Anaerobic osteomyelitis of femoral head with intraosseous, intra-articular, bursal and muscle pneumatosis

Multifocal emphysematous osteomyelitis, a do not miss diagnosis for the emergency radiologist: a case report with literature review

Emphysematous osteomyelitis (EO) is an uncommon fatal condition with high morbidity and mortality. Simultaneous involvement of the axial and appendicular skeleton with multifocal disease is even rarer, with only a few cases being reported in the literature. We present a case of multifocal emphysematous osteomyelitis in a 56-year-old woman with concurrent emphysematous pyelonephritis complicated by psoas and epidural abscesses. The causative organism in our patient was Escherichia coli. Emergency radiologists should be aware of this condition and differentiate it from other benign entities that can present with intraosseous gas. Prompt diagnosis is important given the high morbidity and mortality with this condition. This case report emphasizes the specific pattern of intraosseous gas seen with EO, which can help diagnose EO with confidence.

Emphysematous Osteomyelitis Involving the Spine, a Case of a Rare Form of Osteomyelitis

Gas-forming bacteria like Staphylococcus aureus (SA), along with the worrisome infections it causes, can lead to a fairly overlooked but lethal complication, called emphysematous osteomyelitis (EO). It is a condition characterized by the infection of bones complicated by the presence of gas-forming organisms. Here, we present a 50-year-old woman with insulin-dependent type 2 diabetes, who presented with cough, high-grade fevers, rigors, chills, and back pain from the last seven days. Laboratory tests revealed elevated inflammatory markers and a hyperosmolar hyperglycemic state. Sputum smear and blood cultures both reported the presence of SA. The presence of air foci in the third lumbar spine vertebra (L3) and the surrounding soft tissue was confirmed by computed tomography (CT). The posterior elements were spared, and the vertebral height and intervertebral disc were preserved. The extent of the damage done to the bone was analyzed by magnetic resonance imaging (MRI). The findings showed transverse relaxation time (T2) and short tau inversion recovery (STIR) sequences, consistent with the diagnosis of EO. She was put on strict glucose monitoring and a combination of intravenous antibiotics for three weeks followed by two weeks of oral therapy. Her symptoms improved with conservative management and reported no recurrence of any symptom of such type ever since.

A Rare Case of Emphysematous Osteomyelitis of Femur in an Intravenous Drug User

Emphysematous osteomyelitis (EO) is a rare condition characterized by the appearance of gas locules within the bone on imaging, usually as a result of anaerobic bacterial infection. We present the case of a 46-year-old known intravenous (IV) drug user who was admitted to the emergency department with intractable pain in the right groin. He was febrile with elevated white cell count and C-reactive protein. He underwent an X-ray and CT of the pelvis which demonstrated intraosseous gas in the proximal right femur. A diagnosis of EO was made radiologically, allowing for prompt antibiotic treatment and a plan for surgical debridement. There are only a handful of published cases of EO in the literature, only one of which has described IV drug use as the underlying factor.

Emphysematous osteomyelitis: Report of two cases and review of literature

Emphysematous osteomyelitis is a rare condition characterized by the presence of intraosseous gas. A prompt diagnosis is required for this disease to expedite management as it is a potentially fatal condition. Many comorbidities, such as malignancy, diabetes mellitus, alcohol abuse, Crohn's disease, and other etiologies causing immunosuppression, predispose to this condition. The causative organisms are generally anaerobes or members of Enterobacteriaceae family; however, the infection can be mono or polymicrobial. We report two cases affected with emphysematous osteomyelitis due to varied underlying comorbidities. The purpose of this study is to (a) emphasize the importance of computed tomography in diagnosing emphysematous osteomyelitis and (b) to highlight an unusual location of this rare pathology.

Hip bone osteonecrosis with intraosseous pneumatosis after abdominal aortic aneurysm repair: a case of emphysematous osteomyelitis

Intraosseous pneumatosis is a rare and often fatal condition characterised by air accumulation in the bone that may be brought about by infection, trauma (surgical or otherwise), degenerative disease or neoplastic processes. Here, we present a case of pelvic emphysematous osteomyelitis following repair of an infected abdominal aortic aneurysm.

A 56-year-old Saudi male, known to have diabetes and hypertension, presented to the emergency department complaining of intermittent abdominal pain over the right lower quadrant. The patient was later diagnosed intraoperatively with an infected abdominal aortic aneurysm and treated appropriately. During multiple follow-up imaging studies, the patient was noted to have multiple intra-abdominal fluid collections, as well as intraosseous pneumatosis in the pelvis and right femur. 3 months later, intervention was again required due to patient deterioration and possible aortic graft leakage. Graft abscess was diagnosed and managed.

We present a case of an infected abdominal aortic aneurysm that eventually led to emphysematous osteomyelitis of the pelvis. This case report sheds light on intraosseous pneumatosis and emphysematous osteomyelitis, which is characterised by the former, in addition to signs of an underlying infection or abscess formation.

Gas forming infection of the spine: a systematic and narrative review

PURPOSE

Gas forming infection (GFI) of the spine is a rapidly progressive and potentially life-threatening infection. It can be a consequence of aetiologies such as Emphysematous Osteomyelitis (EOM), Necrotizing Fasciitis (NF), and Gas-containing Spinal Epidural Abscess (Gas-containing SEA). This review aims to summarize the characteristics of these subtypes of GFI, describing their aetiology, diagnosis, management, and prognosis.

METHODS

PubMed, Embase, Web of Science and the Cochrane Database were systematically searched for studies reporting on gas forming infections of the spine or a known subtype. Cases of post-operative and iatrogenic spinal infection were excluded.

RESULTS

The literature review revealed 35 studies reporting on 28 cases of EOM, three cases of NF involving the spine and seven cases of Gas-containing SEA. Thirty studies reporting on 32 cases of GFI were available for data analysis. The mean age of the patients was 60.9 years and a concomitant diagnosis of diabetes mellitus was reported in 57.5% of patients infected. Fever and back pain were the most common presenting symptoms. The lumbar spine was the most commonly affected spinal segment. Mortality from EOM, NF and Gas-containing SEA were 34.8, 100 and 28.5%, respectively.

DISCUSSION

Gas forming infection of the spine is a rare condition with an extremely poor prognosis, requiring early and aggressive surgical treatment. A multi-disciplinary approach is necessary for management. Nonetheless, even in cases of early recognition and optimal management, multisystem failure may still occur, and mortality rates remain high due to the aggressive nature of this infection.

LEVEL OF EVIDENCE

Systematic review of level IV studies.

Extensive multifocal emphysematous osteomyelitis: fatal outcome in a patient with psychiatric history

Emphysematous osteomyelitis is a rare entity with potentially devastating consequences, even after prompt and aggressive intervention. It is characterized by intraosseous gas and may be complicated by adjacent abscess formation. There are a handful of previously reported cases of emphysematous osteomyelitis, but none to the degree as reported here. Specifically, we report an extremely rare case of extensive multifocal emphysematous osteomyelitis involving both the axial and appendicular skeleton in a 20-year-old woman.

Emphysematous osteomyelitis of the clavicle: a pleural process?

Emphysematous osteomyelitis (EO) is a rare infection associated with intraosseous gas. EO is an often fatal disease with an estimated 34% mortality. We present a case of a 63-year-old man with sternoclavicular EO with pleural involvement and significant subcutaneous emphysema diagnosed by CT. Extension of intraosseous gas into the pleural cavity is an extremely interesting presentation that has not been previously reported. The patient underwent a multidisciplinary treatment approach with surgical debridement and an extended antibiotic course. Intraoperative cultures of the pectoralis muscle and bone biopsy grew pan-sensitive Escherichia coli Prompt recognition and treatment are paramount to avoid a potentially fatal outcome. A review of the literature of the previous 46 cases of EO is presented for associated risk factors, the role of surgical management and antibiotic therapy.

Emphysematous osteomyelitis of the spine: A rare case report

RATIONALE

Emphysematous osteomyelitis is a rare disease caused by gas-forming bacteria. But only 45 cases have been reported in the literature since then.

PATIENT CONCERNS

A 72-year-old female presented to our hospital with severe lower back pain that aggravated 4 days ago.

DIAGNOSES

Computed tomography (CT) revealed intraosseous mottled air in the T12 and L1 vertebral bodies and epidural space. The enhanced T1 and T2 magnetic resonance imaging scans showed heterogeneous signal intensity of vertebral bodies, suggestive of emphysematous osteomyelitis.

INTERVENTIONS

Surgery was performed to identify culture strains and to remove emphysematous lesions of the vertebral body using extensive transpedicular irrigation.

OUTCOMES

Escherichia coli (E coli) was identified in the surgical specimen, and intravenous antibiotic therapy was continued with cefotaxime. The patient had a significant decrease in lower back pain after the surgery and the final CT scan before discharge revealed significantly decreased air at T12 and L1 vertebral bodies and no air density in the epidural space.

LESSONS

We present a patient diagnosed with emphysematous osteomyelitis in vertebral bodies caused by E coli and successfully treated with surgical intervention.

Emphysematous osteomyelitis caused by Salmonella typhi in beta thalassemia major

There have been various cases of salmonella osteomyelitis reported in sickle cell anemia. We present a case of emphysematous osteomyelitis caused by Salmonella typhi in a 29-year-old beta thalassemia major patient. Diagnosis of emphysematous osteomyelitis was confirmed by computed tomography and magnetic resonance imaging, and culture of pus drained during surgical debridement confirmed the causative microorganism, Salmonella typhi. Antimicrobials were given according to microbiological sensitivity for a period of 8 weeks. Our patient also received hyperbaric oxygen therapy. At the end of therapy, he was afebrile and laboratory parameters normalized with a residual joint deformity which developed within 3 months.

Emphysematous Osteomyelitis of the Spine: A Case Report and Literature Review

Emphysematous osteomyelitis is a rare but potentially fatal infection. It is caused by gas-forming organisms and is characterized by the presence of intraosseous gas. A 75-year-old woman with untreated diabetes mellitus presented with difficulty in moving and anorexia. Laboratory studies revealed inflammation, a urinary infection, and diabetic ketoacidosis. Klebsiella pneumoniae was detected in both urine and blood cultures. Computed tomography and magnetic resonance imaging revealed emphysematous lesions in the paravertebral soft tissue, spinal canal, and iliopsoas muscle, with intraosseous gas at L1 and L2. These findings led to a diagnosis of emphysematous osteomyelitis. We herein review 35 reported cases of emphysematous osteomyelitis including our case.

Emphysematous osteomyelitis of the forefoot

Emphysematous osteomyelitis is a very rare, potentially fatal infection that requires immediate diagnosis and prompt treatment. Emphysematous osteomyelitis is usually considered whenever intraosseous gas is detected on imaging. Most organisms implicated in emphysematous osteomyelitis are members of the Enterobacteriaceae family or anaerobes; sometimes the infection is polymicrobial. We report a case of emphysematous osteomyelitis of the forefoot in a 33-year-old man with type 1 diabetes mellitus.

Emphysematous Osteomyelitis due to Escherichia coli

Emphysematous osteomyelitis, especially that involving the extra-axial skeleton, is an extremely rare presentation but associated with significant morbidity and mortality. Here, we report a case in which a 58-year-old female patient with diabetes mellitus presented with emphysematous osteomyelitis that involved the sternum, clavicle, and pelvic bone and was caused by Escherichia coli via hematogenous spread of urinary tract infection. We successfully treated her with urgent and aggressive surgical drainage with prolonged antibiotics therapy. Early diagnosis and immediate surgical intervention are required for better outcomes in cases of emphysematous osteomyelitis.

A case of emphysematous osteomyelitis of the midfoot: imaging findings and review of the literature

Emphysematous osteomyelitis is a rare but potentially fatal condition that must be considered whenever intraosseous gas is identified on imaging. The organisms implicated in most cases of emphysematous osteomyelitis are anaerobes or members of the Enterobacteriaceae family. Significant comorbidities, such as malignancy and diabetes mellitus, frequently predispose to this condition, and high mortality rates have been reported. The radiologist must be aware of the implications of identifying intraosseous gas in order to facilitate early diagnosis and expedite management. We report a unique case of a 58-year-old male with diabetes mellitus who presented with emphysematous osteomyelitis of the midfoot and necrotising fasciitis of the ipsilateral distal lower limb. Specimen cultures in this case revealed a pure growth of Group G Streptococcus.

The life-saving little tip: intraosseous gas

A case is presented of an-aerobic osteomyelitis with intraosseous gas resulting in the extension of gas in soft tissue structures in a patient with diabetes mellitus. The finding of intraosseous gas and its extension into the pubic joint and the left anterior abdominal wall is depicted. Intraosseous gas is a rare but worrying finding for osteomyelitis in the absence of a penetrative wound, recent surgery, biopsy or fracture.

Emphysematous osteomyelitis: a case report and review of the literature

We report the case of a 15-year-old girl with pelvic and sacral emphysematous osteomyelitis caused by Fusobacterium necrophorum. This infection was cured following four surgical procedures and 4 weeks of intravenous then 4 weeks of oral antibiotics. We review our case alongside the 24 previously reported cases of emphysematous osteomyelitis in the literature. The 25 cases include 15 monomicrobial and 10 polymicrobial infections. The causative organism(s) in all but three cases included an anaerobe or a member of the Enterobacteriaceae family. A significant underlying comorbidity was reported in 18 cases. At least 15 cases required one or more surgical procedures. There was a significant associated mortality with eight (32%) patients dying in hospital at 7 to 56 days after the diagnosis of emphysematous osteomyelitis.

A lethal form of Gorham disease associated with extensive musculoskeletal pneumatosis: case report and review of the literature

We report here the imaging findings of a rare case of a lethal form of Gorham disease in a young female patient. Multimodality imaging findings over 13 year-follow-up demonstrated progressive wide spread skeletal and soft tissue abnormalities with permeative osteolysis, pathological fractures and severe skeletal deformities. Unusual extensive osseous and soft tissue pneumatosis was illustrated on cross-sectional studies. The progressive nature of this form of Gorham disease and the subsequent complications eventually culminated in patient's death.