Multifocal osteomyelitis in a child with sickle cell disease and review of the literature regarding best diagnostic approach

Bilaterally Symmetrical Serratia Osteomyelitis of Distal Third Radius in an Adolescent Female with Sickle Cell Disease: A Rare Case Report

Introduction

Osteomyelitis as a condition in adolescents is difficult to diagnose as it is. In patients with sickle cell disease, the diagnosis is even more difficult due to the occurrence of Vaso occlusive crisis which being the most common acute clinical manifestation of sickle cell disease in bone may mimic osteomyelitis. No single clinical presentation, laboratory result, or imaging finding can definitively distinguish these diagnoses.

Case Report

A 15-year-old female presented to the outpatient department with mild pain and swelling in both forearms persisting for the past 3 months. Radiographs revealed predominantly diaphyseal expansile osteolytic lesions in the bilateral distal third radius with periosteal reaction along with a small radiolucent area in the right distal radius. She was subsequently admitted for further assessment. On the 3rd day of admission, pus pointing was noted on the volar aspect of the right forearm while the left side only had bony swelling. Surgical intervention (debridement with saucerization) was performed on both sides. Pus culture (collected intraoperatively) showed Serratia marcescens as the causative organism. Culture-sensitive antibiotics were administered intravenously for 3 weeks followed by oral antibiotics for 3 weeks. At 1-year follow-up near complete resolution of bony lesions with full range of motion in both upper limbs was noted.

Conclusion

Subacute osteomyelitis may present with just bony swelling without significant pain or fever and can present a diagnostic dilemma, a high index of suspicion is important to rule out other conditions and diagnose osteomyelitis in such cases. Unusual organisms like Serratia can cause osteomyelitis in immunodeficient patients like those with sickle cell disease. Appropriate management in the form of thorough surgical debridement, saucerization, and appropriate antibiotics can lead to complete resolution of the infection with good clinical results.

Unique Bilaterally Symmetrical Multifocal Osteomyelitis Presentation in a Health-care Worker with Sickle Cell Disease Secondary to Klebsiella Infection - A Case Report

Introduction

Osteomyelitis is one of the most common infectious complications in people with sickle cell disease (SCD). The most common infecting organisms in SCD are the Salmonella species and Staphylococcus aureus; Streptococcus pneumoniae and Bacteroides species have also been described, however, osteomyelitis attributable to infection with hypervirulent Klebsiella spp. is a rare entity. We describe our experience with a rare presentation of multifocal bilateral symmetrical ulna and fibula osteomyelitis in a patient with SCD due to Klebsiella bacteremia with 1-year follow-up.

Case Report

A 25-year-old female known SCD since childhood who underwent treatment for dengue at our hospital had her blood cultures positive for Klebsiella, following which she was treated with appropriate antibiotics. Two weeks following the asymptomatic period patient presented with complaints of pain over the bilateral forearm and legs. The patient was evaluated for laboratory parameters and plain radiograph of the bilateral forearm and bilateral legs. The radiological features were suggestive of osteomyelitis, showing "Bilaterally symmetrical involvement." Laboratory parameters erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were found raised. The patient was planned for biopsy and debridement of the lesion from the right ulna. The culture from the biopsy showed growth of Klebsiella sp. and was sensitive to co-trimoxazole. The patient was started on co-trimoxazole for 6 weeks and had a significant clinical improvement in the form of subsidence of pain, normalization of the blood counts along with the acute phase reactants (ESR, CRP).

Conclusion

Our case contributes to the growing awareness of the unusual manifestations of this serious disease and the rarity of bilateral symmetrical involvement. Our case highlights the importance of clinician awareness, manifestations, and management of Klebsiella sp. hypervirulent strains.