The Journal of Foot & Ankle Surgery xxx (2014) 1–4
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Case Reports and Series
Osteomyelitis Calcaneum due to a Scorpion Sting Saraswathivilasam S. Suresh, MS Orth, MCh Orth 1, Hosam Zaki, MBBS, D Orth 2, Jamshid Etemadi Shalamzari, MS Orth 2, Gunmala Bhatnagar, MD 3 1
Senior Consultant and Head, Department of Orthopaedics, Ibri Regional Referral Hospital, Ibri, Sultanate of Oman Specialist, Department of Orthopedics, Ibri Regional Referral Hospital, Ibri, Sultanate of Oman 3 Senior Consultant, Department of Pathology, Royal Hospital, Muscat, Oman 2
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Children are susceptible to various injuries, including insect bites, and scorpion bites are common in the lower extremity of children in Middle East countries. In most cases, the sting will produce just a local reaction; however, serious complications that can result in death have occurred. In this case report, we describe a case of osteomyelitis of the calcaneum after a scorpion sting. Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: arthropod calcaneus envenomation infection surgery toxin
Scorpion stings are common in the tropical and subtropical countries and more common in the rural areas of Middle East countries (1,2). Osteomyelitis of the calcaneum can occur from blood stream spread or direct inoculation of the bacteria from a puncture wound (3). The incidence of calcaneal osteomyelitis in children has been 7% to 8%, with most cases due to hematogenous spread (3). Although trauma has been reported as a predisposing factor for acute hematogenous osteomyelitis, we believe the scorpion sting triggered the infection in our patient (3).
showed a lytic lesion in the posterior plantar aspect of the right calcaneum (Fig. 1). The boy recollected the site of the sting, the mark of which was present at his visit to us (Fig. 2). The erythrocyte sedimentation rate was 83 mm fall in the first hour. The results of the C-reactive protein and other blood investigations were normal. A well-defined lytic lesion was present in the posterior part of the right calcaneum on the computed tomography scan (Fig. 3), with a narrow zone of transition without any cortical breakthrough. No soft tissue component was seen.
Case Report A 9-year-old male presented to the orthopedic clinic with a painful right heel and difficulty in putting load on the right leg. Three weeks before to his visit to us, he had been seen in the emergency department with a scorpion sting to the right heel on the medial aspect. Because he had not been experiencing any systemic effects from the envenomation, he was discharged home on analgesics and oral tablets of amoxicillin and clavulanate 3 times a day for 2 weeks (Gloclav 375 USP, Global Pharma, Dubai, United Arab Emirates). On his presentation to us, he was unable to bear weight on his right foot. Radiographs Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Saraswathivilasam S. Suresh, MS Orth, MCh Orth, Department of Orthopaedics, Ibri Regional Referral Hospital, PO Box 396, Ibri 516 Sultanate of Oman. E-mail address: [email protected] (S.S. Suresh).
Fig. 1. Lateral radiographs of both feet showing the lytic lesion (arrow).
1067-2516/$ - see front matter Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.01.004
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S.S. Suresh et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
Fig. 2. Clinical photograph showing the sting mark (arrow) on the right foot.
The patient underwent surgery under general anesthesia, and the lesion was approached through a cortical window. Pale brown granulation tissue was curetted out of the calcaneus (Fig. 4). Gram staining was negative for bacteria, and the Ziehl-Neelsen stain was negative for acid fast bacilli. Bacterial culture (both aerobic and anaerobic) of the tissue was negative for organisms. The tissue was also negative for fungus. The patient was kept nonweightbearing for 3 weeks in a plaster of Paris cast, with axillary crutch walking. Histologic examination showed sections with bony trabeculae with marrow spaces showing dense infiltration by lymphoplasmacytic cells admixed with polymorphs. The periodic acid-Schiff stain was negative for fungus. The study results were consistent with osteomyelitis (Fig. 5). We continued the antibiotic coverage for another 3 weeks, with Gloclav 375 mg 3 times daily (amoxicillin and clavulanate USP 375 mg, Global Pharma), although the culture findings were negative. At 1 year of follow-up, the lesion had completely resolved, and our patient was as active as before the sting. However, mild irregularity of the calcaneal tuberosity was present (Figs. 6 to 8).
Fig. 3. Axial computed tomography scan showing the lytic lesion (arrow) without intralesional calcifications and an intact cortex.
Fig. 4. Perioperative photograph showing the window created in the medial wall of the mass.
Discussion Injuries due to scorpion stings are common in Middle East countries. In our case, the sting was from a type of scorpion, as recollected
Fig. 5. (A) Low power view of hematoxylin and eosin stain showing the bony trabeculae and inflammatory cells. (B) High power view showing the bony trabeculae and inflammatory cells.
S.S. Suresh et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
3
Fig. 6. Lateral radiograph showing outcome at 1 year of follow-up.
by the patient and his parents, Hottentotta Jayakari Salei belonging to the species of Buthidae (4). At the site of the sting, a papule will appear within the first hour that can progress to a purple plague, which can ulcerate and result in necrosis of the tissue (5). Extensive coagulative necrosis of the underlying muscle can also develop (5,6). The release of cytokines by the action of the venom is associated with activation of vasodilatation and increased vessel permeability (7). The clinical findings are related to the excessive systemic inflammatory response to stings (7). Lymphangitis due to envenomation of the lymphatic system can occur. All these local features could have produced a local tissue reaction in the heel pad of our patient, resulting in spreading of the venom into the posterior aspect of the calcaneum. If the patient presents with only local symptoms, reassurance and symptomatic treatment will be all that is required (2). The radiologic changes of osteomyelitis can take 1 to 3 weeks to develop (3). In hematogenous osteomyelitis, the posterior part of the calcaneum adjacent to the apophysis is commonly affected (3). The cultures will usually be negative (3). In our case, the patient presented to us after 3 weeks, and at presentation, the radiographs showed the lesion.
Although a history of a scorpion sting was present, we also considered Ewing’s sarcoma, simple bone cyst, chondroblastoma, chondromyxoid fibroma, and giant cell tumor in the differential diagnosis. Giant cell tumor was ruled out because of the patient’s age. Because of the elevated erythrocyte sedimentation rate and local tenderness, we also considered Ewing’s tumor in the differential diagnosis. However, the lamellated appearance and periosteal reaction typical of Ewing’s tumor of other bones will be absent in tumors of the tarsal bones (8). Solitary bone cysts of the calcaneum will be confined to the trigonum calcis and were excluded. A simple bone cyst, which will have a well-defined rounded lytic lesion, usually in the anterior third of the calcaneum (9), was also ruled out because of the location of the mass in our patient. Intraosseous lipoma will have thin sclerotic margins that are well defined (9,10). The intralesional calcification typical of intraosseous lipoma was not present in our case, and the lesion did not show fat density on the computed tomography scans. Chondroblastoma, another differential diagnosis for our case, will have lytic areas, with well-defined, often sclerotic, margins and some septations centrally (9,11). It can also have endosteal scalloping or expansion, cystic changes, and, occasionally, fine stippled calcifications (12). Chondroblastomas will usually be located in the region of the talocalcaneal articulation and posterior part of the calcaneus (11,12). However, the incidence is in the second decade of life (11).
Fig. 7. Axial view of the calcaneum showing the result at 1 year of follow up.
Fig. 8. Clinical photograph at 1 year of follow-up.
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S.S. Suresh et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
Aneurysmal bone cysts will have an expansile lytic blown out appearance contained by a thin layer of periosteal new bone formation (9,13). However, it is predominantly a tumor of childhood and located toward the posterior plantar aspect of the bone (12). Magnetic resonance imaging of aneurysmal bone cysts will show lobulated or septate mass, with a thin, well-defined rim of low-signal intensity. Typically, fluid–fluid levels will be seen (9,12). The signal intensity of the mass will vary according to the contents and age of the blood products (9,12). Osteoblastomas are benign primary tumors of the bone affecting young adults aged 20 to 30 years (13). The presentation is that of a well-circumscribed, round, or oval lesion that is eccentric and with expansile lucency (14). Matrix mineralization and sclerosis around the margins have occasionally been seen (13). Chondromyxoid fibromas will usually be located in the subarticular region or near the inferior surface of the calcaneum (12,15). Chronic recurrent osteomyelitis can involve the calcaneum and other tarsal bones (16); however, the course can be prolonged and chronic, with disease-free intervals in between. Radiographs will show multiple foci of osteolysis with surrounding sclerosis (16). Although muscle necrosis (5) and brachial plexopathy due to direct compression from tissue edema or the effects of toxin (17) from scorpion envenomation has been reported, no reports have been published of osteomyelitis due to scorpion stings. Growth disturbance with radiologic shortening in the anteroposterior length, increased height of the calcaneum, and irregular calcaneal tuberosity are the known sequela of calcaneal osteomyelitis. Thorough curettage and antibiotic coverage resulted in complete resolution of the lesion in our patient, and at 1 year of follow-up, no evidence was seen of a growth disturbance.
References 1. Al Asmari AK, Al-Saif AA, Abdo NM. Morphological identification of scorpion species from Jazan and Al-Medina Al- Munawara regions, Saudi Arabia. J Venom Anims Toxins Incl Trop Dis 13:821–843, 2007. 2. Prasad R, Mishra OP, Pandey N, Singh TB. Scorpion sting envenomation in children: factors affecting the outcome. Indian J Pediatr 78:544–548, 2011. 3. Jaakkola J, Douglas K. Hematogenous calcaneal osteomyelitis in children. J Pediatr Orthop 19:699–704, 1999. 4. Lowe G. Two new species of Hottentotta Birula, 1908 (Scorpiones:Buthidae) from Northern Oman. Euscorpius 103:1–23, 2010. 5. Gordon RM. Reactions produced by arthropods directly injurious to the skin of man. BMJ 2:316–318, 1950. 6. Ansari MY. Gangrene after scorpion sting. BMJ 2:388, 1948. 7. Petricevich VL. Scorpion venom and the inflammatory response. Mediators Inflamm 2010:903295, 2010. 8. Ramachandran K, Sasidharan K, Pradeep VM, Kusumakumari P, Krishnakumar AS. Ewing’s sarcoma of the calcaneum. Indian J Radiol Imaging 10:45–46, 2000. 9. Van Dyck P, Vanhoenacker FM, Gielen JL, De Schepper AM, Parizel PM. Imaging of tumors of the foot and ankle. JBR-BTR 87:252–257, 2004. 10. Revenga Martinez M, Bachiller Corral FJ, Rubio Garcia J, Munoz Beltran M, Zea Mendoza AC. Cystic lesion of the calcaneus: intraosseous lipoma. Reumatol Clin 3:139–142, 2007. 11. Kricun ME, Kricun R, Haskin ME. Chondroblastoma of the calcaneus: radiographic features with emphasis on location. AJR Am J Roentgenol 128:613–616, 1977. 12. Tsai TY, Wu CC, Lin KY, Hsu CK, Lin YC, Wang SJ. Treatment of a calcaneal chondroblastoma with curettage and bone substitute grafting mixed with autologous bone marrow. J Med Sci 30:165–168, 2010. 13. Wilde GE, Gakhal MS. Radiological reasoning: Imaging of a talar mass. AJR Am J Roentgenol 196:ws47–ws52, 2011. 14. Eisenberg RL. Bubbly lesions of bone. AJR Am J Roentgenol 193:W79–W94, 2009. 15. Schajowicz F, Gallardo H. Chondromyxoid fibroma (fibromyxoid chondroma) of bone: a clinico-pathological study of thirty-two cases. J Bone Joint Surg 53B:198– 216, 1971. 16. Khanna G, Sato TSP, Ferguson P. Imaging of chronic recurrent multifocal osteomyelitis. Radiographics 29:1159–1177, 2009. 17. Rubi DI, Vavra M. Brachial plexopathy as a rare presenting manifestation of scorpion envenomation. Muscle Nerve 44:131–135, 2011.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Case Reports and Series
Osteomyelitis Calcaneum due to a Scorpion Sting Saraswathivilasam S. Suresh, MS Orth, MCh Orth 1, Hosam Zaki, MBBS, D Orth 2, Jamshid Etemadi Shalamzari, MS Orth 2, Gunmala Bhatnagar, MD 3 1
Senior Consultant and Head, Department of Orthopaedics, Ibri Regional Referral Hospital, Ibri, Sultanate of Oman Specialist, Department of Orthopedics, Ibri Regional Referral Hospital, Ibri, Sultanate of Oman 3 Senior Consultant, Department of Pathology, Royal Hospital, Muscat, Oman 2
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Children are susceptible to various injuries, including insect bites, and scorpion bites are common in the lower extremity of children in Middle East countries. In most cases, the sting will produce just a local reaction; however, serious complications that can result in death have occurred. In this case report, we describe a case of osteomyelitis of the calcaneum after a scorpion sting. Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: arthropod calcaneus envenomation infection surgery toxin
Scorpion stings are common in the tropical and subtropical countries and more common in the rural areas of Middle East countries (1,2). Osteomyelitis of the calcaneum can occur from blood stream spread or direct inoculation of the bacteria from a puncture wound (3). The incidence of calcaneal osteomyelitis in children has been 7% to 8%, with most cases due to hematogenous spread (3). Although trauma has been reported as a predisposing factor for acute hematogenous osteomyelitis, we believe the scorpion sting triggered the infection in our patient (3).
showed a lytic lesion in the posterior plantar aspect of the right calcaneum (Fig. 1). The boy recollected the site of the sting, the mark of which was present at his visit to us (Fig. 2). The erythrocyte sedimentation rate was 83 mm fall in the first hour. The results of the C-reactive protein and other blood investigations were normal. A well-defined lytic lesion was present in the posterior part of the right calcaneum on the computed tomography scan (Fig. 3), with a narrow zone of transition without any cortical breakthrough. No soft tissue component was seen.
Case Report A 9-year-old male presented to the orthopedic clinic with a painful right heel and difficulty in putting load on the right leg. Three weeks before to his visit to us, he had been seen in the emergency department with a scorpion sting to the right heel on the medial aspect. Because he had not been experiencing any systemic effects from the envenomation, he was discharged home on analgesics and oral tablets of amoxicillin and clavulanate 3 times a day for 2 weeks (Gloclav 375 USP, Global Pharma, Dubai, United Arab Emirates). On his presentation to us, he was unable to bear weight on his right foot. Radiographs Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Saraswathivilasam S. Suresh, MS Orth, MCh Orth, Department of Orthopaedics, Ibri Regional Referral Hospital, PO Box 396, Ibri 516 Sultanate of Oman. E-mail address: [email protected] (S.S. Suresh).
Fig. 1. Lateral radiographs of both feet showing the lytic lesion (arrow).
1067-2516/$ - see front matter Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.01.004
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S.S. Suresh et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
Fig. 2. Clinical photograph showing the sting mark (arrow) on the right foot.
The patient underwent surgery under general anesthesia, and the lesion was approached through a cortical window. Pale brown granulation tissue was curetted out of the calcaneus (Fig. 4). Gram staining was negative for bacteria, and the Ziehl-Neelsen stain was negative for acid fast bacilli. Bacterial culture (both aerobic and anaerobic) of the tissue was negative for organisms. The tissue was also negative for fungus. The patient was kept nonweightbearing for 3 weeks in a plaster of Paris cast, with axillary crutch walking. Histologic examination showed sections with bony trabeculae with marrow spaces showing dense infiltration by lymphoplasmacytic cells admixed with polymorphs. The periodic acid-Schiff stain was negative for fungus. The study results were consistent with osteomyelitis (Fig. 5). We continued the antibiotic coverage for another 3 weeks, with Gloclav 375 mg 3 times daily (amoxicillin and clavulanate USP 375 mg, Global Pharma), although the culture findings were negative. At 1 year of follow-up, the lesion had completely resolved, and our patient was as active as before the sting. However, mild irregularity of the calcaneal tuberosity was present (Figs. 6 to 8).
Fig. 3. Axial computed tomography scan showing the lytic lesion (arrow) without intralesional calcifications and an intact cortex.
Fig. 4. Perioperative photograph showing the window created in the medial wall of the mass.
Discussion Injuries due to scorpion stings are common in Middle East countries. In our case, the sting was from a type of scorpion, as recollected
Fig. 5. (A) Low power view of hematoxylin and eosin stain showing the bony trabeculae and inflammatory cells. (B) High power view showing the bony trabeculae and inflammatory cells.
S.S. Suresh et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
3
Fig. 6. Lateral radiograph showing outcome at 1 year of follow-up.
by the patient and his parents, Hottentotta Jayakari Salei belonging to the species of Buthidae (4). At the site of the sting, a papule will appear within the first hour that can progress to a purple plague, which can ulcerate and result in necrosis of the tissue (5). Extensive coagulative necrosis of the underlying muscle can also develop (5,6). The release of cytokines by the action of the venom is associated with activation of vasodilatation and increased vessel permeability (7). The clinical findings are related to the excessive systemic inflammatory response to stings (7). Lymphangitis due to envenomation of the lymphatic system can occur. All these local features could have produced a local tissue reaction in the heel pad of our patient, resulting in spreading of the venom into the posterior aspect of the calcaneum. If the patient presents with only local symptoms, reassurance and symptomatic treatment will be all that is required (2). The radiologic changes of osteomyelitis can take 1 to 3 weeks to develop (3). In hematogenous osteomyelitis, the posterior part of the calcaneum adjacent to the apophysis is commonly affected (3). The cultures will usually be negative (3). In our case, the patient presented to us after 3 weeks, and at presentation, the radiographs showed the lesion.
Although a history of a scorpion sting was present, we also considered Ewing’s sarcoma, simple bone cyst, chondroblastoma, chondromyxoid fibroma, and giant cell tumor in the differential diagnosis. Giant cell tumor was ruled out because of the patient’s age. Because of the elevated erythrocyte sedimentation rate and local tenderness, we also considered Ewing’s tumor in the differential diagnosis. However, the lamellated appearance and periosteal reaction typical of Ewing’s tumor of other bones will be absent in tumors of the tarsal bones (8). Solitary bone cysts of the calcaneum will be confined to the trigonum calcis and were excluded. A simple bone cyst, which will have a well-defined rounded lytic lesion, usually in the anterior third of the calcaneum (9), was also ruled out because of the location of the mass in our patient. Intraosseous lipoma will have thin sclerotic margins that are well defined (9,10). The intralesional calcification typical of intraosseous lipoma was not present in our case, and the lesion did not show fat density on the computed tomography scans. Chondroblastoma, another differential diagnosis for our case, will have lytic areas, with well-defined, often sclerotic, margins and some septations centrally (9,11). It can also have endosteal scalloping or expansion, cystic changes, and, occasionally, fine stippled calcifications (12). Chondroblastomas will usually be located in the region of the talocalcaneal articulation and posterior part of the calcaneus (11,12). However, the incidence is in the second decade of life (11).
Fig. 7. Axial view of the calcaneum showing the result at 1 year of follow up.
Fig. 8. Clinical photograph at 1 year of follow-up.
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S.S. Suresh et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
Aneurysmal bone cysts will have an expansile lytic blown out appearance contained by a thin layer of periosteal new bone formation (9,13). However, it is predominantly a tumor of childhood and located toward the posterior plantar aspect of the bone (12). Magnetic resonance imaging of aneurysmal bone cysts will show lobulated or septate mass, with a thin, well-defined rim of low-signal intensity. Typically, fluid–fluid levels will be seen (9,12). The signal intensity of the mass will vary according to the contents and age of the blood products (9,12). Osteoblastomas are benign primary tumors of the bone affecting young adults aged 20 to 30 years (13). The presentation is that of a well-circumscribed, round, or oval lesion that is eccentric and with expansile lucency (14). Matrix mineralization and sclerosis around the margins have occasionally been seen (13). Chondromyxoid fibromas will usually be located in the subarticular region or near the inferior surface of the calcaneum (12,15). Chronic recurrent osteomyelitis can involve the calcaneum and other tarsal bones (16); however, the course can be prolonged and chronic, with disease-free intervals in between. Radiographs will show multiple foci of osteolysis with surrounding sclerosis (16). Although muscle necrosis (5) and brachial plexopathy due to direct compression from tissue edema or the effects of toxin (17) from scorpion envenomation has been reported, no reports have been published of osteomyelitis due to scorpion stings. Growth disturbance with radiologic shortening in the anteroposterior length, increased height of the calcaneum, and irregular calcaneal tuberosity are the known sequela of calcaneal osteomyelitis. Thorough curettage and antibiotic coverage resulted in complete resolution of the lesion in our patient, and at 1 year of follow-up, no evidence was seen of a growth disturbance.
References 1. Al Asmari AK, Al-Saif AA, Abdo NM. Morphological identification of scorpion species from Jazan and Al-Medina Al- Munawara regions, Saudi Arabia. J Venom Anims Toxins Incl Trop Dis 13:821–843, 2007. 2. Prasad R, Mishra OP, Pandey N, Singh TB. Scorpion sting envenomation in children: factors affecting the outcome. Indian J Pediatr 78:544–548, 2011. 3. Jaakkola J, Douglas K. Hematogenous calcaneal osteomyelitis in children. J Pediatr Orthop 19:699–704, 1999. 4. Lowe G. Two new species of Hottentotta Birula, 1908 (Scorpiones:Buthidae) from Northern Oman. Euscorpius 103:1–23, 2010. 5. Gordon RM. Reactions produced by arthropods directly injurious to the skin of man. BMJ 2:316–318, 1950. 6. Ansari MY. Gangrene after scorpion sting. BMJ 2:388, 1948. 7. Petricevich VL. Scorpion venom and the inflammatory response. Mediators Inflamm 2010:903295, 2010. 8. Ramachandran K, Sasidharan K, Pradeep VM, Kusumakumari P, Krishnakumar AS. Ewing’s sarcoma of the calcaneum. Indian J Radiol Imaging 10:45–46, 2000. 9. Van Dyck P, Vanhoenacker FM, Gielen JL, De Schepper AM, Parizel PM. Imaging of tumors of the foot and ankle. JBR-BTR 87:252–257, 2004. 10. Revenga Martinez M, Bachiller Corral FJ, Rubio Garcia J, Munoz Beltran M, Zea Mendoza AC. Cystic lesion of the calcaneus: intraosseous lipoma. Reumatol Clin 3:139–142, 2007. 11. Kricun ME, Kricun R, Haskin ME. Chondroblastoma of the calcaneus: radiographic features with emphasis on location. AJR Am J Roentgenol 128:613–616, 1977. 12. Tsai TY, Wu CC, Lin KY, Hsu CK, Lin YC, Wang SJ. Treatment of a calcaneal chondroblastoma with curettage and bone substitute grafting mixed with autologous bone marrow. J Med Sci 30:165–168, 2010. 13. Wilde GE, Gakhal MS. Radiological reasoning: Imaging of a talar mass. AJR Am J Roentgenol 196:ws47–ws52, 2011. 14. Eisenberg RL. Bubbly lesions of bone. AJR Am J Roentgenol 193:W79–W94, 2009. 15. Schajowicz F, Gallardo H. Chondromyxoid fibroma (fibromyxoid chondroma) of bone: a clinico-pathological study of thirty-two cases. J Bone Joint Surg 53B:198– 216, 1971. 16. Khanna G, Sato TSP, Ferguson P. Imaging of chronic recurrent multifocal osteomyelitis. Radiographics 29:1159–1177, 2009. 17. Rubi DI, Vavra M. Brachial plexopathy as a rare presenting manifestation of scorpion envenomation. Muscle Nerve 44:131–135, 2011.
