%. Among those with either an ESR > 50 mm/hr or a CRP > 7 mg/dl, an organism was identified in 83.2% Depiction of the relative frequency of major pathogens among a cohort of 586 cases of acute hematogenous osteomyelitis in children Depiction of the relative frequency of different organisms in children with AHO with various history, exam and laboratory findings Scatterplot depicting ESR and CRP levels across major hematogenous osteomyelitis pathogens Conclusion Subtle differences in symptoms, history and laboratory parameters can provide clues to etiology in pediatric AHO. A CRP > 7 mg/dl at time of presentation is suggestive of MRSA AHO, and this should be considered when planning empiric therapy. Likewise, the absence of extreme elevation of CRP may serve an antibiotic stewardship role in MRSA endemic regions. Disclosures Sheldon L. Kaplan, MD, Pfizer (Research Grant or Support) Jonathon C. McNeil, MD, Agency for Healthcare Research and Quality (Research Grant or Support)Allergan (Grant/Research Support)Nabriva (Grant/Research Support, Other Financial or Material Support, Site PI for a multicenter trial)

Reconstructive and restorative interventions at the proximal end of the thigh and pelvic bones in destructive pathological dislocation of the hip in children after hematogenous osteomyelitis

It is generally known that children tend to get injured more easily than adults. Moreover, these injuries they get in growing period may leave for long in the forms of disability. This paper is about reconstructive and restorative interventions at the proximal end of the thigh and pelvic bones in destructive pathological dislocation of the hip in children after hematogenous osteomyelitis. After hematogenous osteomyelitis of the proximal end of the femur, destruction of the head and neck of the femur is often observed, up to their destruction. The optimal age for surgical treatment of pathological dislocation of the hip, according to our data, is 4-5 years of age of the child, because by this time the process of ossification of the structures of the hip joint ends in most patients, and early surgical intervention often causes severe secondary deformities, up to their destruction.

Acute hematogenous osteomyelitis with total sequestration of the left anonymous bone in a child

As you know, in children, the treatment of osteomyelitis should be more conservative than in adults. However, the use of antibiotics, even in the early stages and in large doses, does not give favorable results in all cases, and surgical intervention becomes inevitable, which was observed in the given case.

Linezolid Versus Vancomycin for the Treatment of Methicillin-Resistant Staphylococcus Aureus Acute Hematogenous Osteomyelitis in Children: Higher Anemia Rate During Therapy.

Background: Clinical use of linezolid for the treatment of methicillin-resistant staphylococcus aureus (MRSA) acute hematogenous osteomyelitis (AHO) is still limited by lacking data about clinical outcomes and adverse effects of long-term usage in children. This study aimed to compare the efficacy and safety of linezolid and vancomycin for the treatment of MRSA AHO in children.Methods: This retrospective study was conducted between January 2011 and December 2018 at the Xijing Hospital, Air Force Military Medical University, China, and compared the clinical efficacy and safety of linezolid and vancomycin in children with MRSA AHO. Demographics, clinical features, laboratory tests, susceptibilities of isolates, treatment outcomes, and adverse events were collected. Variables were analyzed by Fisher’s exact test or Mann-Whitney U-test.Results: 17 patients with MRSA AHO were included in this study (6 children received linezolid and 11 children received vancomycin). Statistically significant differenc was observed in the minimum hemoglobin during the treatment between 2 groups [71.0 (IQR 65.0-91.0) vs 102.0 (IQR 91.0-114.0) g/L, P=0.009], and patients in the linezolid group presented higher anemia rate [5 (83.3%) vs 3 (27.3%), P=0.049] than those in the vancomycin group. Conclusions: Although linezolid and vancomycin have no significant difference in efficacy and safety in the treatment of children with MRSA AHO, the incidence rate of anemia was higher during therapy. Children seemed to be more sensitive to the transient bone marrow suppression effect of linezolid in the prolonged use for MRSA AHO.

Italian consensus on the therapeutic management of uncomplicated acute hematogenous osteomyelitis in children

Background Acute hematogenous osteomyelitis (AHOM) is an insidious infection of the bone that more frequently affects young males. The etiology, mainly bacterial, is often related to the patient’s age, but it is frequently missed, owing to the low sensitivity of microbiological cultures. Thus, the evaluation of inflammatory biomarkers and imaging usually guide the diagnosis and follow-up of the infection. The antibiotic treatment of uncomplicated AHOM, on the other hand, heavily relies upon the clinician experience, given the current lack of national guidelines for the management of this infection. Methods A systematic review of the studies on the empirical treatment of uncomplicated AHOM in children published in English or Italian between January 1, 2009, and March 31, 2020, indexed on Pubmed or Embase search engines, was carried out. All guidelines and studies reporting on non-bacterial or complicated or post-traumatic osteomyelitis affecting newborns or children older than 18 years or with comorbidities were excluded from the review. All other works were included in this study. Results Out of 4576 articles, 53 were included in the study. Data on different topics was gathered and outlined: bone penetration of antibiotics; choice of intravenous antibiotic therapy according to the isolated or suspected pathogen; choice of oral antibiotic therapy; length of treatment and switch to oral therapy; surgical treatment. Conclusions The therapeutic management of osteomyelitis is still object of controversy. This study reports the first Italian consensus on the management of uncomplicated AHOM in children of pediatric osteomyelitis, based on expert opinions and a vast literature review.

Culture-negative chronic hematogenous osteomyelitis in a two months old girl: a case report

Background Previous articles have focused on the diagnosis and treatment of acute hematogenous osteomyelitis. Here, we present a case of chronic hematogenous osteomyelitis in a 2-month-old girl. The diagnostic procedure was unusual and difficult due to negative culture results. Case presentation A girl aged 2 months and 23 days had fever and swelling in her right lower leg for 7 days. On the basis of her medical history, physical, and histological examination results; and radiologic and magnetic resonance imaging findings, a diagnosis of chronic osteomyelitis was made. The patient underwent surgical treatment and was discharged successfully. The patient showed good recovery and no sequelae at the 12-month follow-up. Conclusion Hematogenous osteomyelitis in babyhood is different from that at any other age. Hematogenous osteomyelitis-related bone destruction in babyhood is more serious and occurs faster. The transition from acute hematogenous osteomyelitis to chronic hematogenous osteomyelitis takes only 7 days. To the best of our knowledge, this chronic hematogenous osteomyelitis patient is the youngest ever reported.