Images in…
Metatarsal Brodie’s abscess in a Tunisian child Kaouther Ben Abdelghani, Leila Souabni, Selma Kassab, Leith Zakraoui Department of Rheumatology, Mongi Slim Hospital, La Marsa, Tunisia Correspondence to Dr Kaouther Ben Abdelghani, [email protected] Accepted 18 April 2014
DESCRIPTION Brodie’s abscess is a subacute or chronic variant of osteomyelitis usually involving the metaphysis of long bones. The clinical presentation is often atypical and the diagnosis is challenging. It is rare except in developing countries. A 10-year-old Tunisian girl reported left metatarsalgia with loss of motion evolving since 3 weeks. One month previously, she had suffered from rhinopharyngitis. On examination, the temperature was 38.5°C. There was tenderness and swelling of the dorsal left foot. The erythrocyte sedimentation rate was at 31 mm and the C reactive protein was 20 mg/L. Plain radiographs revealed a metatarsal lytic lesion with important periosteal apposition (figure 1). MRI revealed the characteristic pattern of Brodie’s abscess (figure 2). The patient was prescribed antibiotics (amoxicilline-clavulinic acid 1.5 g/day during 45 days) and foot immobilisation with good clinical response. The X-ray of the foot made
Figure 2 Coronal MRI of the foot showing enhancement after gadolinium injection on T1 sequences consistent with oedema of bone marrow and soft tissue of the second metatarsal.
1 month later showed a full metaphyseal consolidation with sequestration (figure 3). In this case, Brodie’s abscess was difficult to diagnose because of its insidious onset, mild symptoms and especially atypical site. The skeletal lesion affects almost usually the metaphysis of long bones and involves the lower limbs. The predilection site is the femur and tibia. A little more than 15 cases of metatarsial osteomyelitis have been reported in the literature.1–3 In our case, the outcome was favourable under antibiotics. The abscess had disappeared without recurrence or fistulisation with a decline of 2 years.
To cite: Ben Abdelghani K, Souabni L, Kassab S, et al. BMJ Case Rep Published online: [ please include Day Month Year] doi:10.1136/ bcr-2014-203936
Figure 1 Metatarsal lytic lesion with important periosteal apposition.
Ben Abdelghani K, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-203936
Figure 3
Metaphyseal consolidation with sequestration. 1
Images in… Competing interests None.
Learning points
Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
▸ Brodie’s abscess usually affects the metaphyseal regions of long bone especially the tibia. Metatarsal location is a rare condition. ▸ Brodie’s abscess should be kept in mind in case of bone pain and fever in a child in order to avoid misdiagnosis.
REFERENCES 1 2 3
Contributors KBA and LS were involved in conception and drafting of the manuscript. SK and LZ approved the final manuscript.
Robb JE. Primary acute haematogenous osteomyelitis of an isolated metatarsal in children. Arch Orthop Scand 1984;55:334–8. Freund KG. Haematogenous osteomyelitis of the first metatarsal sesamoid. Case report and review of the literature. Arch Orthop Trauma Surg 1989;108:53–4. Uslu M, Okur M, Gonen I. Low-grade osteomyelitis of the fifth metatarsal with possible concomitant Freiberg’s disease of the metatarsal head. J Foot Ankle Surg 2012;51:798–800.
Copyright 2014 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
2
Ben Abdelghani K, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-203936
Metatarsal Brodie’s abscess in a Tunisian child Kaouther Ben Abdelghani, Leila Souabni, Selma Kassab, Leith Zakraoui Department of Rheumatology, Mongi Slim Hospital, La Marsa, Tunisia Correspondence to Dr Kaouther Ben Abdelghani, [email protected] Accepted 18 April 2014
DESCRIPTION Brodie’s abscess is a subacute or chronic variant of osteomyelitis usually involving the metaphysis of long bones. The clinical presentation is often atypical and the diagnosis is challenging. It is rare except in developing countries. A 10-year-old Tunisian girl reported left metatarsalgia with loss of motion evolving since 3 weeks. One month previously, she had suffered from rhinopharyngitis. On examination, the temperature was 38.5°C. There was tenderness and swelling of the dorsal left foot. The erythrocyte sedimentation rate was at 31 mm and the C reactive protein was 20 mg/L. Plain radiographs revealed a metatarsal lytic lesion with important periosteal apposition (figure 1). MRI revealed the characteristic pattern of Brodie’s abscess (figure 2). The patient was prescribed antibiotics (amoxicilline-clavulinic acid 1.5 g/day during 45 days) and foot immobilisation with good clinical response. The X-ray of the foot made
Figure 2 Coronal MRI of the foot showing enhancement after gadolinium injection on T1 sequences consistent with oedema of bone marrow and soft tissue of the second metatarsal.
1 month later showed a full metaphyseal consolidation with sequestration (figure 3). In this case, Brodie’s abscess was difficult to diagnose because of its insidious onset, mild symptoms and especially atypical site. The skeletal lesion affects almost usually the metaphysis of long bones and involves the lower limbs. The predilection site is the femur and tibia. A little more than 15 cases of metatarsial osteomyelitis have been reported in the literature.1–3 In our case, the outcome was favourable under antibiotics. The abscess had disappeared without recurrence or fistulisation with a decline of 2 years.
To cite: Ben Abdelghani K, Souabni L, Kassab S, et al. BMJ Case Rep Published online: [ please include Day Month Year] doi:10.1136/ bcr-2014-203936
Figure 1 Metatarsal lytic lesion with important periosteal apposition.
Ben Abdelghani K, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-203936
Figure 3
Metaphyseal consolidation with sequestration. 1
Images in… Competing interests None.
Learning points
Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
▸ Brodie’s abscess usually affects the metaphyseal regions of long bone especially the tibia. Metatarsal location is a rare condition. ▸ Brodie’s abscess should be kept in mind in case of bone pain and fever in a child in order to avoid misdiagnosis.
REFERENCES 1 2 3
Contributors KBA and LS were involved in conception and drafting of the manuscript. SK and LZ approved the final manuscript.
Robb JE. Primary acute haematogenous osteomyelitis of an isolated metatarsal in children. Arch Orthop Scand 1984;55:334–8. Freund KG. Haematogenous osteomyelitis of the first metatarsal sesamoid. Case report and review of the literature. Arch Orthop Trauma Surg 1989;108:53–4. Uslu M, Okur M, Gonen I. Low-grade osteomyelitis of the fifth metatarsal with possible concomitant Freiberg’s disease of the metatarsal head. J Foot Ankle Surg 2012;51:798–800.
Copyright 2014 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
2
Ben Abdelghani K, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-203936
