Osteomyelitis

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Osteomyelitis
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Osteomyelitis

• Inflammation of bone and marrow
• Types
• Pyogenic osteomyelitis
• Tuberculous osteomyelitis

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Pyogenic Osteomyelitis
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Pyogenic osteomyelitis

• Always caused by bacteria
• Routes of infection
• Hematogenous spread
• Extension from a contiguous site
• Direct implantation

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• Causes
• Staphylococcus aureus in 80 to 90 of cases
• E.coli, Pseudomonas, and Klebsiella in patients
  with genitourinary tract infections and IV drug
  abusers.
• In neonates Hemophilus influenza and group B
  streptococci
• In patients with sickle cell disease Salmonella
  infection

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• Morphology
• Acute
• Subacute
• Chronic

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• Organisms once localized in bone
• Bacteria proliferate and induce inflammatory
  reaction and cause cell death.
• Bone undergoes necrosis within first 48 hours
• Bacteria and inflammation spread within the shaft
  of the bone and may percolate throughout the
  haversian systems and reach the periosteum
• Subperiosteal abscess
• Segmental bone necrosis? sequestrum (dead piece
  of bone)
• Rupture of periosteum leads to an abscess in the
  surrounding soft tissue and the formation of
  draining sinus.

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• Over time, host response develops
• After first week of infection chronic
  inflammatory cells become more numerous
• Cytokines from leukocytes stimulates osteoclastic
  bone resorption? ingrowth of fibrous tissue?
  deposition of reactive bone in the periphery
• Reactive woven or lamellar bone which forms
  sleeve of living tissue surrounding dead bone is
  called as involucrum.

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• Brodie abscess is a small intraosseous abscess
  that frequently involves the cortex and is walled
  off by reactive bone
• Sclerosing osteomyelitis of Garre typically
  develops in jaw and is associated with extensive
  new bone formation

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PATHOLOGY
Acute ?Infiltration of PMNs
Congested or thrombosed vessels Chronic ?
Necrotic bone Absence of
living osteocyte Mixed
inflmmatory cells
predominate Granulation
fibrous tissue
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Osteomyelitis-gross microscopy
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Sequestrum (necrotic bone)
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Involucrum (new bone)
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Osteomyelitis of the tibia of a young child.
Numerous abscesses in the bone show as
radiolucency.
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HEMATOGENOUS OSTEOMYELITIS

• Clinical manifestation
• Classic presentation Sudden onset
• High fever, Night sweats
• Fatigue, Anorexia, Weight loss
• Restriction of movement
• Local edema, Erythema, Tenderrness

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Clenched fist osteomyelitis
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HEMATOGENOUS OSTEOMYELITIS

• Diagnosis work-up
• Lab study
• WBC ? May be elevated, Usually normal
• C-Reactive Protein (CRP)
• Erythrocyte Sedimentation Rate
• (Usually is elevated at presentation
• Falls with successful therapy)
• Blood culture
• ( Acute osteomyelitis ve gt 50 )

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HEMATOGENOUS OSTEOMYELITIS

• Diagnosis work-up
• Imaging
• Radiology
• Normal
• Soft tissue swelling
• Periosteal elevation
• Lytic change
• Sclerotic change

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Complications of chronic osteomyelitis

1. Deformities of bones
2. Pathological fractures.
3. Systemic effects such as chronic fever fatigue.
4. Amyloidosis of the AA type (secondary
   amyloidosis).This can get further deposited in
   the kidney, liver blood vessels.
5. Squamous cell carcinoma of the skin The skin at
   the edges of the draining sinus tracts may
   undergo malignant transformation over time.
6. Sepsis
7. Rarely sarcoma in the infected bone

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Specific forms of chronic osteomyelitis

• Forms of chronic osteomyelitis include
• Brodie abscess,
• Tuberculous osteomyelitis,
• Osteomyelitis of congenital syphilis, and
• Osteomyelitis of acquired syphilis.

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TB osteomyelitis

• Dissemination of tuberculosis outside the lungs
  can lead to the appearance of skeletal TB
• Skeletal Tuberculosis
• Tuberculous osteomyelitis involves mainly the
  thoracic and lumbar vertebrae (known as Pott
  disease) followed by knee and hip.
• There is extensive necrosis and bony destruction
  with compressed fractures (with kyphosis) and
  extension to soft tissues, including psoas "cold"
  abscess.

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• Tuberculous osteomyelitis of the bone is
  secondary hematogenous spread from a primary
  source in the lung or GI tract.
• It most commonly occurs in the vertebrae (body)
  and long bones.
• Once established, the bacilli provoke a chronic
  inflammatory reaction.
• Small patches of caseous necrosis occur, and
  these coalesce to form larger abscesses.
• The infection spreads across the epiphysis into
  the joints.
• The infection may track along soft tissue to
  appear as a cold abscess at a distant site (eg
  psoas abscess in case of spinal tuberculosis).

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Spinal tuberculosis. Magnetic resonance imaging
of the spine revealing osteomyelitis involving
T10 and T11 vertebral bodies and disc space (A
arrow) and an adjacent multiloculated
paravertebral abscess (B arrow).
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Psoas abscess Computed tomographic scan of the
abdomen showing a left iliopsoas abscess (arrow)
that likely originated from tuberculous
osteomyelitis involving the T12, L1, and L2
vertebrae.
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Syphilitic osteomyelitis

• The transplacental spread of spirochetes from
  mother to the fetus results in congenital
  syphilis.
• Long bones, such as the tibia, are mainly
  affected.
• Congenital syphilis has 2 forms
• Periosteitis and osteochonditis.

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• Regarding acquired syphilis, bone lesions are
  manifestations of tertiary syphilis.
• Gummatous lesions appear as discrete punched-out
  radiolucent lesions in medulla or destructive
  lesions within the cortex.
• The surrounding bone is sclerotic, and no
  discharge is present.
• Bones frequently affected are those of nose,
  palate, skull and extremities, especially the
  long tubular bones such as tibia.
• Histology edematous granulation tissue
  containing numerous plasma cells and necrotic
  bone.

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Sabre tibia

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