Hashmi, R

Masroor, I

English

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eCommons@AKUDepartment of Radiology Medical College, PakistanDecember 2002View box case--12 OsteomyelitisI MasroorAga Khan University, imrana.masroor@aku.eduR HashmiFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_radiolPart of the Radiology CommonsRecommended CitationMasroor, I., Hashmi, R. (2002). View box case--12 Osteomyelitis. Journal of Pakistan Medical Association, 52(12), 583-584.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_radiol/289View Box Case - 12I. Masroor,R. Hashmi  ( Department of Radiology, Aga Khan University Hospital, Karachi. ) A 25 year old male presented with high grade fever and swelling of right knee with limitation ofmovements for two weeks. Laboratory findings reveled increased WBC count and raised ESR. A lateralview of right knee showed patchy lysis and sclerosis involving the metadiaphysis of right tibia withperiosteal reaction; the articular surface was also involved with associated joint effusion (Figure).The differential considerations included osteomyelitis, Ewing’s sarcoma, lymphoma, and osteogenicsarcoma.Diagnosis: Osteomyelitis.Discussion Osteomyelitis continues to present a difficult diagnostic problem because of similarity of clinical,laboratory, and radiographic signs in patients with a variety of traumatic, neoplastic, and inflammatoryconditions1. Extensive destructive changes often occur before accurate identification and therapy takeplace. Importantly, radiographic findings usually are delayed after the onset of clinical signs ofinfection.The four major routes by which bony structures can be contaminated include hematogenous spread,contiguous spread, direct implantation and post-operative infection2. In children, the most commonmechanism is hematogenous dissemination. Because of differences in the vascular supply of the tubularbones, the radiologic and pathologic appearance of osteomyelitis differs in the child, infant and adult.In children, the open cartilagenous growth plate results in separate vascular supplies for the metaphysisand the epiphysis. As a result, there is a tendency for hematogenously disseminated osteomyelitis toinvolve the metaphysis in children.Radiographic appearance is highly variable and may mimic many other pathologic processes1,3. Thereis a latent period of approximately 10 days between onset of symptoms and the presence of osseouschanges in a long bone. Soft tissue swelling may be seen in 3 days. Clear lucent planes between bone,muscle, fat are obliterated. Earliest bony changes include single or multiple areas of demineralizationas trabeculae are destroyed. These are often seen in 2 weeks. Periostitis with involucrum formationoccurs when infection penetrates cortex and may be seen at 3-6 weeks. Sequestra (dead bone) appeardenser due to reactive osteolysis of adjacent bone. Identification of a bony sequestrum narrows thedifferential diagnosis. A Brodie’s abscess will appear as a lucent region with a sclerotic rim. Chronicinfection is characterized by thick involucrum with areas of destruction and sequestrae. 99mTc bonescans are positive early but are nonspecific3.Jn addition to osteomyelitis differential diagnosis of permeative lesion with cortical destruction in thepediatric population includes Ewing’s sarcoma, eosinophilic granuloma and atypical osteosarcoma.Treatment necessitates immediate and appropriate antibiotic therapy, and requires either a positiveblood culture or open bone biopsy2. If clinical improvement does not occur within 48-72 hours, chronicinfection with sequestra or abscess can be assumed, requiring surgical debridement. Antibiotic therapyis extended over 4-6 weeks, and the course is often complicated by pathologic fracture, nonunion,spread of infection to the joint and hematogenous dissemination.References 1.God RH, Randall AH, Katz RD. Bacterial Osteomyelitis: findings on Plain Radiography, CT, MR.and scintigraphy. AJR., 1991;157:365-70.2.Caiek PJ, Dickerson LM, Sack JL. Diagnosis and management of osteomyelitis, Am. Fam. Physician,2001 ;63: 2413-20.3.Tehranzadeh J, Wong E, Wang F, et al. Imaging of osteomyelitis in the mature skeleton. Radiol. Clin.North Am., 2001 ;39:223-50.

View box case--12 Osteomyelitis

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View box case--12 Osteomyelitis

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