Participation in everyday activities and quality of life in pre-teenage children living with cerebral palsy in South West Ireland

Background

Osteomyelitis can be difficult to diagnose and there has previously not been a prospective approach to identify all children in a defined geographic area. The aim of this study was to assess the annual incidence of osteomyelitis in children, describe the patient and disease characteristics in those with acute (< 14 days disease duration) and subacute osteomyelitis (≥ 14 days disease duration), and differentiate osteomyelitis patients from those with other acute onset musculoskeletal features.

Methods

In a population-based Norwegian study physicians were asked to refer all children with suspected osteomyelitis. Children with osteomyelitis received follow-up at six weeks, six months and thereafter as long as clinically needed.

Results

The total annual incidence rate of osteomyelitis was 13 per 100 000 (acute osteomyelitis 8 and subacute osteomyelitis 5 per 100 000). The incidence was higher in patients under the age of 3 than in older children (OR 2.9, 95%: CI 2.3–3.7). The incidence of non-vertebral osteomyelitis was higher than the incidence of vertebral osteomyelitis (10 vs. 3 per 100 000; p = .002). Vertebral osteomyelitis was more frequent in girls than in boys (OR 7.0, 95%: CI 3.3–14.7). ESR ≥ 40 mm/hr had the highest positive predictive laboratory value to identify osteomyelitis patients at 26% and MRI had a positive predictive value of 85%. Long-bone infection was found in 16 (43%) patients. ESR, CRP, white blood cell count, neutrophils and platelet count were higher for patients with acute osteomyelitis than for patients with subacute osteomyelitis. Subacute findings on MRI and doctor's delay were more common in subacute osteomyelitis than in acute osteomyelitis patients. Blood culture was positive in 26% of the acute osteomyelitis patients and was negative in all the subacute osteomyelitis patients.

Conclusion

The annual incidence of osteomyelitis in Norway remains high. ESR values and MRI scan may help to identify osteomyelitis patients and differentiate acute and subacute osteomyelitis.     

Course and treatment of osteomyelitis in childhood (author's transl)]

In the years 1955-1972 132 children with osteomyelitis were treated in the Pediatric, Surgical and Orthopedic Department of the university of Kiel. There was no increase in the incidence of osteomyelitis during this period. Acute hematogenous osteomyelitis was diagnosed in 111 children, chronic hematogenous osteomyelitis in 11 children, traumatic and postoperative osteomyelitis in 10 children. Secondary chronic osteomyelitis occurred in 1 patient. Mainly staphylococci (in 90%) were the pathogenic bacteria, whereas haemophilus, pseudomonas, streptococci group A, E. coli and mixed infections occurred less frequently. In 17 of 111 patients with acute hematogenous osteomyelitis there were no roentgenological changes. Bacteriological investigations of blood and pus, and the antistaphylolysin reaction (repeated in the course of the disease) were helpful to establish the diagnosis in many cases. 107 of 111 patients with acute hematogenous osteomyelitis were cured (8 patients with defects). 4 children died in septic shock or because of complications (meningitis, pleural empyema, pneumonia). Bactericidal antibiotics in high dosage (penicillins, gentamicin) were superior to bacteriostatic antibiotics. Additional surgical treatment was necessary in 49 of 111 patients with acute hematogenous osteomyelitis. Recommendations for antibiotic therapy of osteomyelitis are given.     

Lytic rib lesion in a 1-year-old child: group A beta streptococcal osteomyelitis mimicking tumor

Pediatric osteomyelitis commonly occurs in the long bones and has rarely been reported in small bones such as the vertebrae and ribs. Rib osteomyelitis occurs in approximately 1% or less of all cases of hematogenous osteomyelitis, and is usually caused by Staphylococcus aureus. We present a case of acute osteomyelitis in the rib of an otherwise healthy and afebrile 1-year-old infant that appeared as a lytic bone lesion on imaging studies and was mistaken for a tumor. Biopsy was needed to rule out malignancy and establish the diagnosis of osteomyelitis caused by group A Streptococcus. This is one of the few reported cases of pediatric rib osteomyelitis caused by this organism.     

Bacterial bone and joint infections in childhood--a review. 4. Subacute and primary-chronic osteomyelitis, rare forms of osteomyelitis

This is an overview of the most important aspects of pathogenesis, etiology, diagnostics, therapy and differential diagnostics of the subacute and primary chronic osteomyelitis in children. This group of disease includes Brodie's abscess, plasma cellular osteomyelitis, sclerosing osteomyelitis (Garré) and the chronic recurrent multifocal osteomyelitis. The treatment of children with these not completely understood diseases requires a close cooperation between pediatricians, pediatric surgeons and radiologists.     

Osteomyelitis: early scintigraphic detection in children.

The value of scintigraphy in the early detection of osteomyelitis is demonstrated in children who had signs and symptoms suggestive of bone infection. Nine patients between 2 and 13 years of age were evaluated with technetium Tc 99m diphosphonate bone scintigrams and roentgenograms. Blood cultures were performed in all patients, and bone biopsy or drainage was obtained in six patients. The diagnosis of osteomyelitis was made in seven patients; one patient had a subperiosteal abscess surrounded by osteomyelitis, and one patient had cellulitis. The seven children with osteomyelitis had focal increase of radiopharmaceutical uptake in the bone. The child with the subperiosteal abscess had an area of decreased uptake in the center of the abscess surrounded by a zone of increased uptake of the radioactive bone-seeker. The patient with cellulitis had soft tissue changes by X-ray and a normal bone scintigram. In the seven patients with osteomyelitis, the bone scintigram was performed during the early phase of the disease and no bony changes were present on the roentgenogram. In one patient with subacute osteomyelitis, soft tissue changes were seen radiologically. Only three of the seven children with osteomyelitis developed radiological bony changes. Since bone scintigraphy can detect early local bone derangement, it is recommended in the initial evaluation of children in whom osteomyelitis is suspected.     

Rare forms of chronic osteomyelitis in children (author's transl)

4 cases of chronic osteomyelitis in children and adolescents are described. The first one concerns a girl with severe plasmacellular osteomyelitis of the right upperarm. As the treatment with antibiotics failed a partial resection of the right humerus, followed by plastic covering of the resulting defect was successful. Two further cases of chronic metatarsal osteomyelitis of both feet could be classified as a kind of "sclerosing osteomyelitis Garré", mostly corresponding to the clinical feature of the "chronic recurrent multifocal osteomyelitis" (Bj?rkstén et al., 1978). Furthermore, a case of chronic ostitis localized in the symphyseal area is described, the clinical symptoms of which were resembling to the cortical osteoid, a special kind of sclerosing osteomyelitis. It is suggested that these different forms of chronic osteomyelitis in children are caused by bacterial infections. Nevertheless, this hypothesis remains to be proved. The problems of the differential diagnosis are discussed. Generally, the only therapy with antibotics is not successful, whereas the combination of removing of the inflammatory process with plastic covering of the bone-defect usually results in recovery.     

Acute osteomyelitis and septic arthritis in children: a spectrum of disease

A spectrum of acute osteomyelitis and septic arthritis seen in children was studied, identifying four major groups, each with a different clinical presentation and different expected prognosis: (1) the usual group of osteomyelitis with a 10% incidence of poor results; (2) neonatal osteomyelitis (10% of osteomyelitis) with 25% poor results; (3) a group of severely ill patients with disseminated staphylococcal disease (10% of osteomyelitis) with 13% mortality and 38% poor results; and (4) the usual group of septic arthritis, with 5% poor results. Almost all cases of osteomyelitis were due to Staphylococcus aureus except in the neonatal group, where 28% were due to -haemolytic streptococci. Surgical drainage was performed in 91% of the usual osteomyelitis cases, in all with disseminated staphylococcal disease, and in 88% of babies with neonatal osteomyelitis, i.e. all the cases involving a joint. Cloxacillin was the drug of choice in osteomyelitis. In septic arthritis Staph. aureus was cultured in 29%, Haemophilus influenzae in 18%, streptococcus in 12%, pneumococcus in 6%, and no growth in 33%. Open arthrotomy was performed in all cases. Cloxacillin was used for cases infected with Staph. aureus, ampicillin for H. influenzae, and penicillin for streptococcal and pneumococcal infections. Offprint requests to: EB Hoffman     

Group A streptococcal osteomyelitis: severe presentation and course

AIM: To evaluate the course of group A streptococcal osteomyelitis associated with severe disease nowadays. METHODS: Three consecutive cases of severe group A streptococcal disease with osteomyelitis in children that were documented in Beer Sheva, Israel are described in detail. RESULTS: Two of the three cases were postvaricella. Early in the course of the disease, the presentation resembled that of severe cellulitis. All three patients had severe osteomyelitis and required surgery, and one patient developed chronic osteomyelitis. Sepsis was diagnosed in two cases. CONCLUSION: Our cases are distinguishable from typical haematogenous staphylococcal osteomyelitis by the severe course and the extensive involvement of bone and soft tissues. The increase in severity of invasive group A streptococcal infections documented throughout the world could account for the difference between our complex cases and the previous reports.     

Chronic recurrent multifocal osteomyelitis of the spine and mandible: case report and review of the literature

At initial presentation, chronic recurrent multifocal osteomyelitis may mimic acute hematogenous osteomyelitis; however, cultures of affected bone are sterile. Nuclear scintigraphy identifies additional foci of involvement that present concurrently or sequentially. Unlike acute bacterial osteomyelitis, chronic recurrent multifocal osteomyelitis seems unaffected by antibiotic therapy and typically responds to treatment with antiinflammatory drugs. Surgical decortication has been reported for refractory cases. The case presented here illustrates the rare involvement of the mandible after initial presentation in the spine of a 4-year-old girl and the refractory nature of the disease over 6 years despite treatment with various medical and surgical therapies.     

Ultrasonic signs of pelvic osteomyelitis in children

The ultrasonic findings were reviewed in 13 children in whom pelvic osteomyelitis was diagnosed by a positive^99mtechnetium methylene diphosphonate (MDP) bone scan in conjunction with clinical and laboratory features of osteomyelitis. All patients presented with pain in the region of the hip joint. In six patients the ultrasound study was confined to the hip joint, and all six had normal findings. In seven patients the ultrasound study was extended to include the pelvis. Deep soft tissue swelling was demonstrated in six of these, including a periosseous abscess in one case. Ultrasonography was negative in one patient with a 5-week history, whose pelvic osteomyelitis was resolving at the time of the ultrasound study. Oedema of the obturator internus and externus muscles was observed in osteomyelitis affecting the pubis and ischium, and of the iliacus and/or the gluteus medius muscle in osteomyelitis of the ilium. In children presenting with hip pain who have a normal hip ultrasound study, extension of the ultrasound examination to include these four pelvic muscles may help to identify and document the progression of acute pelvic osteomyelitis.     

Optimal imaging strategy for community-acquired Staphylococcus aureus musculoskeletal infections in children

BACKGROUND: Invasive musculoskeletal infections from community-acquired methicillin-resistant and methicillin-susceptible Staphylococcus aureus (CA-SA) are increasingly encountered in children. Imaging is frequently requested in these children for diagnosis and planning of therapeutic interventions. OBJECTIVE: To appraise the diagnostic efficacy of imaging practices performed for CA-SA osteomyelitis and its complications. MATERIALS AND METHODS: A retrospective review was conducted of the clinical charts and imaging studies of CA-SA osteomyelitis cases since 2001 at a large children's hospital. RESULTS: Of 199 children diagnosed with CA-SA osteomyelitis, 160 underwent MRI examination and 35 underwent bone scintigraphy. The sensitivity of MRI and bone scintigraphy for CA-SA osteomyelitis was 98% and 53%, respectively. In all discordant cases, MRI was correct compared to bone scintigraphy. Extraosseous complications of CA-SA osteomyelitis detected only by MRI included subperiosteal abscesses (n = 77), pyomyositis (n = 43), septic arthritis (n = 31), and deep venous thrombosis (n = 12). CONCLUSION: MRI is the preferred imaging modality for the investigation of pediatric CA-SA musculoskeletal infection because it offers superior sensitivity for osteomyelitis compared to bone scintigraphy and detects extraosseous complications that occur in a substantial proportion of patients.     

Chronic recurrent multifocal osteomyelitis: a noninfectious inflammatory process

We report seven patients with chronic recurrent multifocal osteomyelitis, an uncommon childhood disease of unknown etiology. These patients presented with insidious onset of bone pain at one or more sites associated with erythema, swelling and tenderness. Scintigraphy and radiography were consistent with osteomyelitis at multiple sites. Bone biopsies confirmed osteomyelitis but no organisms were consistently isolated. During a 1- to 3-year follow-up, most patients developed new symptomatic lesions. The disease was unaffected by antimicrobial therapy. Two of our patients had psoriasis and all were rheumatoid factor-, antinuclear factor- and HLA-B27-negative. We speculate that chronic recurrent osteomyelitis is a noninfectious inflammatory condition, a seronegative spondyloarthropathy. Chronic recurrent osteomyelitis is a clinical entity that should be recognized so that invasive diagnostic procedures and antimicrobial therapy are appropriately used. The patient may be reassured that this is not a malignant condition although there may be exacerbations over many years.     

Gram-negative neonatal osteomyelitis: two case reports

Neonatal osteomyelitis is a rare and challenging diagnosis, particularly in the early onset period. Neonatal osteomyelitis is predominantly caused by Staphylococcus aureus with single bone involvement. Here, we report two cases of neonatal osteomyelitis in premature infants caused by Klebsiella pneumoniae with multiple bone lesions. Both cases presented with sepsis and meningitis and were initially diagnosed by incidental findings on plain films, with follow-up bone scan imaging. In both cases, diagnosis was timely and treatment was successful. These cases highlight the need to include neonatal osteomyelitis in the differential diagnosis when late-onset or prolonged neonatal sepsis is present, particularly because long-term outcome is dependent on rapid diagnosis and initiation of treatment.     

Joint and bone infections due to anaerobic bacteria in children

The current review describes the microbiology, diagnosis and management of septic arthritis and osteomyelitis due to anaerobic bacteria in children. Staphylococcus aureus, Haemophilus influenzae type-b, and Group A streptococcus, Streptococcus pneumoniae, Kingela kingae, Neisseria meningiditis and Salmonella spp are the predominant aerobic bacteria that cause arthritis in children. Gonococcal arthritis can occur in sexually active adolescents. The predominant aerobes causing osteomyelitis in children are S. aureus, H. influenzae type-b, Gram-negative enteric bacteria, beta-hemolytic streptococci, S. pneumoniae, K. kingae, Bartonella henselae and Borrelia burgdorferi. Anaerobes have rarely been reported as a cause of these infections in children. The main anaerobes in arthritis include anaerobic Gram negative bacilli including Bacteroides fragilis group, Fusobacterium spp., Clostridium spp. and Peptostreptococcus spp. Most of the cases of anaerobic arthritis, in contrast to anaerobic osteomyelitis, involved a single isolate. Most of the cases of anaerobic arthritis are secondary to hematogenous spread. Many patients with osteomyelitis due to anaerobic bacteria have evidence of anaerobic infection elsewhere in the body, which is the source of the organisms involved in osteomyelitis. Treatment of arthritis and osteomyelitis involving anaerobic bacteria includes symptomatic therapy, immobilization in some cases, adequate drainage of purulent material and antibiotic therapy effective to these organisms.     

Clinical presentation and management of Pseudomonas osteomyelitis

To determine the incidence and clinical characteristics of Pseudomonas aeruginosa osteomyelitis in children, the records of 144 hospitalized patients under 19 years of age were reviewed; 104 fulfilled the study criteria for the diagnosis of acute or chronic osteomyelitis. Pseudomonas aeruginosa was recovered from 10.6 percent of the children and was the second most common pathogen isolated. In comparison to children with staphylococcal infections, patients with pseudomonal osteomyelitis were significantly older, gave an antecedent history of penetrating trauma, and lacked clinical and laboratory evidence of systemic illness. The data collected in this study suggest that osteomyelitis due to Pseudomonas aeruginosa is a distinct entity with clinical features differing from those of Staphylococcus aureus. Management should be directed at adequate surgical debridement followed by 10 to 21 days of antimicrobial therapy.     

Rib osteomyelitis in children. Early radiologic and ultrasonic findings

The earliest radiographic changes of osteomyelitis in the long bones is deep-seated edema manifesting as soft tissue swelling and obliteration of the intermuscular planes adjacent to the affected bone. Similarly, the early change of rib osteomyelitis is pericostal edema demonstrated by soft tissue swelling of the thoracic wall accompanied by an adjacent inward pleural displacement. In both osteomyelitis of the rib and the long bones, the bony changes will appear 1–2 weeks later. Pericostal edema can be readily diagnosed by ultrasound scan. Pericostal edema, although non specific and can occur in other conditions, yet it is a strong warning sign, set within the overall clinical picture of osteomyelitis.     

Differentiating osteomyelitis from bone infarction in sickle cell disease

This brief review discusses one possible approach to evaluating the sickle cell patient with bone pain. The major differential diagnoses include osteomyelitis and bone infarction. Based on previous studies, we provide an approach to assessing and treating patients with the possible diagnosis of osteomyelitis. An algorithm has been provided, which emphasizes the importance of the initial history and physical examination. Specific radiographic studies are recommended to aid in making the initial assessment and to determine whether the patient has an infarct or osteomyelitis. Differentiating osteomyelitis from infarction in sickle cell patients remains a challenge for the pediatrician. This algorithm can be used as a guide for physicians who evaluate such patients in the acute care setting.     

Pneumococcal osteomyelitis and arthritis in children. A hospital series and literature review

Twenty-nine children with pneumococcal osteomyelitis and/or arthritis, 11 of whom had osteomyelitis, were treated at Cook County Hospital, Chicago, Ill, in the past 20 years. They were mostly normal children with a single focus of infection. They represented more than 5% of the hospitalized children with a systemic pneumococcal infection. Most of the pneumococcal isolates were serotyped; serotype 19, in particular, seemed to be unusually common in these children. Twenty-three of the 29 children with pneumococcal osteomyelitis and/or arthritis had been hospitalized in the past 15 years. These 23 children were compared with 161 hospitalized children who had bone and joint infections with other isolated bacteria. The children with pneumococcal osteomyelitis and/or arthritis were indistinguishable from most of the other children, except by age. All but three of the children with pneumococcal osteomyelitis and/or arthritis were between the ages of 3 and 24 months. In this age group, Pneumococcus was the common isolate from children with osteomyelitis, and second only to Haemophilus influenzae from children with bacterial arthritis. Pneumococcal osteomyelitis and/or arthritis has never been rare; the medical literature describes at least 245 other children, most of whom were younger than 2 years.     

Die chronisch rezidivierende multifokale Osteomyelitis (CRMO) Übersicht und erste Befunde einer genetisch-rheumatologischen Studie

Chronic recurrent multifocal osteomyelitis (CRMO) is a nonbacterial osteomyelitis and most commonly occurs during childhood. Associations with palmoplantar pustulosis (PPP) have been reported in about 20%. Since the etiology of the disease is unknown it is suspected to be an autoimmune osteomyelitis. Own studies [27] demonstrate evidence for a genetic basis of CRMO for the first time. The clinical features, diagnostic procedures and therapeutic options are demonstrated.     

Osteomyelitis and pyogenic infection of the sacroiliac joint

Acute pyogenic sacroiliac joint infection and osteomyelitis of adjacent bones often present with severe, poorly localized lower back, pelvic or hip pain. Five cases of sacroiliac joint infection or sacroiliac bone osteomyelitis were evaluated by MRI. MRI may be a helpful diagnostic tool to evaluate early changes of infection in the sacroiliac area. It is very sensitive for detecting bone marrow abnormalities; however, it is nonspecific and can not accurately differentiate osteomyelitis from sacroiliitis.