Osteomyelitis

Last updated
Osteomyelitis
Other namesBone infection
OsteomylitisMark.png
Osteomyelitis of the 1st toe
Specialty Infectious disease, orthopedics
Symptoms Pain in a specific bone, overlying redness, fever, weakness [1]
Complications Amputation [2]
Usual onsetYoung or old [1]
DurationShort or long term [2]
CausesBacterial, fungal [2]
Risk factors Diabetes, intravenous drug use, prior removal of the spleen, trauma to the area [1]
Diagnostic method Blood tests, medical imaging, bone biopsy [2]
Differential diagnosis Charcot's joint, rheumatoid arthritis, infectious arthritis, giant cell tumor, cellulitis [1] [3]
Treatment Antimicrobials, surgery [4]
Prognosis Low risk of death with treatment [5]
Frequency2.4 per 100,000 per year [6]

Osteomyelitis (OM) is an infection of bone. [1] Symptoms may include pain in a specific bone with overlying redness, fever, and weakness. [1] The long bones of the arms and legs are most commonly involved in children e.g. the femur and humerus, [7] while the feet, spine, and hips are most commonly involved in adults. [2]

Contents

The cause is usually a bacterial infection, [1] [7] [2] but rarely can be a fungal infection. [8] It may occur by spread from the blood or from surrounding tissue. [4] Risks for developing osteomyelitis include diabetes, intravenous drug use, prior removal of the spleen, and trauma to the area. [1] Diagnosis is typically suspected based on symptoms and basic laboratory tests as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). This is because plain radiographs are unremarkable in the first few days following acute infection. [7] [2] Diagnosis is further confirmed by blood tests, medical imaging, or bone biopsy. [2]

Treatment of bacterial osteomyelitis often involves both antimicrobials and surgery. [7] [4] In people with poor blood flow, amputation may be required. [2] Treatment of the relatively rare fungal osteomyelitis as mycetoma infection entails the use of antifungal medications. [9] In contrast to bacterial osteomyelitis, amputation or large bony resections is more common in neglected fungal osteomyelitis (mycetoma) where infections of the foot account for the majority of cases. [8] [9] Treatment outcomes of bacterial osteomyelitis are generally good when the condition has only been present a short time. [7] [2] About 2.4 per 100,000 people are affected each year. [6] The young and old are more commonly affected. [7] [1] Males are more commonly affected than females. [3] The condition was described at least as early as the 300s BC by Hippocrates. [4] Prior to the availability of antibiotics, the risk of death was significant. [10]

Signs and symptoms

Symptoms may include pain in a specific bone with overlying redness, fever, and weakness and inability to walk especially in children with acute bacterial osteomyelitis. [7] [1] Onset may be sudden or gradual. [1] Enlarged lymph nodes may be present. [11] In fungal osteomyelitis, there is usually a history of walking bare-footed, especially in rural and farming areas. Contrary to the mode of infection in bacterial osteomyelitis, which is primarily blood-borne, fungal osteomyelitis starts as a skin infection, then invades deeper tissues until it reaches bone. [8]

Cause

Age groupMost common organisms
Newborns (younger than 4 mo) Staphylococcus aureus , Enterobacter species, and group A and B Streptococcus species
Children (aged 4 mo to 4 y) S. aureus , group A Streptococcus species, Haemophilus influenzae , and Enterobacter species
Children, adolescents (aged 4 y to adult)S. aureus (80%), group A Streptococcus species, H. influenzae, and Enterobacter species
AdultS. aureus and occasionally Enterobacter or Streptococcus species
Sickle cell anemia patients Salmonella species are most common in patients with sickle cell disease. [12]

In children, the metaphyses, the ends of long bones, are usually affected. In adults, the vertebrae and the pelvis are most commonly affected. [7]

Acute osteomyelitis almost invariably occurs in children who are otherwise healthy, because of rich blood supply to the growing bones. When adults are affected, it may be because of compromised host resistance due to debilitation, intravenous drug abuse, infectious root-canaled teeth, or other disease or drugs (e.g., immunosuppressive therapy). [7]

Osteomyelitis is a secondary complication in 1–3% of patients with pulmonary tuberculosis. [13] In this case, the bacteria, in general, spread to the bone through the circulatory system, first infecting the synovium (due to its higher oxygen concentration) before spreading to the adjacent bone. [13] In tubercular osteomyelitis, the long bones and vertebrae are the ones that tend to be affected. [13]

Staphylococcus aureus is the organism most commonly isolated from all forms of osteomyelitis. [13]

Osteomyelitis is often caused by Staphylococcus aureus. [14] In infants, S. aureus, Group B streptococci and Escherichia coli are commonly isolated; in children from one to 16 years of age, S. aureus, Streptococcus pyogenes , and Haemophilus influenzae are common. In some subpopulations, including intravenous drug users and splenectomized patients, Gram-negative bacteria, including enteric bacteria, are significant pathogens. [15]

The most common form of the disease in adults is caused by injury exposing the bone to local infection. [14] Staphylococcus aureus is the most common organism seen in osteomyelitis, seeded from areas of contiguous infection. But anaerobes and Gram-negative organisms, including Pseudomonas aeruginosa , E. coli, and Serratia marcescens , are also common. Mixed infections are the rule rather than the exception. [15]

Systemic mycotic infections may also cause osteomyelitis. The two most common are Blastomyces dermatitidis and Coccidioides immitis .[ citation needed ]

In osteomyelitis involving the vertebral bodies, about half the cases are due to S. aureus, and the other half are due to tuberculosis (spread hematogenously from the lungs). Tubercular osteomyelitis of the spine was so common before the initiation of effective antitubercular therapy, it acquired a special name, Pott's disease.[ citation needed ]

The Burkholderia cepacia complex has been implicated in vertebral osteomyelitis in intravenous drug users. [16]

Pathogenesis

In general, microorganisms may infect bone through one or more of three basic methods

The area usually affected when the infection is contracted through the bloodstream is the metaphysis of the bone. [17] Once the bone is infected, leukocytes enter the infected area, and, in their attempt to engulf the infectious organisms, release enzymes that lyse the bone. Pus spreads into the bone's blood vessels, impairing their flow, and areas of devitalized infected bone, known as sequestra , form the basis of a chronic infection. [13] Often, the body will try to create new bone around the area of necrosis. The resulting new bone is often called an involucrum. [13] On histologic examination, these areas of necrotic bone are the basis for distinguishing between acute osteomyelitis and chronic osteomyelitis. Osteomyelitis is an infective process that encompasses all of the bone (osseous) components, including the bone marrow. When it is chronic, it can lead to bone sclerosis and deformity.[ citation needed ]

Chronic osteomyelitis may be due to the presence of intracellular bacteria. [19] Once intracellular, the bacteria are able to spread to adjacent bone cells. [20] At this point, the bacteria may be resistant to certain antibiotics. [21] These combined factors may explain the chronicity and difficult eradication of this disease, resulting in significant costs and disability, potentially leading to amputation. The presence of intracellular bacteria in chronic osteomyelitis is likely an unrecognized contributing factor in its persistence.[ citation needed ]

In infants, the infection can spread to a joint and cause arthritis. In children, large subperiosteal abscesses can form because the periosteum is loosely attached to the surface of the bone. [13]

Because of the particulars of their blood supply, the tibia, femur, humerus, vertebrae, maxilla and the mandibular bodies are especially susceptible to osteomyelitis. [22] Abscesses of any bone, however, may be precipitated by trauma to the affected area. Many infections are caused by Staphylococcus aureus , a member of the normal flora found on the skin and mucous membranes. In patients with sickle cell disease, the most common causative agent is Salmonella , with a relative incidence more than twice that of S. aureus. [12]

Diagnosis

Mycobacterium doricum osteomyelitis and soft tissue infection. Computed tomography scan of the right lower extremity of a 21-year-old patient, showing abscess formation adjacent to nonunion of a right femur fracture. Mycobacterium doricum Osteomyelitis and Soft Tissue Infection.jpg
Mycobacterium doricum osteomyelitis and soft tissue infection. Computed tomography scan of the right lower extremity of a 21-year-old patient, showing abscess formation adjacent to nonunion of a right femur fracture.
Extensive osteomyelitis of the forefoot OsteomylitisWorse.png
Extensive osteomyelitis of the forefoot
Osteomyelitis in both feet as seen on bone scan BonescanOsteobothfeet.png
Osteomyelitis in both feet as seen on bone scan

The diagnosis of osteomyelitis is complex and relies on a combination of clinical suspicion and indirect laboratory markers such as a high white blood cell count and fever, although confirmation of clinical and laboratory suspicion with imaging is usually necessary. [23]

Radiographs and CT are the initial method of diagnosis, but are not sensitive and only moderately specific for the diagnosis. They can show the cortical destruction of advanced osteomyelitis, but can miss nascent or indolent diagnoses. [23]

Confirmation is most often by MRI. [24] The presence of edema, diagnosed as increased signal on T2 sequences, is sensitive, but not specific, as edema can occur in reaction to adjacent cellulitis. Confirmation of bony marrow and cortical destruction by viewing the T1 sequences significantly increases specificity. The administration of intravenous gadolinium-based contrast enhances specificity further. In certain situations, such as severe Charcot arthropathy, diagnosis with MRI is still difficult. [23] Similarly, it is limited in distinguishing avascular necrosis from osteomyelitis in sickle cell anemia. [25]

Nuclear medicine scans can be a helpful adjunct to MRI in patients who have metallic hardware that limits or prevents effective magnetic resonance. Generally a triple phase technetium 99 based scan will show increased uptake on all three phases. Gallium scans are 100% sensitive for osteomyelitis but not specific, and may be helpful in patients with metallic prostheses. Combined WBC imaging with marrow studies has 90% accuracy in diagnosing osteomyelitis. [26]

Diagnosis of osteomyelitis is often based on radiologic results showing a lytic center with a ring of sclerosis. [13] Culture of material taken from a bone biopsy is needed to identify the specific pathogen; [27] alternative sampling methods such as needle puncture or surface swabs are easier to perform, but cannot be trusted to produce reliable results. [28] [29]

Factors that may commonly complicate osteomyelitis are fractures of the bone, amyloidosis, endocarditis, or sepsis. [13]

Classification

The definition of osteomyelitis (OM) is broad, and encompasses a wide variety of conditions. Traditionally, the length of time the infection has been present and whether there is suppuration (pus formation) or osteosclerosis (pathological increased density of bone) are used to arbitrarily classify OM. Chronic OM is often defined as OM that has been present for more than one month. In reality, there are no distinct subtypes; instead, there is a spectrum of pathologic features that reflects a balance between the type and severity of the cause of the inflammation, the immune system, and local and systemic predisposing factors.[ citation needed ]

OM can also be typed according to the area of the skeleton in which it is present. For example, osteomyelitis of the jaws is different in several respects from osteomyelitis present in a long bone. Vertebral osteomyelitis is another possible presentation.[ citation needed ]

Treatment

Osteomyelitis often requires prolonged antibiotic therapy for weeks or months. A PICC line or central venous catheter can be placed for long-term intravenous medication administration. Some studies of children with acute osteomyelitis report that antibiotic by mouth may be justified due to PICC-related complications. [30] [31] It may require surgical debridement in severe cases, or even amputation. Antibiotics by mouth and by intravenous appear similar. [32] [33]

Due to insufficient evidence it is unclear what the best antibiotic treatment is for osteomyelitis in people with sickle cell disease as of 2019. [34]

Initial first-line antibiotic choice is determined by the patient's history and regional differences in common infective organisms. A treatment lasting 42 days is practiced in a number of facilities. [35] Local and sustained availability of drugs have proven to be more effective in achieving prophylactic and therapeutic outcomes. [36] Open surgery is needed for chronic osteomyelitis, whereby the involucrum is opened and the sequestrum is removed or sometimes saucerization [37] can be done. Hyperbaric oxygen therapy has been shown to be a useful adjunct to the treatment of refractory osteomyelitis. [38]

Before the widespread availability and use of antibiotics, blow fly larvae were sometimes deliberately introduced to the wounds to feed on the infected material, effectively scouring them clean. [39] [40]

There is tentative evidence that bioactive glass may also be useful in long bone infections. [41] Support from randomized controlled trials, however, was not available as of 2015. [42]

Hemicorporectomy is performed in severe cases of Terminal Osteomyelitis in the Pelvis if further treatment won't stop the infection. [43]

History

The word is from Greek words ὀστέον osteon, meaning bone, μυελός myelos meaning marrow, and -ῖτις -itis meaning inflammation.

In 1875, American artist Thomas Eakins depicted a surgical procedure for osteomyelitis at Jefferson Medical College, in an oil painting titled The Gross Clinic . [44]

Canadian politician and premier of Saskatchewan Tommy Douglas suffered from osteomyelitis as a child, and in 1910, underwent several surgeries, which the surgeon performed for free in exchange for allowing his medical students to observe the procedures (which Douglas's parents could not have otherwise afforded). This experience convinced him that medical care should be free for everyone. [45] Douglas became known as the Canadian "Father of Medicare." [46]

Fossil record

Evidence for osteomyelitis found in the fossil record is studied by paleopathologists, specialists in ancient disease and injury. It has been reported in fossils of the large carnivorous dinosaur Allosaurus fragilis . [47] Osteomyelitis has been also associated with the first evidence of parasites in dinosaur bones. [48]

See also

Related Research Articles

<span class="mw-page-title-main">Abscess</span> Localized collection of pus that has built up within the tissue of the body

An abscess is a collection of pus that has built up within the tissue of the body. Signs and symptoms of abscesses include redness, pain, warmth, and swelling. The swelling may feel fluid-filled when pressed. The area of redness often extends beyond the swelling. Carbuncles and boils are types of abscess that often involve hair follicles, with carbuncles being larger. A cyst is related to an abscess, but it contains a material other than pus, and a cyst has a clearly defined wall.

<span class="mw-page-title-main">Sinusitis</span> An inflammation of the mucous membrane that lines the sinuses resulting in symptoms

Sinusitis, also known as rhinosinusitis, is an inflammation of the mucous membranes that line the sinuses resulting in symptoms that may include thick nasal mucus, a plugged nose, and facial pain. Other signs and symptoms may include fever, headaches, a poor sense of smell, sore throat, a feeling that phlegm is oozing out from the back of the nose to the throat along with a necessity to clear the throat frequently and frequent attacks of cough.

<span class="mw-page-title-main">Otitis media</span> Inflammation of the middle ear

Otitis media is a group of inflammatory diseases of the middle ear. One of the two main types is acute otitis media (AOM), an infection of rapid onset that usually presents with ear pain. In young children this may result in pulling at the ear, increased crying, and poor sleep. Decreased eating and a fever may also be present. The other main type is otitis media with effusion (OME), typically not associated with symptoms, although occasionally a feeling of fullness is described; it is defined as the presence of non-infectious fluid in the middle ear which may persist for weeks or months often after an episode of acute otitis media. Chronic suppurative otitis media (CSOM) is middle ear inflammation that results in a perforated tympanic membrane with discharge from the ear for more than six weeks. It may be a complication of acute otitis media. Pain is rarely present. All three types of otitis media may be associated with hearing loss. If children with hearing loss due to OME do not learn sign language, it may affect their ability to learn.

Myelitis is inflammation of the spinal cord which can disrupt the normal responses from the brain to the rest of the body, and from the rest of the body to the brain. Inflammation in the spinal cord can cause the myelin and axon to be damaged resulting in symptoms such as paralysis and sensory loss. Myelitis is classified to several categories depending on the area or the cause of the lesion; however, any inflammatory attack on the spinal cord is often referred to as transverse myelitis.

<span class="mw-page-title-main">Tenosynovitis</span> Medical condition

Tenosynovitis is the inflammation of the fluid-filled sheath that surrounds a tendon, typically leading to joint pain, swelling, and stiffness. Tenosynovitis can be either infectious or noninfectious. Common clinical manifestations of noninfectious tenosynovitis include de Quervain tendinopathy and stenosing tenosynovitis

Bloodstream infections (BSIs) are infections of blood caused by blood-borne pathogens. Blood is normally a sterile environment, so the detection of microbes in the blood is always abnormal. A bloodstream infection is different from sepsis, which is characterized by severe inflammatory or immune responses of the host organism to pathogens.

<span class="mw-page-title-main">Melioidosis</span> Human disease

Melioidosis is an infectious disease caused by a gram-negative bacterium called Burkholderia pseudomallei. Most people exposed to B. pseudomallei experience no symptoms; however, those who do experience symptoms have signs and symptoms that range from mild, such as fever and skin changes, to severe with pneumonia, abscesses, and septic shock that could cause death. Approximately 10% of people with melioidosis develop symptoms that last longer than two months, termed "chronic melioidosis".

<span class="mw-page-title-main">Septic arthritis</span> Medical condition

Acute septic arthritis, infectious arthritis, suppurative arthritis, pyogenic arthritis, osteomyelitis, or joint infection is the invasion of a joint by an infectious agent resulting in joint inflammation. Generally speaking, symptoms typically include redness, heat and pain in a single joint associated with a decreased ability to move the joint. Onset is usually rapid. Other symptoms may include fever, weakness and headache. Occasionally, more than one joint may be involved, especially in neonates, younger children and immunocompromised individuals. In neonates, infants during the first year of life, and toddlers, the signs and symptoms of septic arthritis can be deceptive and mimic other infectious and non-infectious disorders.

<span class="mw-page-title-main">Infective endocarditis</span> Medical condition

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<span class="mw-page-title-main">Clindamycin</span> Antibiotic

Clindamycin is a lincosamide antibiotic medication used for the treatment of a number of bacterial infections, including osteomyelitis (bone) or joint infections, pelvic inflammatory disease, strep throat, pneumonia, acute otitis media, and endocarditis. It can also be used to treat acne, and some cases of methicillin-resistant Staphylococcus aureus (MRSA). In combination with quinine, it can be used to treat malaria. It is available by mouth, by injection into a vein, and as a cream or a gel to be applied to the skin or in the vagina.

<span class="mw-page-title-main">Cellulitis</span> Bacterial infection of the inner layers of the skin called the dermis

Cellulitis is usually a bacterial infection involving the inner layers of the skin. It specifically affects the dermis and subcutaneous fat. Signs and symptoms include an area of redness which increases in size over a few days. The borders of the area of redness are generally not sharp and the skin may be swollen. While the redness often turns white when pressure is applied, this is not always the case. The area of infection is usually painful. Lymphatic vessels may occasionally be involved, and the person may have a fever and feel tired.

<span class="mw-page-title-main">Pyelonephritis</span> Medical condition

Pyelonephritis is inflammation of the kidney, typically due to a bacterial infection. Symptoms most often include fever and flank tenderness. Other symptoms may include nausea, burning with urination, and frequent urination. Complications may include pus around the kidney, sepsis, or kidney failure.

<span class="mw-page-title-main">Mastoiditis</span> Middle ear disease

Mastoiditis is the result of an infection that extends to the air cells of the skull behind the ear. Specifically, it is an inflammation of the mucosal lining of the mastoid antrum and mastoid air cell system inside the mastoid process. The mastoid process is the portion of the temporal bone of the skull that is behind the ear. The mastoid process contains open, air-containing spaces. Mastoiditis is usually caused by untreated acute otitis media and used to be a leading cause of child mortality. With the development of antibiotics, however, mastoiditis has become quite rare in developed countries where surgical treatment is now much less frequent and more conservative, unlike former times.

<span class="mw-page-title-main">Mediastinitis</span> Inflammatory process affecting the mediastinum

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<span class="mw-page-title-main">Oritavancin</span> Pharmaceutical drug

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<span class="mw-page-title-main">Iclaprim</span> Chemical compound

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Vertebral osteomyelitis is a type of osteomyelitis that affects the vertebrae. It is a rare bone infection concentrated in the vertebral column. Cases of vertebral osteomyelitis are so rare that they constitute only 2%-4% of all bone infections. The infection can be classified as acute or chronic depending on the severity of the onset of the case, where acute patients often experience better outcomes than those living with the chronic symptoms that are characteristic of the disease. Although vertebral osteomyelitis is found in patients across a wide range of ages, the infection is commonly reported in young children and older adults. Vertebral osteomyelitis often attacks two vertebrae and the corresponding intervertebral disk, causing narrowing of the disc space between the vertebrae. The prognosis for the disease is dependent on where the infection is concentrated in the spine, the time between initial onset and treatment, and what approach is used to treat the disease.

<span class="mw-page-title-main">Diabetic foot infection</span> Medical condition

Diabetic foot infection is any infection of the foot in a diabetic person. The most frequent cause of hospitalization for diabetic patients is due to foot infections. Symptoms may include pus from a wound, redness, swelling, pain, warmth, tachycardia, or tachypnea. Complications can include infection of the bone, tissue death, amputation, or sepsis. They are common and occur equally frequently in males and females. Older people are more commonly affected.

Prosthetic joint infection (PJI), also known as peri-prosthetic joint infection (PJI), is an acute, sub-acute or chronic infection of a prosthetic joint. It may occur in the period after the joint replacement or many years later. It usually presents as joint pain, erythema, joint swelling and sometimes formation of a sinus tract. PJI is estimated to occur in approximately 2% of hip and knee replacements, and up to 4% of revision hip or knee replacements. Other estimates indicate that 1.4-2.5% of all joint replacements worldwide are complicated by PJIs. The incidence is expected to rise significantly in the future as hip replacements and knee replacements become more common. It is usually caused by aerobic gram positive bacteria, such as Staph epidermidis or Staphylococcus aureus but enterococcus species, gram negative organisms and Cutibacterium are also known causes with fungal infections being a rare culprit. The definitive diagnosis is isolation of the causative organism from the synovial fluid, but signs of inflammation in the joint fluid and imaging may also aid in the diagnosis. The treatment is a combination of systemic antibiotics, debridement of infectious and necrotic tissue and local antibiotics applied to the joint space. The bacteria that usually cause prosthetic joint infections commonly form a biofilm, or a thick slime that is adherent to the artificial joint surface, thus making treatment challenging.

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