Bacterial bone and joint infections in childhood--a review. 1. Acute hematogenous osteomyelitis

This is an overview of modern aspects concerning diagnostics and therapy in children with acute hematogenous osteomyelitis. A close cooperation of pediatricians, pediatric surgeons, microbiologists and radiologists in this field is essential.     

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.     

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.     

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.     

Chronic recurrent multifocal osteomyelitis: report of five cases

Chronic recurrent multifocal osteomyelitis is a rare disease of unknown etiology that mainly affects children. We present a retrospective review of the medical records of five patients with a diagnosis of chronic recurrent multifocal osteomyelitis in an infectious diseases clinic at a tertiary center. We describe the epidemiological, clinical and radiological features, laboratory, microbiological and histological findings, treatment, course and prognosis in these patients. There is no specific treatment for chronic recurrent multifocal osteomyelitis. There are new treatment options such the combination of azithromycin and calcitonin in children without clinical improvement with non-steroidal anti-inflammatory drugs.     

Systematic review of systemic antibiotic treatment for children with chronic and sub‐acute pyogenic osteomyelitis

Background: There is a lack of consensus on the most appropriate antibiotics to treat children with chronic or sub‐acute pyogenic bacterial osteomyelitis and on the optimal duration of antibiotic therapy. Aim: To review the published evidence on the duration of antibiotic therapy and outcomes in children with chronic and sub‐acute pyogenic bacterial osteomyelitis. Methods: Systematic review of the literature. Results: We found no randomised controlled trials comparing different antibiotic regimens or comparing duration of antibiotic treatment for chronic or sub‐acute osteomyelitis in children. We found 14 observational case series published between 1973 and 2008. Most children with chronic osteomyelitis received 4–6 weeks of parenteral antibiotics followed by oral antibiotics to a total duration of 3–6 months. Small observational studies suggest that a shorter duration of parenteral and oral antibiotics may be equally effective. Conclusion: There is no high level evidence on the optimal duration of parenteral and oral antibiotics for children with chronic or sub‐acute osteomyelitis. A large randomised controlled trial is needed comparing short course parenteral and oral antibiotics with longer antibiotic duration.     

Chronic sclerosing osteomyelitis (so-called Garré's). Review of 12 cases

This study reports 12 cases of chronic sclerosing osteomyelitis in children. The authors recall the past history of this disease and describe the clinical, radiological and pathological picture found nowadays. They insist upon the salient features that allow to differentiate this lesion from other types of infectious osteomyelitis and osteoid osteoma.     

儿童慢性骨髓炎应用抗感染活性骨Ⅰ期植骨治疗的疗效评价

目的 验证抗感染活性骨(anti-infective reconstituted bone xenograft,ARBX)Ⅰ期植骨治疗儿童慢性骨髓炎的疗效.方法 自2001年9月对21例慢性骨髓炎患儿进行病灶清除,应用抗感染活性异种骨(anti-infective reconstituted bone xenograft,ARBX)Ⅰ期植骨治疗,其中获得12个月以上随访的儿童慢性骨髓炎患儿共16例.包括血源性慢性骨髓炎8例,原发性慢性骨髓炎3例,创伤性慢性骨髓炎5例.结果 16例中除1例骨髓炎复发,1例骨髓炎合并大段骨缺损在术后发生骨不连外,其余14例感染均获得控制无复发,病变部位均获得确实骨修复.本组感染治愈率(感染控制且无复发)为93.8%,完全治愈率(感染控制既无复发又完成骨修复)为87.5%.结论 ARBX具有高效诱导成骨活性和强效抗感染能力,是Ⅰ期植骨治疗儿童慢性骨髓炎的有效方法.     

Locations of osteomyelitis in children with sickle-cell disease at Tokoin teaching hospital (Togo)

Background  The sickle-cell children are particularly affected by osteomyelitis in specific locations. This study was done in order to point out the locations of osteomyelitis in children with sickle-cell disease. This direct clinical examination for a quick diagnosis. Materials and methods  This is a retrospective study done by examining files of 43 children (15 girls and 28 boys), aged from 0 to 15 years, treated for osteomyelitis between January 1998 and December 2006. Their phenotypes included 18 SS, 14 SC and 11 AS. Osteomyelitis was acute in 20 cases and chronic in 23 cases. The different localisations are classified according to the type of osteomyelitis and the kind of bones concerned. Results  The 43 children presented 63 locations: 57 on long bones and 6 on short bones. The osteomyelitis was unifocal in 32 cases, and multifocal in 11 cases. The locations on long bones were humeral (18 cases), tibial (12 cases), femoral (9 cases), fibular (7 cases), radial (7 cases) and ulnar (4 cases). The 6 short bones included 3 metacarpus and 3 phalanxes. The 11 multifocal locations concerned 8 SS, 2 AS and 1 SC. In chronic osteomyelitis, 7 patients had sequestrum and 2 had pathological fracture. Conclusion  During examination of sickle-cell children with fever, particular attention must be shown, respectively to the arm, the leg and the thigh, in order to track down quickly, an acute osteomyelitis. Early diagnosis and quick treatment permit to avoid complications and heavy sequela in these children.     

Acute multilocular osteomyelitis in infancy and childhood

38 cases of acute multilocular osteomyelitis out of a total of 165 osteomyelitis patients were treated between 1974 and 1986 at the Department of Paediatric Surgery and Paediatric Diseases at the University of Mainz. Osteomyelitis in infants was separated from juvenile osteomyelitis because of the different problems inherent to this disease depending upon the age; likewise, multilocular remote involvement was separated from regional multiple involvement. It was found that distant involvement is of special importance in infancy. 6 of the 8 cases in this group presented with symmetrical involvement. This interesting phenomenon is described in this article for the first time in acute multilocular osteomyelitis; so far, it was known to occur only in chronic recurrent multifocal osteomyelitis (CRMO). The infants in this group were predominantly newborn who were particularly severely handicapped by predisposing factors such as necessary intensive-care measures or surgical interventions. Our findings showed that in this age group most of the problems occurred, namely: 3 deaths and 2 healing defects in 8 children. For this reason it is imperative to effect particularly close monitoring of multilocular acute osteomyelitis in infancy. This must be considered as a paediatric and paediatric-surgical emergency requiring not only accurate diagnostic measures but also early internistic and surgical treatment to improve the prognosis of this specific disease pattern.     

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.     

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.     

带血供腓骨移植Ⅰ期修复小儿慢性骨髓炎死骨缺损

目的：探讨小儿慢性骨髓炎大段死骨早期摘除后骨缺损的Ⅰ期修复效果。方法：16例胫骨慢性骨髓炎并大段死骨清除后，作吻合血管腓骨移植Ⅰ期重建；2例作炎性骨段切除，采用带血供腓骨移植Ⅰ期修复。结果：18例胫骨慢性骨髓炎在摘除大段死骨后，应用吻合血管腓骨移植或带血管蒂腓骨移植重建。术后平均随访26个月，见重建骨完全骨性愈合，累及的炎症得到完全控制；修复技体的功能，外形令人满意。结论：慢性骨髓炎所形成的大段死骨在作病灶清除的同时，进行早期的血管吻合或带血管腓骨移植Ⅰ期重建术，可免疫死骨爬行替代的漫长病程，改善受区血液循环，抑制炎症漫延，缩短了住院时间，阔手术次数，为骨髓炎早期死骨清除骨缺损的重建提供了有效外科治疗手段。     

Oral antibiotic therapy for skeletal infections of children. II. Therapy of osteomyelitis and suppurative arthritis

Antimicrobial regimens consisting of a brief initial period of parenteral therapy followed by oral therapy were investigated in infants and children with suppurative bone and joint disease. There were 30 patients with acute hematogenous disease (19 osteomyelitis; three osteoarthritis; eight arthritis) and five with subacute or chronic osteomyelitis. Disease was due to Staphylococcus aureus in 26, Hemophilus influenzae in five, streptococci in three, and S. aureus plus Streptococcus pyogenes in one patient. Pus was removed by surgical drainage or needle aspiration. Oral therapy was monitored by assay of antibiotic concentration and bactericidal activity in serum. Adjustments in dosage were made when necessary to assure a peak serum bactericidal titer of at least 1:8. One patient progressed to chronic osteomyelitis but all other patients with acute disease responded well. Oral therapy provides increased patient comfort and decreases the risk of nosocomial infection associated with prolonged intravenous therapy. It should be carried out only under carefully monitored conditions in hospital to assure compliance and adequacy of serum bactericidal activity.     

Chronic recurrent multifocal osteomyelitis – report of eight patients

The authors undertook a retrospective review of the clinical records and radiologic findings of eight children with chronic, recurrent multifocal osteomyelitis (CRMO). This disease is a recognized clinicopathologic entity with typical radiographic findings, mostly in the metaphyses of the long bones. The diagnosis is one of exclusion without pathognomonic findings. The patients were treated with non-steroidal anti-inflammatory drugs. There was no evidence of altered bone growth or abnormal joint development. It is concluded that CRMO is a distinct clinical entity that is different from acute or subacute bacterial osteomyelitis. Recognition of this condition is important to avoid treatment with antibiotics and repeated operations. Accepted: 8 April 1998     

Haemophilus influenzae type b osteomyelitis.

Three children had osteomyelitis due to Haemophilus influenzae type b. They were seen with signs and symptoms indistinguishable from infection caused by other organisms. One child was initially misdiagnosed as having septic arthritis because of failure to appreciate that Hemophilus may also cause bone infection. In the second patient osteomyelitis and arthritis developed during ampicillin sodium therapy for treatment of Hemophilus meningitis. His initial infection was caused by an ampicillin-sensitive isolate but his orthopedic infection subsequently responded to therapy only after changing to a regimen of chloramphenicol. In the third patient, bone scintigraphy was helpful in diagnosis since serial roentgenograms were not diagnostic of osteomyelitis. The anticapsular antibody responses of these patients were measured by radioimmune assay. The levels found were low but comparable to age-matched control children with H influenzae type b meningitis.     

The syndrome of chronic recurrent multifocal osteomyelitis and congenital dyserythropoietic anaemia. Report of a new family and a review

A new autosomal recessive syndrome of chronic recurrent multifocal osteomyelitis (CRMO) and congenital dyserythropoietic anaemia (CDA) with microcytosis has recently been described in four children (two sibships) of one consangineous Arab family. In this report, we describe the clinical features and course of the syndrome of CRMO and CDA in two additional patients (one sibship) from another consanguineous Arab family and review the literature. The two patients (brother and sister), the products of a consanguineous marriage, developed the syndrome at an early age of 3 weeks and 2 months respectively. The diagnosis of CRMO was confirmed by radiological and technetium isotope bone scans. Bone marrow studies confirmed the diagnosis of CDA. Peripheral blood films showed hypochromia and microcytosis. The sites involved by CRMO were periarticular, mainly around the elbow, knee, wrist and small joints of the hand. The brother is now 21 years old and the sister 3.5 years old and CRMO is still active with frequent relapses. The brother developed flexion deformities at the age of 13 years. Both patients failed to thrive; weight and height were below the 5th percentile. CONCLUSION: This is the second report of the syndrome of chronic recurrent multifocal osteomyelitis and microcytic congenital dyserythropoietic anaemia, confirming it as a clinical entity, inherited as an autosomal recessive trait. The disease is characterised by an early onset, long clinical course of remissions and relapses, and seems to be different from the sporadic form of chronic recurrent multifocal osteomyelitis.     

Chronic recurrent multifocal osteomyelitis with unusual features

We describe two children with chronic recurrent multifocal osteomyelitis who showed unusual extraskeletal manifestations. The first patient developed an asymptomatic pulmonary consolidation; the second had an atypic localization of the associated pustulosis, which involved the trunk, groin, thighs and buttocks, but spared the palms and soles. We conclude that this disease is clinically more heterogeneous than previously thought.     

Acute osteomyelitis in children. Reassessment of etiologic agents and their clinical characteristics

One hundred thirty-five children with acute osteomyelitis were identified by chart review during a 7-year period, January 1, 1980, through December 31, 1986. Bacteriologic causes were detected in 75 (55%) of the patients. Staphylococcus aureus, Haemophilus influenzae type b, and Pseudomonas aeruginosa were identified in 34 (25%), 16 (12%), and eight (6%) children, respectively. Staphylococcus aureus occurred in all age groups, H influenzae type b occurred only in children younger than 3 years and was the number one cause of disease in this group. Pseudomonas aeruginosa occurred exclusively in children older than 9 years. Children with H influenzae type b had clinical and laboratory findings that were almost indistinguishable from a matched group of children with osteomyelitis due to other known bacteria, although children with H influenzae type b tended to have more joint effusions (63% vs 27%), less lower extremity disease (22% vs 70%), and fewer positive cultures from bone or joint aspirates (41% vs 89%). Unlike most pediatric cases of osteomyelitis, the ones due to P aeruginosa did not represent the hematogenous route of infection; penetrating injury to the foot was present in every case. Children with P aeruginosa infections were older than 9 years (100%), predominantly male (88%), often afebrile (83%), and never bacteremic. These data provide guidelines for the initial work-up and management of osteomyelitis in children.     

Chronic recurrent multifocal osteomyelitis

Chronic recurrent multifocal osteomyelitis is a rare disorder of unknown etiology, characterized by multiple bone lesions and a variable clinical course. We present a 10 year old boy with chronic recurrent multifocal osteomyelitis who improved after treatment with naproxen.