Clinical Picture
Emphysematous osteomyelitis Jörg Larsen, Jonas Mühlbauer, Thomas Wigger, Attila Bardosi Lancet Infect Dis 2015; 15: 486 Department of Clinical Radiology (J Larsen MD, J Mühlbauer) and Department of Anaesthesiology (T Wigger MD), Weende Teaching Hospitals and Amedes Johannes Orth Institute for Laboratory Medicine and Pathology (Prof A Bardosi MD), Göttingen, Germany Correspondence to: Dr JÖrg Larsen, Department of Clinical Radiology, Weende Teaching Hospitals and Amedes Johannes Orth Institute for Laboratory Medicine and Pathology, An der Lutter 24, D-37075 Göttingen, Germany [email protected]
A 72-year-old man with diabetes who was non-insulin dependent presented with unspecific abdominal pain after a fall onto his right side. He was given anticoagulants for atrial fibrillation. CT showed a hepatic haematoma. Raised C-reactive protein and procalcitonin concentrations suggested superinfection. A diagnostic aspiration was done, and antibiotic therapy with intravenous ceftriaxone was initiated, replaced by meropenem the next day. Before the microbiological culture results were available, the patient deteriorated. A follow-up CT scan revealed intraosseous gas in the pelvis and a lumbar vertebra (figure A). CT-guided bone biopsy confirmed the presence of gas (figure B), consistent with emphysematous osteomyelitis, and antibiotic therapy was escalated with the addition of clindamycin. The bone biopsy culture showed non-resistant Escherichia coli. Microbiological culture of the liver sample, urine, and catheter tips and arterial and venous blood cultures did not yield any pathogens. Despite the high-dose intravenous antibiotic therapy, the patient died as a result of multiorgan failure from fulminant sepsis, without a source of infection being identified. The presence of intraosseous gas has a differential diagnosis, including vacuum phenomena, subchondral cysts in degenerative joint disease, penetrating (including A
iatrogenic) injury, ischaemic necrosis, and osteomyelitis caused by gas-forming organisms. Pattern of distribution, detailed appearance, clinical history, and findings on examination provide clues. In systemic illness with septicaemia, CT scanning can be used to localise the site of infection while staging the microbial invasion and host response. A range of microorganisms have been shown to produce gas when colonising bone, including Pseudomonas spp, Streptococcus spp, Enterococcus spp, E coli, Salmonella spp, Staphylococcus aureus, and fungi. In emphysematous osteomyelitis, gas appears as a cluster of small bubbles within the medullary cavity, with a narrow zone of transition and without a sclerotic rim. The presence of introsseous gas in patients with systemic infection might be clinically unsuspected, but should be specifically looked for in CT scans. Contributors JL undertook and interpreted the CT scan, initiated this manuscript, and wrote the report. JM undertook the scientific literature search, collected, analysed, and interpreted the clinical data, and created the CT image. TW cared for the patient, collected, analysed, and interpreted the clinical data, and critically reviewed the report. AB undertook the histopathological analysis, created the microphotograph, and critically reviewed the report. Declaration of interests We declare no competing interests.
B
2 cm
20 µm
Figure: Evidence of intraosseous gas on CT and histopathology (A) Unenhanced CT image using CT bone window settings; arrows point to the sites of intraosseous gas. (B) Microphotograph of histopathology section (periodic acid–Schiff stain) obtained during bone biopsy; asterisks show sites of intraosseous gas.
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Emphysematous osteomyelitis Jörg Larsen, Jonas Mühlbauer, Thomas Wigger, Attila Bardosi Lancet Infect Dis 2015; 15: 486 Department of Clinical Radiology (J Larsen MD, J Mühlbauer) and Department of Anaesthesiology (T Wigger MD), Weende Teaching Hospitals and Amedes Johannes Orth Institute for Laboratory Medicine and Pathology (Prof A Bardosi MD), Göttingen, Germany Correspondence to: Dr JÖrg Larsen, Department of Clinical Radiology, Weende Teaching Hospitals and Amedes Johannes Orth Institute for Laboratory Medicine and Pathology, An der Lutter 24, D-37075 Göttingen, Germany [email protected]
A 72-year-old man with diabetes who was non-insulin dependent presented with unspecific abdominal pain after a fall onto his right side. He was given anticoagulants for atrial fibrillation. CT showed a hepatic haematoma. Raised C-reactive protein and procalcitonin concentrations suggested superinfection. A diagnostic aspiration was done, and antibiotic therapy with intravenous ceftriaxone was initiated, replaced by meropenem the next day. Before the microbiological culture results were available, the patient deteriorated. A follow-up CT scan revealed intraosseous gas in the pelvis and a lumbar vertebra (figure A). CT-guided bone biopsy confirmed the presence of gas (figure B), consistent with emphysematous osteomyelitis, and antibiotic therapy was escalated with the addition of clindamycin. The bone biopsy culture showed non-resistant Escherichia coli. Microbiological culture of the liver sample, urine, and catheter tips and arterial and venous blood cultures did not yield any pathogens. Despite the high-dose intravenous antibiotic therapy, the patient died as a result of multiorgan failure from fulminant sepsis, without a source of infection being identified. The presence of intraosseous gas has a differential diagnosis, including vacuum phenomena, subchondral cysts in degenerative joint disease, penetrating (including A
iatrogenic) injury, ischaemic necrosis, and osteomyelitis caused by gas-forming organisms. Pattern of distribution, detailed appearance, clinical history, and findings on examination provide clues. In systemic illness with septicaemia, CT scanning can be used to localise the site of infection while staging the microbial invasion and host response. A range of microorganisms have been shown to produce gas when colonising bone, including Pseudomonas spp, Streptococcus spp, Enterococcus spp, E coli, Salmonella spp, Staphylococcus aureus, and fungi. In emphysematous osteomyelitis, gas appears as a cluster of small bubbles within the medullary cavity, with a narrow zone of transition and without a sclerotic rim. The presence of introsseous gas in patients with systemic infection might be clinically unsuspected, but should be specifically looked for in CT scans. Contributors JL undertook and interpreted the CT scan, initiated this manuscript, and wrote the report. JM undertook the scientific literature search, collected, analysed, and interpreted the clinical data, and created the CT image. TW cared for the patient, collected, analysed, and interpreted the clinical data, and critically reviewed the report. AB undertook the histopathological analysis, created the microphotograph, and critically reviewed the report. Declaration of interests We declare no competing interests.
B
2 cm
20 µm
Figure: Evidence of intraosseous gas on CT and histopathology (A) Unenhanced CT image using CT bone window settings; arrows point to the sites of intraosseous gas. (B) Microphotograph of histopathology section (periodic acid–Schiff stain) obtained during bone biopsy; asterisks show sites of intraosseous gas.
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