Calcaneal osteomyelitis caused by Acremonium sp in an immunocompetent adult – A case report

Fungal osteomyelitis of calcaneus is rare in immunocompetent adults. A case of fungal osteomyelitis of calcaneus in a 19 year old immunocompetent female without any history of trauma caused by Acremonium sp is presented. The patient was treated with surgical debridement, autogenous iliac crest bone grafting and antifungal chemotherapy for 6 months. At latest follow up after 2 years, patient is asymptomatic and the osteolytic lesion is healed with no signs of recurrence. This case report highlights a rare presentation of chronic painful calcaneal osteomyelitis with an osteolytic lesion.     

Adult Haemophilus influenzae type B vertebral osteomyelitis: a case report and review of the literature.

Osteomyelitis in adults due to Haemophilus influenzae is exceedingly rare. We report a case of H. influenzae type b vertebral osteomyelitis in an adult. Review of the English literature reveals one other adult patient with H. influenzae osteomyelitis, and sporadic pediatric cases. Although a variety of predisposing host resistance factors have been postulated to account for this infection, the deficiency responsible for adult infection remains undelineated. Bone biopsy is mandatory for diagnosis when blood cultures are negative. The isolation and identification of H. influenzae may be delayed because of its fastidious growth requirements. Treatment with ampicillin or chloramphenicol appear to be most efficacious considering the antibiotic sensitivities of the organism.     

Atypical mycobacterial granulomatous epiphyseal osteomyelitis in an immunocompetent child

Osteomyelitis caused by atypical mycobacteria is rare in children. The majority of affected patients have had some kind of predisposing factor, namely a penetrating injury or surgery, or were immune-compromised. Our experience shows that this diagnosis should be considered in apparently healthy children as well. The use of polymerase chain reaction has now made it possible to identify the pathogen in cases that were previously diagnosed as granulomatous osteomyelitis. We present a case of atypical mycobacterial osteomyelitis affecting the distal femoral epiphysis in an immunocompetent 10-year-old child. The diagnosis in this case was made by the use of the polymerase chain reaction assay.     

Coccidioidomycosis of the spine in an immunocompetent patient

Coccidioidomycosis is a fungal disease caused by inhalation of airborne particles of Coccidioides spp. Coccidioidomycosis is endemic in several parts of the South-western US and South America. There are no symptoms in 60% of cases and, when symptoms exist, they usually consist of mild flu-like manifestations or mild lung disease. Disseminated coccidioidomycosis accounts for only 5% of symptomatic cases but can be life-threatening. The main targets of disseminated coccidioidomycosis are the skin, lymphoid tissue, central nervous system, and musculoskeletal system. Prolonged antifungal therapy is required and some patients may need surgical debridement. We report a case of disseminated spinal coccidioidomycosis in an immunocompetent patient.     

Candida albicans cerebral granuloma in an immunocompetent patient. A case report

We report a case of temporal lobe granuloma caused by Candida albicans in an immunocompetent patient. This 54-year-old patient had experienced headaches and some memory disorders for two to three months before his admission to the neurosurgical department. Cerebral-computer tomography and magnetic resonance imaging showed a single right-temporal lesion with a large peritumoral edema. We operated on the patient via a temporal approach using neuronavigation and resected the lesion. The anatomopathological result and the cultures of the granuloma showed C. albicans species. The patient received antifungal therapy for three months. No predisposing factors or immunosuppression was found. After seven months, he presented an ischemic cerebrovascular accident of the brain stem and then chronic meningitis complicated by hydrocephalus. The patient's condition progressively deteriorated and he died 18 months later in an other department. C. albicans can be found even in the immunocompetent patient, but is seldom observed. Surgery can provide an accurate diagnosis and therapeutic management in the initial phase, completed by antifungal therapy.     

Acute staphylococcal hind foot osteomyelitis in a healthy adult: A case report

IntroductionAcute osteomyelitis of the hind foot is uncommon in a normal immunocompetent adult.Case presentationWe present a previously healthy 52year old caucasian male who developed painful swelling of his ankle/hindfoot following closed soft tissue football injury. He had no antecedent systemic symptoms. Magnetic resonance imaging and bone scan imaging, followed by surgical decompression and bone biopsy confirmed a diagnosis of Staphylococcus aureus hind foot osteomyelitis. He underwent triple fusion after debridement and had suppressive antibiotics. His pain and swelling resolved at 6 weeks postoperation and CT confirmed fusion at 6 months. His inflammatory markers normalised over the course of 7 months. After 18 months, he remained asymptomatic without any evidence of recurrence.ConclusionThis case represents an unusual and important variation of presentation of acute osteomyelitis in a healthy adult. It can be easily overlooked when a normal patient presents with pain and functional impairment after a closed soft tissue trauma, but a high index of suspicion is paramount because virulent organisms can infect immunologically normal patients.     

Primary subacute epiphyseal and metaepiphyseal osteomyelitis in children. diagnosis and treatment guided by MRI

We present three children with primary subacute epiphyseal and metaepiphyseal osteomyelitis. The diagnosis was delayed because of subtle radiological findings and mild general symptoms. Primary epiphyseal osteomyelitis is extremely rare. We believe that this is the first time that the MRI findings have been presented. In the first case they revealed a perforation into the knee and therefore an intra-articular epiphyseal approach was used for debridement. In the second and third cases the metaepiphyseal lesions showed considerable physical involvement and a metaphyseal approach was chosen. We believe that in this condition MRI is essential both for diagnosis and in the planning of surgical treatment.     

Initial presentation of coccidioidomycosis during inguinal herniorrhaphy

Coccidioidomycosis is a fungal infection endemic to the desert regions of the southwestern United States. Pulmonary symptoms predominate and are usually mild and self-limited. Dissemination is rare in the immunocompetent host. We present a case of disseminated, peritoneal coccidioidomycosis diagnosed during routine inguinal herniorrhaphy in an adult male. The current literature is summarized, and management recommendations are suggested.     

Chronic osteomyelitis of the metacarpals. Report of a case

Chronic osteomyelitis of the hand is uncommon and affects the metacarpals in only 3% of cases. We report a case of chronic osteomyelitis involving two metacarpals, and we present a review of the relevant literature. CASE-REPORT: A 41-year-old man with a 5-year history of psoriatic arthritis was admitted for a swelling over the dorsum of the left hand. At admission, he was in good general health and had no fever. In addition to the swelling, he had synovitis of the right ankle and psoriasis over the hands and elbows. The spine and sacroiliac joints were normal to physical examination. The erythrocyte sedimentation rate was 110 mm/h, the C-reactive protein level was 48 mg/l, and the leukocyte count was 9600/mm3. A radiograph of the hands disclosed a bone-within-bone image in the second and third metacarpals of the left hand and arthritis of the left carpal joints. A fluid collection over the dorsum of the left hand was visualized by ultrasonography. Aspiration recovered serous fluid that contained no organisms by microscopic examination or culture. Investigations for tuberculosis and a serological test for HIV infection were negative. Computed tomography showed a florid periosteal reaction encasing the diaphyses of the second and third metacarpals and enclosing bony sequestra; abnormal carpal bone architecture and thickening of the soft tissues related to joint effusions were seen also. The diagnosis was chronic osteomyelitis of the metacarpals. Two antimicrobials active against staphylococci were given and the bony sequestra were removed surgically. Histological examination of the operative specimens showed nonspecific osteitis. After 3 months of treatment, the outcome was favorable. CONCLUSION: Chronic osteomyelitis of the metacarpals is exceedingly rare but results in severe functional incapacitation and major social and economic burdens. Our case illustrates an unusual pattern with involvement of two metacarpals in the same hand. An early diagnosis followed by prompt treatment increases the likelihood of a favorable outcome.     

Osteomyelitis of the sacrum as the initial manifestation of Crohn's disease

A 17-year-old boy had low back pain for four months prior to the development of sacral osteomyelitis, which led to the initial diagnosis of Crohn's disease. Musculoskeletal problems occur in about one-third of the patients with Crohn's disease. Only a few patients with osteomyelitis complicating Crohn's disease have been reported. This case is rare because he had had no gastrointestinal symptoms. This patient illustrates the point that musculoskeletal signs and symptoms, including osteomyelitis, may prove to be a manifestation of gastrointestinal tract disease.     

Cryptococcal meningitis in an immunocompetent patient with obstructive hydrocephalus: A case report

Background

Cryptococcal infections of the central nervous system are very rare in immunocompetent patients. They usually present as meningitis or as fungal cysts with or without hydrocephalus. Rapid diagnosis and treatment is crucial to the prognosis.

Tuberculosis infection of the talonavicular joint

Isolated tuberculosis osteomyelitis affecting the foot is extremely rare. Symptoms are nonspecific and haematological investigations are often unhelpful making diagnosis difficult.We report the case of a 41-year-old female who presented with a 7-month history of a painful hindfoot following a minor ankle sprain. Inflammatory markers were mildly raised and initial radiographs showed only some mild narrowing of the talonavicular joint. MRI scanning suggested osteomyelitis centred over the talonavicular joint. Open biopsy confirmed areas of caseous necrosis but no acid-fast bacilli were seen. The final diagnosis was confirmed with culture of mycobacterium tuberculosis. A good recovery was seen following debridement and commencement of anti-tuberculosis chemotherapy.Unless an awareness of this condition exists, the diagnosis and therefore the appropriate treatment can often be delayed which may lead to significant consequences for the patient.     

Cytomegalovirus duodenitis associated with life-threatening duodenal hemorrhage in an immunocompetent patient: A case report

IntroductionCytomegalovirus (CMV) is known to be opportunistic in immunocompromised patients. However, there have been emerging cases of severe CMV infections found in immunocompetent patients. Gastrointestinal (GI) CMV disease is the most common manifestation affecting immunocompetent patients, with duodenal involvement being exceedingly rare. Presented is a case of an immunocompetent patient with life-threatening bleeding caused by CMV duodenitis, requiring surgical intervention.Presentation of caseA 60-year-old male with history of disseminated Methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia and aortic valve infective endocarditis, presented with life-threatening upper GI hemorrhage. Endoscopy revealed ulcerations, with associated generalized mucosal bleeding in the duodenum. After repeated endoscopic therapies and failed interventional-radiology arterial embolization, the patient required a duodenectomy and associated total pancreatectomy, to control the duodenal hemorrhage. Pathologic review of the surgical specimen demonstrated CMV duodenitis. Systemic ganciclovir was utilized postoperatively.DiscussionGI CMV infections should be on the differential diagnosis of immunocompetent patients presenting with uncontrollable GI bleeding, especially in critically ill patients due to transiently suppressed immunity. Endoscopic and histopathological examinations are often required for diagnosis. Ganciclovir is first-line treatment. Surgical intervention may be considered if there is recurrent bleeding and CMV duodenitis is suspected because of high potential for bleeding-associated mortality.ConclusionPresented is a rare case of life-threatening GI hemorrhage caused by CMV duodenitis in an immunocompetent patient. The patient failed endoscopic and interventional-radiology treatment options, and ultimately stabilized after surgical intervention.     

Chronic Osteomyelitis of the Lumbar Transverse Process

Pyogenic spondylitis involving only the posterior element of a vertebra is rare. To the best of our knowledge, there have been no reports of osteomyelitis of the transverse process. We report here on a 45-year-old male with a one month history of swelling associated with lower back pain. The magnetic resonance imaging showed a paraspinal soft tissue mass, and computed tomography revealed a fine osteolytic lesion in the right transverse process of the 5th lumbar spine, and this was all consistent with chronic osteomyelitis. A mixed staphylococcal infection was identified. Open drainage, resection of the transverse process and intravenous injection of anti-staphylococcal antibiotics resolved the back pain and reduced the erythrocyte sedimentation rate to normal. Pyogenic osteomyelitis of the transverse process is extremely rare, which can cause a misdiagnosis or a delayed diagnosis. Careful consideration of this disease is needed when evaluating patients who complain of back pain.     

Delayed diagnosis of Ewing's sarcoma of the right humerus initially treated as chronic osteomyelitis: a case report

We report a case of limited stage Ewing's sarcoma which was initially treated as chronic osteomyelitis for 3 years. A 24-year-old man presented with a one-week history of pain in the right arm and fever, with histology suggestive of osteomyelitis of the affected humerus. He developed multiple relapses of pain and fever; each episode responded to antibiotic treatment. A second biopsy was performed 3 years later and confirmed a diagnosis of Ewing's sarcoma. Despite a 3-year delay in diagnosis, the disease remained localised. This case report highlights an atypical facet of the natural history of Ewing's sarcoma: a response to antibiotic and anti-inflammatory agents, and the limited stage of the disease despite a misdiagnosis of 3 years. This suggests the possibility that anti-inflammatory agents exert an inhibitory effect on the tumour growth. We also highlight the newer histologic and immunologic staining used in the diagnosis of Ewing's sarcoma.     

Hematogenous osteomyelitis of the patella

Osteomyelitis is an uncommon infection that is considered to be a childhood disease. Diagnosis is frequently delayed, as it is a very rare condition and also because of its variable presentation. After an accurate diagnosis and treatment, the outcome is favorable in children. We present one case without recent previous infection, antecedent trauma, or penetrating injury, illustrating the difficulties in diagnosis. Nontraumatic osteomyelitis of the patella should be regarded as a rare hematogenous infection. A high index of suspicion should be addressed for early recognition. Study design is level of evidence: level IV.     

Bone and joint infection in patients with sickle cell disease

Because of recent literature reports of the rare occurrence of osteomyelitis in patients with sickle cell disease, we reviewed 5 years of experience at Dhahran Health Center (Dhahran, Saudi Arabia). Twelve cases of bone and/or joint infection were identified in patients with sickle cell disease; 83% caused by Salmonella species. This relatively high incidence might be related to the common occurrence of infection with Salmonella in this region. Long bone and multiple site involvements were noticed. Differentiation from acute bone infarcts is difficult, and a systemic and aggressive approach to early diagnosis, management, and follow-up is suggested. Before therapy is started, full history, physical examination, blood cultures, local cultures, stool and urine cultures, and measurement of febrile agglutinin levels should be done. Once diagnosis is confirmed or highly suspected, adequate surgical drainage, prolonged parenteral antibiotic therapy, and transfusion of packed red blood cells should be used. A prolonged follow-up is recommended.     

Trichophyton rubrum Osteomyelitis after Calcaneus External Fixation Pin Stabilization of a Pilon Fracture

Fungal organisms are an uncommon cause of osteomyelitis, and no dermatophyte osteomyelitis infections have been reported in published studies. We present the case of Trichophyton rubrum osteomyelitis of the calcaneus. Our patient initially presented with a pilon fracture requiring temporary external fixation while awaiting definitive fixation. From our review of the published data, the present case is the first of this type of fungal osteomyelitis to be reported. The patient was evaluated for a left neck mass during his hospitalization that was later found to be consistent with salivary duct carcinoma of the tail of the parotid gland. A left neck dissection and superficial excision of the parotid gland was performed after fixation of his pilon fracture. Subsequently, he developed an increasing lucency in the calcaneus and symptoms of pain and erythema months after the calcaneus pin had been removed. The osteomyelitis was treated with surgical debridement and 3 months of itraconazole once cultures had definitively grown T. rubrum.     

Sinonasal Non-Hodgkin's Lymphoma with Skull Base Involvement

Non-Hodgkin's lymphoma (NHL) is a rare tumor of the skull base. As the incidence of primary central nervous system (CNS) lymphoma has increased, atypical presentations involving the skull or cranial base exclusively have been reported. In immunocompetent patients with no previous history or predisposing factors, the diagnosis of primary NHL of the skull base may be delayed. We present four cases of nasal and paranasal sinus NHL with both skull base and intracranial involvement in immunocompetent patients. Clinicopathologic correlation suggests that cranial base and intracranial involvement with NHL represents advanced-stage primary sinonasal disease. Surgical biopsy before definitive treatment is recommended. Radiation therapy provides local control; adjuvant chemotherapy after primary radiation therapy may be required for recurrent disease.     

Iatrogenic pyogenic osteomyelitis of C-1 and C-2 treated with transoral decompression and delayed posterior occipitocervical arthrodesis. Case report

The authors describe a case of osteomyelitis of the craniocervical junction caused by iatrogenic infection of the spine during corticosteroid injection therapy. This 58-year-old diabetic man presented with acute exacerbation of neck pain that had began 4 months prior to admission. He did not experience the associated fever, chills, or sweats, but he did notice transient weakness in the right upper extremity. A computed tomography (CT) scan of the cervical spine demonstrated a destructive process involving the odontoid and the left occipitocervical and atlantoaxial joints that was not present on a CT obtained 2 months earlier, just before trigger-point and left-sided C1-2 facet joint corticosteroid injections. A diagnosis of staphylococcal osteomyelitis was made, and initial treatment with external immobilization and appropriate antibiotic therapy failed to control radiographically demonstrated and clinical progression. The patient was successfully treated using staged anterior decompression and posterior instrumented fusion with prolonged antibiotic therapy. To the authors' knowledge this case is the first reported instance of iatrogenic pyogenic osteomyelitis of the craniocervical junction successfully treated with anterior decompression and delayed posterior arthrodesis.