Acute osteomyelitis in the child with sickle cell disease in a tropical zone: value of oral fluoroquinolones]

AIM: This study was designed to assess the efficacy and the safety of fluoroquinolones in their compassionate use for acute osteomyelitis in children with sickle cell disease in a tropical country. PATIENTS AND METHODS: This study was non comparative, including twelve children (eight SS, three SC and one SEzerothalassemia) treated for acute osteomyelitis with oral ciprofloxacin or ofloxacin because of the following reasons: financial inability to afford conventional parenteral beta-lactams therapy (nine patients), refusal of hospitalization (two patients), and failure of conventional treatment (one patient). RESULTS: The mean age of patients was 9.5 +/- 2.6 years. The long bones were the predominantly site. Salmonella species were present in 75% of cases, followed by other enterobacteriaceae (16.7%), and Staphylococcus aureus (8.3%). Successful outcome occurred in all cases after three to four-weeks of treatment and 45 days of plaster immobilization. Transient bilateral Achilles tendon tendinitis was noted in a five-year-old patient. CONCLUSION: In economically developing countries, oral fluoroquinolones may be a therapeutic alternative for acute osteomyelitis in patients with sickle cell disease particularly in cases of financial hardship or failure with conventional therapy.     

Sickle cell haemoglobinopathies in England.

Ninety-six Birmingham children with sickle cell disease were studied prospectively between 1969 and 1979. Thirty-five were homozygotes for HbS (SS), 12 had sickle thalassaemia (S thal), and 23 were double heterozygotes for HbS and C (SC). Twenty-six whose family studies were incomplete were classified as SS or S thal although most were thought to be SS. The average length of follow-up was 5.1 years. Four SS children and 1 SC child died, the annual mortality rates being 1.3% for SS and presumed SS, 0% for S thal, and 0.9% for SC children. The incidence of pulmonary illnesses and anaemic crises was greater than reported from Jamaica, while leg ulceration described there and in New York was not observed in Birmingham. Severe infections were less common than in the series reported from New York and no case of salmonella osteomyelitis was observed in Birmingham. In general the S thal and SC children had milder illnesses than the SS, and the SS children often showed impairment of growth and sexual maturation.     

Ostéomyélites aiguës de l’enfant drépanocytaire en zone tropicale : intérêt de l’utilisation des fluoroquinolones par voie oraleAcute osteomyelitis in children with sickle cell disease in a tropical country : benefit of the use of oral fluoroquinolones.

Aim. – This study was designed to assess the efficacy and the safety of fluoroquinolones in their compassionate use for acute osteomyelitis in children with sickle cell disease in a tropical country.Patients and methods. – This study was non comparative, including twelve children (eight SS, three SC and one SE°thalassemia) treated for acute osteomyelitis with oral ciprofloxacin or ofloxacin because of the following reasons : financial inability to afford conventional parenteral beta-lactams therapy (nine patients), refusal of hospitalization (two patients), and failure of conventional treatment (one patient).Results. – The mean age of patients was 9,5 ± 2,6 years. The long bones were the predominantly site. Salmonella species were present in 75 % of cases, followed by other enterobacteriaceae (16,7 %), and Staphylococcus aureus (8,3 %). Successful outcome occurred in all cases after three to four weeks of treatment and 45 days of plaster immobilization. Transient bilateral Achilles tendon tendinitis was noted in a five-year-old patient.Conclusion. – In economically developing countries, oral fluoroquinolones may be a therapeutic alternative for acute osteomyelitis in patients with sickle cell disease particularly in cases of financial hardship or failure with conventional therapy.     

Bacteremia in sickle hemoglobinopathies

We analyzed 178 episodes of bacteremia that occurred during 13,771 patient-years of follow-up of 3451 patients with sickle hemoglobinopathies. Age-specific incidence rates of bacteremia were calculated for patients with sickle cell anemia (SS) and sickle cell-hemoglobin C (SC) disease. The incidence rate was highest among children with SS and SC younger than age 2 years. Children with SC showed an abrupt decrease after age 2 years, whereas children with SS had a gradual decline in rate from 2 to 6 years of age. The predominant pathogen in patients younger than 6 years was Streptococcus pneumoniae (66%); gram-negative organisms were responsible for 50% of bacteremias in patients 6 years and older. Urinary tract infection was present during 73% of Escherichia coli bacteremias, and 77% of Salmonella bacteremias were associated with osteomyelitis. In contrast, no focus of infection was present in 52% of pneumococcal bacteremias. The incidence of pneumococcal bacteremia in children with SS younger than age 3 years was 6.1 events/100 patient-years; the case fatality rate for pneumococcal sepsis in this age group was 24%. No hematologic or demographic variables were associated with occurrence of pneumococcal bacteremia in young children. Retrospective analysis of pneumococcal bacteremia suggests that the prophylactic use of penicillin may decrease the incidence in children younger than 3 years of age.     

Osteomielitis aguda: epidemiología,manifestaciones clínicas,diagnóstico y tratamiento

Background and aimsThe present study focuses on the epidemiology, clinical and laboratory data, and management of osteomyelitis in a pediatric third level hospital.MethodologyAll cases of children under 15 years-old admitted with osteomyelitis between 2000 and 2011 were retrospectively reviewed until July 2006, then prospectively from then until 2011.ResultsA total of 50 patients were identified (52% males) with median age at diagnosis of 2 years. Principal onset manifestations were pain (94%), functional impairment (90%) and fever (72%). The femur (32%), fibula (28%) and calcaneus (22%) were most affected bones.Leucocytosis > 12.000/μl was found in 56%, elevated ESR > 20 mm/h in 26%, and elevated CRP > 20 mg/L in 64%. Blood culture was positive in 20%, with group A streptococcus being the most frequently isolated bacteria (11%).All diagnoses were confirmed by a ⁹⁹Tc scintigraphy bone scan.Antibiotic therapy was initially intravenously (mean time of administration: 10 days ± 3 SD), followed by oral medication (mean time of administration: 18 days ± 6 SD). Surgery was necessary in 3 patients. Evolution of all cases was excellent, despite 3 exceptions that resolved over time.ConclusionsThe current short-term intravenous therapy led to shorter hospitalizations. There were no statistically significant differences between time from clinical onset or in CRP levels at discharge compared to long-term therapies prior to 2006.     

Severe staphylococcal sepsis in Nigerian children: a report of 27 cases

Twenty-seven children with severe staphylococcal sepsis were encountered over a 6-year period in a busy teaching hospital paediatric practice. The clinical manifestations are described, among which anaemia, osteomyelitis, lung infection and purulent pericarditis were most common. Osteomyelitis was particularly severe and multifocal in many of the children, leading to bone and joint deformity in some. Striking features were that all affected children were previously healthy, 83.3% had normal haemoglobin genotype AA and none had homozygous sickle cell haemoglobin SS.     

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     

Streptococcus pneumoniae sepsis and meningitis during the penicillin prophylaxis era in children with sickle cell disease

The purpose of this study was to determine the age-related risks, disease-specific risks, and characteristics of serious pneumococcal infections in children with sickle cell disease (SCD) while penicillin prophylaxis was standard. The clinical experiences of three pediatric sickle cell programs spanning January 1, 1992, to May 31, 1998, were combined. Data were collected regarding the patients followed up and the characteristics of bacteremia and meningitis cases. Forty-seven pneumococcal infections (44 bacteremia, 3 meningitis) among 40 patients with SCD were observed. Forty infections occurred in children with homozygous hemoglobin S (SS) during 4108 patient-years at a median age of 22 months; 7 occurred in double heterozygous hemoglobin SC (SC) children during 1777 patient-years at a median age of 23 months. Ten infections occurred among 9 SS children 5 years or older. Most children in whom infections developed were reportedly taking prophylactic penicillin and when older than 24 months old had received Pneumovax (Merck & Co., Inc., West Point, PA, U.S.A. The following pneumococcal serotypes were identified in 15 cases studied: 6A, 6B, 9V, 14, 15B, 18B, 18F, 19F, and 23F. Infections resulted in five deaths and two strokes. The observed severe pneumococcal infection rate in SS children younger than 5 years was less than that reported before penicillin prophylaxis, supporting routine penicillin prophylaxis in this specific population. The optimal duration of penicillin prophylaxis in older children with SCD remains unknown. The administration of 7-valent Prevnar (Wyeth Lederle Vaccines, Philadelphia, PA, U.S.A.) to children younger than 24 months old with SCD should be beneficial, based on the serotype data.     

Dramatic pain relief and resolution of bone inflammation following pamidronate in 9 pediatric patients with persistent chronic recurrent multifocal osteomyelitis (CRMO)

Background  

Chronic recurrent multifocal osteomyelitis (CRMO) is an inflammatory, non-infectious osteopathy that affects predominantly patients ≤ 18 years of age. There is no uniformly effective treatment. Our objective is to describe clinical, magnetic resonance imaging (MRI), and bone resorption response to intravenous pamidronate in pediatric CRMO.     

Life-threatening infection due to community-acquired methicillin-resistant Staphylococcus aureus: case report and review

We report an unusual case of serious, multifocal, invasive infection due to community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) in a 10-year-old girl with favorable outcome. The child manifested femoral osteomyelitis, pyomyositis, deep femoral vein thrombosis, pneumonia, encephalopathy, and disturbances of almost all organs. She remained in a critical condition for a week. Fever persisted for 6 weeks and acute phase reactants remained increased for 6 months, necessitating a 7-month antistaphylococcal therapy with a glycopeptide and clindamycin. This led to resolution of infection-associated problems during the subsequent 36 months of follow-up. CA-MRSA strain isolated from the patient harbored both staphylococcal chromosomal cassette type IV (SCCmec type IV) and Panton–Valentine leukocidin genes. A literature review of serious CA-MRSA infections indicated that only a small minority of published cases had favorable outcome.     

Synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome in childhood: a report of ten cases and review of the literature

Chronic recurrent multifocal osteomyelitis is a rare chronic inflammatory musculoskeletal process observed in children and young adults. Recently, the acronym SAPHO syndrome (for synovitis, acne, pustulosis, hyperostosis, osteitis) was coined to emphasise the association between osteo-articular inflammations and different skin abnormalities which are aseptic and filled with neutrophils. In adults, chronic recurrent multifocal osteomyelitis is now a classical manifestation of SAPHO syndrome. Chronic skin disorders were seen in eight of ten children on follow-up at the University Children's Hospitals in Bern and Zurich and in 61 of 260 paediatric cases reported in the literature. The different skin lesions were palmoplantar pustulosis (n=40), non-palmoplantar pustulosis (n=6), psoriasis vulgaris (n=16) or severe acne (n=4). More rarely Sweet syndrome (n=2) or pyoderma gangrenosum (n=1) were reported. Conclusion The synovitis, acne, pustulosis, hyperostosis, osteitis syndrome is pertinent even in paediatrics since skin involvement is frequent. Received: 13 October 1999 and in revised form: 19 January 2000 / Accepted: 16 February 2000     

Chronic recurrent osteomyelitis with clavicular involvement in children: diagnostic value of different imaging techniques and therapy with non-steroidal anti-inflammatory drugs

Chronic recurrent, uni- or multifocal osteomyelitis (CRMO), an inflammatory disorder of unknown origin, involves mk:/night/arul/4310946m.3dultiple osseous sites and may affect the clavicle. We report on 6 children with clavicular involvement out of 11 children suffering from CRMO. The major clinical symptoms were local swelling and pain. Five children had hyperostosis of the clavicle and synovitis of adjacent joints. Histology showed chronic osteomyelitis with a predominance of lymphocytes in the inflammatory infiltrates. Cultures of biopsy tissue specimens were sterile. The patients were followed for at least 3.5 years. Three patients had up to six relapses. The most effective diagnostic tools to define CRMO were standard X-ray and bone scan in combination with biopsy and cultures. In our patients CT and MRI were misleading as they suggested the presence of malignancy. However, the sensitivity of MRI to detect involvement of bone, adjacent joints and soft tissues were better in comparison to X-ray or bone scan. Non-steroidal anti-inflammatory drugs were effective in reducing pain, swelling and limitation of motion. Reconstructive surgery was not indicated in any case. The long-term outcome of growth and function of affected bones was excellent. Conclusion Diagnosis of chronic osteomyelitis of the clavicle should be made by history and physical examination and be confirmed by standard X-ray, bone scan and open biopsy. In contrast MRI and CT can provide data on the involvement of adjacent joints, soft tissue and muscles especially in the early process of disease, but do not add information relevant to the patient's management. Treatment with non-steroidal anti-inflammatory drugs is rapidly beneficial in most patients. Received: 24 January 1997 / Accepted: 26 May 1997     

Clinical and pathological characteristics of Alagille syndrome in Chinese children

Background  Alagille syndrome (AS) is regarded as the most common cause of chronic cholestasis in childhood associated with specific phenotypic features in western countries. This study was undertaken to investigate the significance of AS in Chinese children with chronic cholestasis and to describe its clinical and histological features. Methods  From October 2004 to January 2007, 157 children who presented with conjugated jaundice from less than 3 months of age were admitted to a tertiary hospital in Shanghai. Investigations of the heart, spine, eyes and kidneys were conducted in 13 children who experienced prolonged cholestasis beyond 1 year of age after exclusion of biliary atresia and familial progressive intrahepatic cholestasis type 1 or 2. In patients with interlobular bile duct paucity, AS was diagnosed if 3 or more of the following 5 major features were present: cardiac murmur, posterior embryotoxon, butterfly-like vertebrae, renal abnormalities and characteristic faces. In patients without interlobular bile duct paucity or who did not receive liver biopsy, 4 or more features were required for the diagnosis. Results  Of the 13 children, 6 were diagnosed with AS at ages ranging from 1 year and 7 months to 3 years and 11 months. Jaundice was noticed in early infancy and then pruritus developed in all the 6 patients, of whom 5 presented with acholic stool and 4 had been misdiagnosed as having presumed biliary atresia by hepatobiliary scintigraphy or laparoscopic cholangiography. Biochemical examinations demonstrated increased concentration of total bile acid and hyperlipidemia. Interlobular bile duct paucity was demonstrated histologically in 5 patients who received liver biopsy. Vertebral abnormalities, heart murmur, characteristic faces and failure to thrive were found in all the 6 patients. Two patients had evidence of renal involvement. Micropenis, empty scrotum, and gall stone were seen in 1 patient. Conclusion  AS is also an important cause of prolonged cholestasis in Chinese children. It is difficult to differentiate AS from biliary atresia. Liver biopsy and spine X-ray may be helpful in the early detection of AS.     

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.     

Changing pattern of osteomyelitis in infants and children

A retrospective analysis of 332 children with osteomyelitis (OM), managed from 1966 to 1996, was undertaken to evaluate etiology, clinical course and treatment results. In 64% of all patients positive bacterial cultures were obtained, Staphylococcus aureus, streptococci, pneumococci, and Haemophilus influenzae were the most frequently cultured pathogens. In two-thirds of the cases long bones (femur, tibia, humerus) were affected. Osteoarthritis or suppurative arthritis was evident in 27%; 32 of 170 (19%) re-evaluated patients had moderate or severe sequelae. Risk factors for an unfavorable course were the onset of disease in early infancy, suppurative arthritis, and an affected epiphysis. Suppurative arthritis, in particular, needs early evacuation to prevent sequelae. In recent years we observed an increasing number of patients presenting with atypical forms of OM. Since 1989 10 patients were considered to have chronic recurrent multifocal OM (CRMO). In 6 of them the clavicle was involved; their ages ranged from 3 to 14 years. The erythrocyte sedimentation rate was elevated (median 48, range 9–110 mm), while other inflammatory parameters like C-reactive protein (median 9, range <5–85 mg/l) or leucocyte count were slightly elevated or normal. Histopathology was stage-dependent, with a predominance of lymphoplasmacellular infiltration. A nonbacterial origin of CRMO is probable but not proven. Histopathology is not suitable for differentiation between bacterial and nonbacterial forms of bone inflammation. Accepted: 5 January 1999     

Cholecystectomy in children with sickle-cell disease

Cholelithiasis is a common complication of sickle-cell disease (SCD); its frequency is variable, ranging from 4% to 55%. Twenty-two children with SCD (Hb SS) underwent cholecystectomy for cholelithiasis. All were managed with a preoperative transfusion regimen to achieve a hemoglobin concentration of 10–12 g/dl and a hematocrit of 30%–40%. On the evening before surgery, each patient was hydrated with IV fluids (5% dextrose in 1/2 or 1/4 normal saline) at 1.5 times the maintenance rate and postoperatively they received IV morphine infusions for analgesia. Intraoperative cholangiograms revealed common bile duct (CBD) stones in 7 patients (30%), only 4 of which were detected preoperatively by ultrasound (US). Two patients also had a splenectomy together with the cholecystectomy, 1 for a splenic abscess and the other for recurrent sequestration crises. There was no mortality, but 2 patients developed acute chest syndrome, 1 developed a minor wound infection, and 1 had postoperative bleeding from the splenic bed. Careful perioperative management permits safe cholecystectomy in children with SCD. Routine intraoperative cholangiography is recommended in these cases, as while 7 of our patients had CBD stones, only 4 of them were detected preoperatively by US.     

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-- I. Review

Juvenile and adolescent "Chronic Recurrent Multifocal Osteomyelitis" (CRMO) is described on the basis of literature and analysis of 43 own cases (23 cases in children or adolescents).This systemic, non-purulent inflammatory disease occurs mainly metaphyseal in long bones, in pelvic bones or as spondylitis and is not as rare as it seemed. Basis of the disease is a primarily chronic, sterile, in phase of onset often monotopic (e.g. clavicle) and later frequently polytopic osteomyelitis, possibly triggered by an immuno-pathological process (e.g. Proprionibacterium acnes), and showing histologically plasmacellular invasion and a sclerosing process in different stages. Association with pustulous dermatosis (psoriasis, acne, palmo-plantar pustulosis) is found in about 25 % of children and adolescents and in more than 50 % of the adult patients. 5 differents types of distribution of osteomyelitic lesions can be found by using Te99m-bone scan primarily, of which the "pelvic type" is the most common. Because of the close neighbourhood of meta-/epiphyseal osteomyelitic focuses, "sympathetic arthritis" with synovitis is seen frequently. A therapeutic approach with azithromycine and calcitonine is presented.     

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.