Osteomyelitis in newborn infants is a rare infection. Lower extremity joints are commonly affected. Most of the cases have a haematogenous spread. Aerobes are the common group of organism involved, of which Staphylococcus aureus is the commonest. Klebsiella osteomyelitis has been reported as a cause of Osteomyelitis. However, to the best of our knowledge, this is the first case report of Klebsiella pneumoniae associated osteomyelitis in an infant from Pakistan

Ali, Syed Rehan

Amirali, Ahsen

Hashmi, Pervaiz

Lakhani, Mumtaz

Qadir, Maqbool

eCommons@AKU

eCommons@AKUDepartment of Paediatrics and Child Health Division of Woman and Child HealthSeptember 2010Klebsiella osteomyelitis of the right humerusinvolving the right shoulder joint in an infantMaqbool QadirAga Khan UniversitySyed Rehan AliAga Khan UniversityMumtaz LakhaniZiauddin UniversityPervaiz HashmiAga Khan UniversityAhsen AmiraliAga Khan UniversityFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_women_childhealth_paediatrPart of the Pediatrics CommonsRecommended CitationQadir, M., Ali, S., Lakhani, M., Hashmi, P., Amirali, A. (2010). Klebsiella osteomyelitis of the right humerus involving the rightshoulder joint in an infant. Journal of the Pakistan Medical Association, 60(9), 769-71.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_women_childhealth_paediatr/27AbstractOsteomyelitis in newborn infants is a rare infection.Lower extremity joints are commonly affected. Most of thecases have a haematogenous spread. Aerobes are thecommon group of organism involved, of whichStaphylococcus aureus is the commonest. Klebsiellaosteomyelitis has been reported as a cause of Osteomyelitis.However, to the best of our knowledge, this is the first casereport of Klebsiella pneumoniae associated osteomyelitis inan infant from Pakistan.IntroductionOsteoarticular infections, although uncommon,represent a severe condition in neonates. Infections innewborns are largely of an acute nature, transmitted byhaematogenous means.1 The osteomyelitic focus is usuallyfound in the metaphysis of a long bone, although infectionmay spread to the contiguous epiphysis and joint inneonates.1,2 The intracapsular metaphysis of proximal femurand humerus, results in a high risk of concomitant septicarthritis in these joints.3 The most commonly affected jointsare the Hip joints (31%), Knee joints (25%), and Ankle joints(18%).4 Affected neonates usually survive, but withpermanent skeletal deformities.5Etiologically, the most common organisms affectingthe joints in the neonatal period are aerobes. The predominantaerobes causing osteomyelitis in children are Staphylococcusaureus, Haemophilus influenzae type-b, Gram-negativeenteric bacteria, beta-haemolytic Streptococci, Streptococcuspneumoniae, Bartonella henselae and Borrelia burgdorferi.Anaerobes have rarely been reported as a cause of theseinfections in children. Many patients with osteomyelitis dueto anaerobic bacteria have evidence of anaerobic infectionelsewhere in the body, which is the source of the organismsinvolved in osteomyelitis.6,7Case ReportA five week old infant first presented to us in thepaediatric outpatient clinic. This infant was born in anotherhospital by vacuum assisted vaginal delivery. Birth weightwas 3.7 Kg. He was treated for ten days at another hospital forKlebsiella bacteraemia with IV Meropenem. He was broughtto our clinic because his mother had noticed that the child washaving difficulty moving his right upper limb since the last 2weeks. He was also increasingly irritable. He was given all theroutine vaccinations at birth and at 6 weeks of life.On examination in our clinic, we saw that the infantwas active, alert, and had gained adequate weight for his age.There was some movement in the right hand, but movementat the elbow and shoulder joints was minimal. The rightshoulder joint looked swollen and felt mildly warm to touch.On palpation of the right shoulder, extreme pain wasdemonstrated. Rest of the systemic examination wasunremarkable. An X-ray of Right shoulder showed a significantperiosteal reaction in the proximal humerus, along with anirregularity at the proximal metaphysis. These findings wereconsistent with an infectious etiology and hence a diagnosisof osteomyelitis was made, and the child was admitted to thepaediatric ward.In the ward, intravenous Meropenem was started at adose of 40mg/kg/dose Q8hourly. Orthopaedic and Infectiousdisease consults were generated.His blood work showed Leukocytosis, WBC31.5x109/liter, with 60.6% Neutrophils. The platelet countwas 978x 109/liter and ESR was 80mm/hr. CRP was 23.8. ABlood culture was positive for corynebacterium species,which was probably a contaminant.The orthopaedic team decided to operate followingVol. 60, No. 9, September 2010 769Case ReportKlebsiella Osteomyelitis of the right humerus involving theright shoulder joint in an infantMaqbool Qadir,1 Syed Rehan Ali,2 Mumtaz Lakhani,3 Pervaiz Hashmi,4 Ahsen Amirali5Department of Pediatrics,1,2 Department of Orthopedic,4 Medical Student,5 Aga Khan University Hospital,Department of Pediatrics, Ziauddin University,3 Karachi.Figure: Appearance of the Right Humeral Head aftertreatment compared to the Left Side.RT LTclinical assessment, laboratory tests and x-rays. The shoulderjoint was aspirated under image intensifier and one ml of puswas aspirated, and sent for culture and sensitivity. Theshoulder joint and proximal humerus were exposed throughdeltopectoral approach. The lytic area in the metaphysis ofhumerus and shoulder joint was debrided thoroughly andirrigated with saline. Necrotic bone and granulation tissuewere removed. The intracapsular biopsy showed synovialtissue with acute and chronic inflammation and microabscessformation. No evidence of malignancy or granulomaformation was seen. Pus and tissue cultures both grew moderateamounts of Klebsiella pneumoniae colonies which weresensitive to several antibiotic including Gentamicin, andImipenem/Meropenem. Both samples did not grow anyanaerobes. Tissue cultures for Acid Fast Baeilli (AFB)and fungi were negative. Hence, it was decided tocontinue Meropenem at 20mg/kg/dose Q12 hintravenously for 3 weeks.A repeat X-ray done on 7th day showed a lytic lesionin the proximal metaphysis of the humerus which was nowmore conspicuous compared to the previous examination anda periosteal reaction was noted in few areas. The infant wasdischarged on the 7th day to continue home intravenousantibiotic for 3 weeks. On the follow up visit after 2 weeks of IV antibiotic, agood grasp of the right hand was noted with the baby beingable to lift his right forearm. Movements at the shoulder jointwere still painful and the joint was still tender. Parents wereasked to bring the infant for follow up in the orthopaedic clinicafter a week with repeat CRP, ESR and a standard X-ray.On the 20th day of treatment, the orthopedic teamreviewed the lab results (CRP 2.2, ESR 30), and saw the X-ray, which demonstrated that the previously seen multiplecystic areas in the right proximal humerus had now becomemore confluent with some evidence of sclerosis. On the 26thday, following a CRP of 2.0 and an ESR of 15, it was decidedby the orthopaedics team to discontinue intravenousantibiotics and start the infant on oral Amoxicillin clavulanatefor 2 weeks, as the organism was sensitive to it.On follow up visits after 6 weeks the baby had goodmovements all throughout the right upper limb. There was nojoint swelling or tenderness. The baby, according to hismother, was feeding appropriately and weight gain wasadequate. The clinical examination in the final follow up at 7months showed full range of motion on both sidescomparable. The elevation in both flexion and abductionwere 180 degree and good internal and external rotations witharm abducted. Although the baby is presently using bothhands and arms freely, but he has not started crawling.On radiologic follow at 7 months age, it wasappreciated that although the initial x-rays showedradiolucency in the proximal humeral metaphysis withoutappearance of humeral head, the last x-rays showedappearance of humeral head but smaller than opposite(normal) side without any residual bone changes likeradiolucency or sclerosis (Figure).DiscussionKlebsiella pneumoniae osteomyelitis was firstreported in an infant from Israel in 1969.7 The incidence ofseptic arthritis and osteomyelitis among hospital babies froman Indian Hospital was reported as1 in 1500. Klebsiellapneumoniae and Staphylococcus aureus were thecommonest isolates.8 A more recent article9 shows 1%incidence of gram negative organism (excluding E. Coli)osteomyelitis in children.To our knowledge this is the first reported case ofKlebsiella osteomyelitis from Pakistan.On literature review only one such study wherepresenting complaints, natural progression of the diseasebefore intervention, and sequalae after adequate treatment,were more or less similar to the case we have presentedhere.10 The study reports on a neonate with osteomyelitis ofthe right humerus infected with the uncommon pathogen inquestion, Klebsiella pneumoniae. In the absence of anyperinatal disease, premature rupture of the membranes wassuggested to be the cause of the illness in that case. The infantwas initially regarded as having Erb's palsy because of theabsence of systemic symptoms and lack of perinatal high-riskfactors. Antibiotic administration was delayed for 3 weeks.Luckily, nearly complete recovery was noted after 2 monthsof follow up with adequate treatment. In our case, the infant had been delivered through avacum extraction but there was no evidence of prematurerupture of membranes. The earlier Klebsiella bacteraemiawas a nosocomial infection acquired after 5th day of life.Also, our surgical intervention through wound debridement,followed by 4 weeks of intravenous Meropenem, and 2weeks of oral Amoxicillin clavulanate, seemed to besuccessful. This was supported by the clinical examination inthe final follow up at 7 months which showed full range ofmotion at both shoulder joints. The elevation in both flexionand abduction are 180 degrees and good internal and externalrotation.In a review from 29 USA hospitals of cases ofosteomyelitis in children aged 2 months to 17 years, it wasreported that treatment of acute osteomyelitis with earlytransition to oral therapy is not associated with a high risk oftreatment failures and avoids the risks of prolongedintravenous therapy through central venous catheters.11 Multi770 J Pak Med Assocdrug resistance (MDR) Klebsiella have been emergingrecently, however, our patient culture were not MDR. As nonew antibiotics with novel mechanisms against many of thesegram-negative bacilli are expected to be developed in theforeseable future, careful and conservative use of agentscombined with good infection control practices is required.12ConclusionAlthough Staphylococcus aureus is still the mostcommon organism causing osteomyelitis in infants, but withthe changing epidemiology of microorganism in ourcommunity, gram negatives should be considered indifferential diagnosis of Osteomyelitis, especially in infants.References1. Dessì A, Crisafulli M, Accossu S, Setzu V, Fanos V. Osteo-articular infectionsin newborns: diagnosis and treatment. J Chemother 2008; 20: 542-50. 2. Haddad F, Sahyoun S, Maalouf G. [Neonatal osteomyelitis of the proximalfemur: a case with ten-year follow-up and review of the literature]. Rev ChirOrthop Reparatrice Appar Mot 2007; 93: 594-8.3. Lamprecht E. Acute osteomyelitis in childhood. Orthopade 1997; 26: 868-78.4. Halder D, Seng QB, Malik AS, Choo KE. Neonatal septic arthritis. SoutheastAsian J Trop Med Public Health 1996; 27: 600-5.5. Brook I. Joint and bone infections due to anaerobic bacteria in children. PediatrRehabil 2002; 5: 11-9.6. Dich VQ, Nelson JD, Haltalin KC. Osteomyelitis in Infants and Children: AReview of 163 Cases. Am J Child 1975; 129: 1273-8.7. Berant M, Kahana D. Klebsiella osteomyelitis in a newborn. Am J Dis Child1969; 118: 634-7.8. Narang A, Mukhopadhyay K, Kumar P, Bhakoo ON. Bone and joint infectionin neonates. Indian J Pediatr 1998; 65: 461-4.9. Zaoutis T, Localio AR, Leckerman K, et al .Therapy for Acute Osteomyelitis inChildren Prolonged Intravenous Therapy Versus Early Transition to OralAntimicrobial Pediatrics 2009; 123: 636-42.10. Liao SL, Lai SH, Lin TY, Chou YH, Hsu JF. Premature rupture of themembranes: a cause for neonatal osteomyelitis? Am J Perinatol 2005; 22: 63-6.11. Zaoutis T, Localio AR, Leckerman K, Saddlemire S, Bertoch D, Keren R.Prolonged intravenous therapy versus early transition to oralantimicrobial therapy for acute osteomyelitis in children. Pediatrics 2009;123: 636-42.12. Nicasio AM, Kuti JL, Nicolau DP. The current state of multidrug-resistant gram-negative bacilli in North America. Pharmacotherapy 2008; 28: 235-49.Vol. 60, No. 9, September 2010 771

Klebsiella osteomyelitis of the right humerus involving the right shoulder joint in an infant

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Klebsiella osteomyelitis of the right humerus involving the right shoulder joint in an infant

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