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Jardon M, Alaia EF. Approach to imaging modalities in the setting of suspected infection. Skeletal Radiol 2024; 53:1957-1968. [PMID: 37857751 DOI: 10.1007/s00256-023-04478-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/03/2023] [Accepted: 10/04/2023] [Indexed: 10/21/2023]
Abstract
Imaging plays an important role in the workup of musculoskeletal infection, in conjunction with clinical history and physical exam. There are multiple imaging modalities that can be of clinical utility in the setting of suspected infection, each with their own benefits and limitations. Radiography is a low-cost, accessible modality providing a broad osseous overview, but can be insensitive for early osteomyelitis. Ultrasound plays a more limited role in the workup of musculoskeletal infection, but can be useful in the pediatric population or for real-time guidance for joint and soft tissue aspirations. Computed tomography (CT) plays an important role in the timely and accurate diagnosis of critically ill patients in the emergency setting. Its superior soft tissue characterization allows for diagnosis of abscesses, and it can help confirm the clinical diagnosis of necrotizing fasciitis when soft tissue gas is present. Magnetic resonance imaging (MRI) is often the modality of choice in the diagnosis of infection, as its superior contrast resolution allows for clear delineation of the presence and extent of both soft tissue infection and osteomyelitis. Additionally, the use of intravenous contrast and advanced imaging sequences such as diffusion weighted imaging (DWI) further increases the diagnostic utility of MRI in the assessment for infection. Familiarity with the diagnostic utility of each imaging modality will allow the radiologist to appropriately guide imaging workup in the setting of clinically suspected infection.
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Affiliation(s)
- Meghan Jardon
- Department of Radiology, NYU Langone Medical Center, New York, NY, USA.
| | - Erin F Alaia
- Department of Radiology, NYU Langone Medical Center, New York, NY, USA
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Díez-Vidal A, Martínez-Martín P, González-Muñoz B, Tung-Chen Y. Point-of-care Ultrasound in Infectious Diseases: Current Insights and Future Perspectives. Clin Infect Dis 2024; 79:420-429. [PMID: 38769593 DOI: 10.1093/cid/ciae285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/09/2024] [Accepted: 05/18/2024] [Indexed: 05/22/2024] Open
Abstract
Point-of-care ultrasound (POCUS) is a safe, noninvasive technique performed at the patient's bedside, providing immediate results to the operator. It complements physical examination and facilitates clinical decision-making. In infectious diseases, POCUS is particularly valuable, offering an initial assessment in cases of suspected infection. It often leads to an early tentative diagnosis enabling the prompt initiation of antimicrobial treatment without the delay associated with traditional radiology. POCUS provides direct visualization of affected organs, assists in evaluating fluid balance, and facilitates various interventions, all while reducing patient discomfort. For infectious disease specialists, becoming proficient in POCUS is a critical future challenge, requiring dedicated training for effective utilization.
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Affiliation(s)
- Alejandro Díez-Vidal
- Infectious Diseases Unit, Internal Medicine Department, La Paz University Hospital, Madrid, Spain
- IdiPAZ Hospital La Paz Institute for Health Research, La Paz University Hospital, Madrid, Spain
| | - Patricia Martínez-Martín
- Infectious Diseases Unit, Internal Medicine Department, La Paz University Hospital, Madrid, Spain
- IdiPAZ Hospital La Paz Institute for Health Research, La Paz University Hospital, Madrid, Spain
- CIBERINFEC, Carlos III Health Institute, Madrid, Spain
| | - Borja González-Muñoz
- IdiPAZ Hospital La Paz Institute for Health Research, La Paz University Hospital, Madrid, Spain
- Internal Medicine Department, La Paz University Hospital, Madrid, Spain
| | - Yale Tung-Chen
- IdiPAZ Hospital La Paz Institute for Health Research, La Paz University Hospital, Madrid, Spain
- Internal Medicine Department, La Paz University Hospital, Madrid, Spain
- Department of Medicine, Alfonso X El Sabio University, Madrid, Spain
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Muralidharan Y, Subramonian SG, Jerosha S, Faizal A, Natarajan P. Extensive Emphysematous Osteomyelitis Attributed to Escherichia coli Infection: Radiological Insights and Detailed Case Report of a Rare Entity. Cureus 2024; 16:e66912. [PMID: 39280445 PMCID: PMC11399814 DOI: 10.7759/cureus.66912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2024] [Accepted: 08/12/2024] [Indexed: 09/18/2024] Open
Abstract
Emphysematous osteomyelitis (EO) is a rare and severe bone infection characterized by the presence of gas within the bone and surrounding soft tissues, commonly caused by gas-forming bacteria. We present a case of an elderly patient with extensive EO due to Escherichia coli infection. The patient exhibited systemic signs of infection and severe localized pain. Radiological assessments, including computed tomography and magnetic resonance imaging, demonstrated significant gas accumulation within the bone and adjacent tissues, confirming the diagnosis. Despite intensive antibiotic treatment and surgical intervention, the patient's condition initially worsened, highlighting the high morbidity and mortality associated with this infection. However, through prompt action and targeted intervention, a positive outcome was ultimately achieved. This case emphasizes the critical need for early diagnosis and aggressive management of EO to improve patient outcomes.
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Affiliation(s)
- Yuvaraj Muralidharan
- Radiodiagnosis, Saveetha Medical College and Hospital, Saveetha Institute of Medical and Technical Sciences (SIMATS) Saveetha University, Chennai, IND
| | - Sakthi Ganesh Subramonian
- Radiodiagnosis, Saveetha Medical College and Hospital, Saveetha Institute of Medical and Technical Sciences (SIMATS) Saveetha University, Chennai, IND
| | - Stany Jerosha
- Radiodiagnosis, Saveetha Medical College and Hospital, Saveetha Institute of Medical and Technical Sciences (SIMATS) Saveetha University, Chennai, IND
| | - Afwaan Faizal
- Radiodiagnosis, Saveetha Medical College and Hospital, Saveetha Institute of Medical and Technical Sciences (SIMATS) Saveetha University, Chennai, IND
| | - Paarthipan Natarajan
- Radiodiagnosis, Saveetha Medical College and Hospital, Saveetha Institute of Medical and Technical Sciences (SIMATS) Saveetha University, Chennai, IND
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Shi X, Li M, Ni H, Wu Y, Li Y, Chen X, Xu Y. Integrative gene expression analysis and animal model reveal immune- and autophagy-related biomarkers in osteomyelitis. Immun Inflamm Dis 2024; 12:e1339. [PMID: 38990187 PMCID: PMC11238574 DOI: 10.1002/iid3.1339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 04/26/2024] [Accepted: 06/29/2024] [Indexed: 07/12/2024] Open
Abstract
BACKGROUND Osteomyelitis (OM) is recognized as a significant challenge in orthopedics due to its complex immune and inflammatory responses. The prognosis heavily depends on timely diagnosis, accurate classification, and assessment of severity. Thus, the identification of diagnostic and classification-related genes from an immunological standpoint is crucial for the early detection and tailored treatment of OM. METHODS Transcriptomic data for OM was sourced from the Gene Expression Omnibus (GEO) database, leading to the identification of autophagy- and immune-related differentially expressed genes (AIR-DEGs) through differential expression analysis. Diagnostic and classification models were subsequently developed. The CIBERSORT algorithm was utilized to examine immune cell infiltration in OM, and the relationship between OM clusters and various immune cells was explored. Key AIR-DEGs were further validated through the creation of OM animal models. RESULTS Analysis of the transcriptomic data revealed three AIR-DEGs that played a significant role in immune responses and pathways. Nomogram and receiver operating characteristic curve analyses were performed, demonstrating excellent diagnostic capability for differentiating between OM patients and healthy individuals, with an area under the curve of 0.814. An unsupervised clustering analysis discerned two unique patterns of autophagy- and immune-related genes, as well as gene patterns. Further exploration into immune infiltration exhibited notable variances across different subtypes, especially between OM cluster 1 and gene cluster A, highlighting their potential role in mitigating inflammatory responses by regulating immune activities. Moreover, the mRNA and protein expression levels of three AIR-DEGs in the animal model were aligned with those in the training and validation data sets. CONCLUSIONS From an immunological perspective, a diagnostic model was successfully developed, and two distinct clustering patterns were identified. These contributions offer a significant resource for the early detection and personalized immunotherapy of patients with OM.
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Affiliation(s)
- Xiangwen Shi
- Kunming Medical University, Kunming, China
- Laboratory of Yunnan Traumatology and Orthopedics Clinical Medical Center, Yunnan Orthopedics and Sports Rehabilitation Clinical Medical Research Center, Kunming, China
- Department of Orthopedic Surgery, 920th Hospital of Joint Logistics Support Force of PLA, Kunming, Yunnan, China
| | - Mingjun Li
- Laboratory of Yunnan Traumatology and Orthopedics Clinical Medical Center, Yunnan Orthopedics and Sports Rehabilitation Clinical Medical Research Center, Kunming, China
- Department of Orthopedic Surgery, 920th Hospital of Joint Logistics Support Force of PLA, Kunming, Yunnan, China
| | - Haonan Ni
- Orthopedic Department, First People's Hospital of Huzhou, First Affiliated Hospital of Huzhou University, Huzhou, China
| | - Yipeng Wu
- Kunming Medical University, Kunming, China
- Laboratory of Yunnan Traumatology and Orthopedics Clinical Medical Center, Yunnan Orthopedics and Sports Rehabilitation Clinical Medical Research Center, Kunming, China
- Department of Orthopedic Surgery, 920th Hospital of Joint Logistics Support Force of PLA, Kunming, Yunnan, China
| | - Yang Li
- Laboratory of Yunnan Traumatology and Orthopedics Clinical Medical Center, Yunnan Orthopedics and Sports Rehabilitation Clinical Medical Research Center, Kunming, China
- Department of Orthopedic Surgery, 920th Hospital of Joint Logistics Support Force of PLA, Kunming, Yunnan, China
| | - Xianjun Chen
- Department of Neurosurgery, Nanping First Hospital Affiliated to Fujian Medical University, Nanping, Fujian, China
| | - Yongqing Xu
- Laboratory of Yunnan Traumatology and Orthopedics Clinical Medical Center, Yunnan Orthopedics and Sports Rehabilitation Clinical Medical Research Center, Kunming, China
- Department of Orthopedic Surgery, 920th Hospital of Joint Logistics Support Force of PLA, Kunming, Yunnan, China
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Mokoala KMG, Ndlovu H, Lawal I, Sathekge MM. PET/CT and SPECT/CT for Infection in Joints and Bones: An Overview and Future Directions. Semin Nucl Med 2024; 54:394-408. [PMID: 38016897 DOI: 10.1053/j.semnuclmed.2023.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 10/30/2023] [Indexed: 11/30/2023]
Abstract
Infections of the bones and joints, if misdiagnosed, may result in serious morbidity and even mortality. A prompt diagnosis followed by appropriate management may reduce the socioeconomic impact of bone and joint infections. Morphologic imaging such as ultrasound and plain radiographs form the first line investigations, however, in early infections findings may be negative or nonspecific. Nuclear medicine imaging techniques play a complementary role to morphologic imaging in the diagnosis of bone and joint infections. The availability of hybrid systems (SPECT/CT, SPECT/MRI, PET/CT or PET/MRI) offers improved specificity with ability to assess the extent of infection. Bone scans are useful as a gatekeeper wherein negative scans rule out sepsis with a good accuracy, however positive scans are nondiagnostic and more specific tracers should be considered. These include the use of labeled white blood cells and antigranulocyte antibodies. Various qualitative and quantitative interpretation criteria have been suggested to improve the specificity of the scans. PET has better image resolution and 18F-FDG is the major tracer for PET imaging with applications in oncology and inflammatory/infective disorders. It has demonstrated improved sensitivity over the SPECT based tracers, however, still suffers from lack of specificity. 18F-FDG PET has been used to monitor therapy in bone and joint infections. Other less studied, noncommercialized SPECT and PET tracers such as 111In-Biotin, 99mTc-Ubiquicidin, 18F-Na-Fluoride, 18F-labeled white blood cells and 124I-Fialuridine to name a few have shown great promise, however, their role in various bone and joint infections has not been established. Hybrid imaging with PET or PET/MRI offers huge potential for improving diagnostics in infections of the joints and bones.
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Affiliation(s)
- Kgomotso M G Mokoala
- University of Pretoria, Pretoria, Gauteng, South Africa; Nuclear Medicine Research Infrastructure (NuMeRI), Pretoria, Gauteng, South Africa
| | - Honest Ndlovu
- Nuclear Medicine Research Infrastructure (NuMeRI), Pretoria, Gauteng, South Africa
| | - Ismaheel Lawal
- University of Pretoria, Pretoria, Gauteng, South Africa; Emory University, Atlanta, Georgia, United States
| | - Mike Machaba Sathekge
- University of Pretoria, Pretoria, Gauteng, South Africa; Nuclear Medicine Research Infrastructure (NuMeRI), Pretoria, Gauteng, South Africa.
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Yu S, Lee S. Recurrent skin opening induced by chronic sternal osteomyelitis caused by a bite wound in a cat: A case report. Vet Med Sci 2024; 10:e1425. [PMID: 38563757 PMCID: PMC10986631 DOI: 10.1002/vms3.1425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 02/07/2024] [Accepted: 03/10/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Chronic sternal osteomyelitis is a rare condition in felines, with limited reported cases to date. OBJECTIVES We report the case of a 2-year-old castrated male, domestic shorthair cat, weighing 4.68 kg, that presented with skin openings every 3-4 months, despite skin debridement and reconstruction. METHODS A subcutaneous dead space larger than the skin defect was detected. Haematological analysis revealed elevated levels of inflammatory markers. Thoracic radiography revealed sternal deformation and suspected osteomyelitis. Computed tomography revealed a fistula extending from the third to the fourth sternebrae. RESULTS Bone and soft tissue debridement and abscess flushing were performed along with long-term antibiotic therapy. The cat remained recurrence-free throughout an 18-month post-surgery follow-up period. CONCLUSION To the best of our knowledge, this is the first report of chronic osteomyelitis occurring in a cat's sternebrae and represents the first successful case of its treatment. This case showcases the potential for improved treatment outcomes in similar cases. Understanding and successful treatment of such cases can pave the way for better management of feline osteomyelitis.
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Affiliation(s)
- Seung‐yeon Yu
- Department of Veterinary SurgeryCollege of Veterinary MedicineChungbuk National UniversityCheongjuRepublic of Korea
| | - Sungin Lee
- Department of Veterinary SurgeryCollege of Veterinary MedicineChungbuk National UniversityCheongjuRepublic of Korea
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Park SB, Lim CH, Chun DI, Kim YJ, Kim TH, Park JM. The usefulness of quantitative 99mTc-HMPAO WBC SPECT/CT for predicting lower extremity amputation in diabetic foot infection. Sci Rep 2024; 14:9260. [PMID: 38649465 PMCID: PMC11035640 DOI: 10.1038/s41598-024-59764-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/15/2024] [Indexed: 04/25/2024] Open
Abstract
We investigated the usefulness of quantitative 99mTc-white blood cell (WBC) single photon emission computed tomography (SPECT)/computed tomography (CT) for predicting lower extremity amputation in diabetic foot infection (DFI). A total of 93 feet of 83 consecutive patients with DFI who underwent WBC SPECT/CT for treatment planning were retrospectively analysed. The clinical and SPECT/CT parameters were collected along with the measurements of the maximum standardized uptake value (SUVmax) at DFI. Statistical logistic regression analysis was performed to explore the predictors of LEA and receiver operating characteristic (ROC) curve was analysed to assess the predictive value of SPECT/CT. The independent predictors of amputation were previous amputation (OR 11.9), numbers of SPECT/CT lesions (OR 2.1), and SUVmax of DFI; either continuous SUVmax (1-increase) (OR 1.3) or categorical SUVmax > 1.1 (OR 21.6). However, the conventional SPECT/CT interpretation failed to predict amputation. In ROC analysis, the SUVmax yielded a fair predictor (area under the curve (AUC) 0.782) of amputation. The model developed from these independent predictors yielded an excellent performance for predicting amputation (AUC 0.873). Quantitative WBC SPECT/CT can provide new information useful for predicting the outcomes and guiding treatment for patients with DFI.
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Affiliation(s)
- Soo Bin Park
- Department of Nuclear Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Chae Hong Lim
- Department of Nuclear Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Dong-Il Chun
- Department of Orthopedic Surgery, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Yong Jae Kim
- Department of Radiology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Tae Hyong Kim
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Jung Mi Park
- Department of Nuclear Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Gyeonggi, Republic of Korea.
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Shihabul Hassan M, Stevenson J, Gandikota G, Veeratterapillay A, Bhamidipaty K, Botchu R. Current updates in MSK infection imaging: A narrative review. J Clin Orthop Trauma 2024; 51:102396. [PMID: 38585385 PMCID: PMC10998214 DOI: 10.1016/j.jcot.2024.102396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/28/2024] [Accepted: 03/18/2024] [Indexed: 04/09/2024] Open
Abstract
This article presents a comprehensive overview of the diagnostic utility of existing imaging techniques including radiography, computed tomography, ultrasonography, magnetic resonance imaging (MRI), and radionuclide imaging in the context of the most common orthopaedic or musculoskeletal infections. It also includes illustrative images showcasing significant findings in various musculoskeletal infections including osteomyelitis, cellulitis, septic arthritis, necrotising infections and peri-prosthetic joint infections and their associated complications.
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Affiliation(s)
- M. Shihabul Hassan
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - J. Stevenson
- Department of Orthopedics, Royal Orthopedic Hospital, Birmingham, UK
| | - G. Gandikota
- Department of Radiology, University of North Carolina, USA
| | | | | | - R. Botchu
- Department of Musculoskeletal Radiology, Royal Orthopedic Hospital, Birmingham, UK
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Ren SQ, Ma Y, Fu LL, Hu KZ, Liang HR, Yu B, Tang GH. A comparative 18F-FDG and an anti-PD-L1 probe PET/CT imaging of implant-associated Staphylococcus aureus osteomyelitis. Front Cell Infect Microbiol 2023; 13:1182480. [PMID: 37293208 PMCID: PMC10244720 DOI: 10.3389/fcimb.2023.1182480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/11/2023] [Indexed: 06/10/2023] Open
Abstract
Background Early and accurate diagnosis of infection-induced osteomyelitis, which often involves increased PD-L1 expression, is crucial for better treatment outcomes. Radiolabeled anti-PD-L1 nuclear imaging allows for sensitive and non-invasive whole-body assessments of PD-L1 expression. This study aimed to compare the efficacy of 18F-FDG and an 18F-labeled PD-L1-binding peptide probe (18F-PD-L1P) in PET imaging of implant-associated Staphylococcus aureus osteomyelitis (IAOM). Methods In this study, we synthesized an anti-PD-L1 probe and compared its efficacy with 18F-FDG and 18F-PD-L1P in PET imaging of implant-associated Staphylococcus aureus osteomyelitis (IAOM). The %ID/g ratios (i.e., radioactivity ratios between the infected and non-infected sides) of both probes were evaluated for sensitivity and accuracy in post-infected 7-day tibias and post-infected 21 days, and the intensity of 18F-PD-L1P uptake was compared with pathological changes measured by PD-L1 immunohistochemistry (IHC). Results Compared with 18F-FDG, 18F-PDL1P demonstrated higher %ID/g ratios for both post-infected 7-day tibias (P=0.001) and post-infected 21 days (P=0.028). The intensity of 18F-PD-L1P uptake reflected the pathological changes of osteomyelitic bones. In comparison to 18F-FDG, 18F-PDL1P provides earlier and more sensitive detection of osteomyelitis caused by S. aureus. Conclusion Our findings suggest that the 18F-PDL1P probe is a promising tool for the early and accurate detection of osteomyelitis caused by S. aureus.
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Affiliation(s)
- Shu-Qi Ren
- GuangDong Medical Products Administration (GDMPA) Key Laboratory for Quality Control and Evaluation of Radiopharmaceuticals, Department of Nuclear Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yuan Ma
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Division of Orthopedics and Traumatology, Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Li-Lan Fu
- GuangDong Medical Products Administration (GDMPA) Key Laboratory for Quality Control and Evaluation of Radiopharmaceuticals, Department of Nuclear Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Kong-Zhen Hu
- GuangDong Medical Products Administration (GDMPA) Key Laboratory for Quality Control and Evaluation of Radiopharmaceuticals, Department of Nuclear Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hao-Ran Liang
- GuangDong Medical Products Administration (GDMPA) Key Laboratory for Quality Control and Evaluation of Radiopharmaceuticals, Department of Nuclear Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Bin Yu
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Division of Orthopedics and Traumatology, Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Gang-Hua Tang
- GuangDong Medical Products Administration (GDMPA) Key Laboratory for Quality Control and Evaluation of Radiopharmaceuticals, Department of Nuclear Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Theologis T, Brady MA, Hartshorn S, Faust SN, Offiah AC. Diagnosing acute bone and joint infection in children. Bone Joint J 2023; 105-B:227-229. [PMID: 36876449 DOI: 10.1302/0301-620x.105b3.bjj-2022-1179.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Acute bone and joint infections in children are serious, and misdiagnosis can threaten limb and life. Most young children who present acutely with pain, limping, and/or loss of function have transient synovitis, which will resolve spontaneously within a few days. A minority will have a bone or joint infection. Clinicians are faced with a diagnostic challenge: children with transient synovitis can safely be sent home, but children with bone and joint infection require urgent treatment to avoid complications. Clinicians often respond to this challenge by using a series of rudimentary decision support tools, based on clinical, haematological, and biochemical parameters, to differentiate childhood osteoarticular infection from other diagnoses. However, these tools were developed without methodological expertise in diagnostic accuracy and do not consider the importance of imaging (ultrasound scan and MRI). There is wide variation in clinical practice with regard to the indications, choice, sequence, and timing of imaging. This variation is most likely due to the lack of evidence concerning the role of imaging in acute bone and joint infection in children. We describe the first steps of a large UK multicentre study, funded by the National Institute for Health Research, which seeks to integrate definitively the role of imaging into a decision support tool, developed with the assistance of individuals with expertise in the development of clinical prediction tools.
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Affiliation(s)
- Tim Theologis
- Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK
| | - Mariea A Brady
- St Helens and Knowsley NHS Teaching Hospital Trust, Whiston Hospital, Liverpool, UK
| | | | - Saul N Faust
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Amaka C Offiah
- Paediatric Musculoskeletal Imaging, Department of Oncology & Metabolism, The University of Sheffield, Sheffield, UK
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Osteomyelitis of the Lower Limb: Diagnostic Accuracy of Dual-Energy CT versus MRI. Diagnostics (Basel) 2023; 13:diagnostics13040703. [PMID: 36832191 PMCID: PMC9955987 DOI: 10.3390/diagnostics13040703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND MRI is the preferred imaging technique for the identification of osteomyelitis. The key element for diagnosis is the presence of bone marrow edema (BME). Dual-energy CT (DECT) is an alternative tool which is able to identify BME in the lower limb. PURPOSE To compare the diagnostic performance of DECT and MRI for osteomyelitis, using clinical, microbiological, and imaging data as reference standards. MATERIALS AND METHODS This prospective single-center study enrolled consecutive patients with suspected bone infections undergoing DECT and MRI imaging from December 2020 to June 2022. Four blinded radiologists with various experience levels (range of 3-21 years) evaluated the imaging findings. Osteomyelitis was diagnosed in the presence of BMEs, abscesses, sinus tracts, bone reabsorption, or gaseous elements. The sensitivity, specificity, and AUC values of each method were determined and compared using a multi-reader multi-case analysis. A p value < 0.05 was considered significant. RESULTS In total, 44 study participants (mean age 62.5 years ± 16.5 [SD], 32 men) were evaluated. Osteomyelitis was diagnosed in 32 participants. For the MRI, the mean sensitivity and specificity were 89.1% and 87.5%, while for the DECT they were 89.0% and 72.9%, respectively. The DECT demonstrated a good diagnostic performance (AUC = 0.88), compared with the MRI (AUC = 0.92) (p = 0.12). When considering each imaging finding alone, the best accuracy was achieved by considering BME (AUC for DECT 0.85 versus AUC of MRI of 0.93, with p = 0.07), followed by the presence of bone erosions (AUC 0.77 for DECT and 0.53 for MRI, with p = 0.02). The inter-reader agreement of the DECT (k = 88) was similar to that of the MRI (k = 90). CONCLUSION Dual-energy CT demonstrated a good diagnostic performance in detecting osteomyelitis.
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Abstract
BACKGROUND Hematogenous osteomyelitis has increased over the past quarter century in frequency, virulence, and degree of soft-tissue involvement, bringing about changes in clinical manifestations and management of the disease especially in children that should be reflected in the current imaging approach. Likewise, the global disease burden of diabetes has increased greatly in the same period, compounding the problem of ascertaining osteomyelitis in diabetic foot. METHOD This article provides an updated overview of imaging findings in hematogenous and contiguous osteomyelitis based on the literature and our institutional experience, along with salient features of recent recommendations from expert groups on the diagnostic algorithms and reporting terminology. RESULTS AND CONCLUSION Findings on radiography and especially magnetic resonance imaging (MRI) closely reflect pathophysiology in osteomyelitis, whereby the characteristic involvement of the metaphysis or metaphyseal-equivalents, the formation and subperiosteal extension of intramedullary pus collection, and the development of cloaca, sequestrum, and involucrum are all diagnostic clues. Non-enhancing foci within the medullary bone, the penumbra sign, intra- or extramedullary fat globules, and surrounding soft tissue inflammation or abscesses are among key MRI findings. Diabetic foot is a special condition with characteristic pathophysiologic and imaging features that suggest the likelihood of osteomyelitis and the main differential diagnostic consideration of acute on chronic neuropathic osteoarthropathy with or without osteomyelitis. KEY POINTS · Imaging closely reflects pathophysiology in hematogenous osteomyelitis.. · Acute hematogenous osteomyelitis predominantly involves metaphyses and metaphyseal equivalent sites.. · MRI clues for hematogenous osteomyelitis include central marrow non-enhancement, intra- or extramedullary fat globules, and the "penumbra" sign.. · An increased fluid-sensitive MRI bone signal abutting a soft tissue ulcer, abscess, or sinus tract suggests a high probability of contact osteomyelitis.. CITATION FORMAT · Aydingoz U, Imaging Osteomyelitis: An Update. Fortschr Röntgenstr 2023; DOI: 10.1055/a-1949-7641.
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Affiliation(s)
- Ustun Aydingoz
- Department of Radiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Zardi EM, Chello M, Zardi DM, Barbato R, Giacinto O, Mastroianni C, Lusini M. Nosocomial Extracardiac Infections After Cardiac Surgery. Curr Infect Dis Rep 2022; 24:159-171. [PMID: 36187899 PMCID: PMC9510267 DOI: 10.1007/s11908-022-00787-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2022] [Indexed: 12/02/2022]
Abstract
Purpose of Review Nosocomial extracardiac infections after cardiac surgery are a major public health issue affecting 3–8.2% of patients within 30–60 days following the intervention. Recent Findings Here, we have considered the most important postoperative infective complications that, in order of frequency, are pneumonia, surgical site infection, urinary tract infection, and bloodstream infection. The overall picture that emerges shows that they cause a greater perioperative morbidity and mortality with a longer hospitalization time and excess costs. Preventive interventions and corrective measures, diminishing the burden of nosocomial extracardiac infections, may reduce the global costs. A multidisciplinary team may assure a more appropriate management of nosocomial extracardiac infections leading to a reduction of hospitalization time and mortality rate. Summary The main and most current data on epidemiology, prevention, microbiology, diagnosis, and management for each one of the most important postoperative infective complications are reported. The establishment of an antimicrobial stewardship in each hospital seems to be, at the moment, the more valid strategy to counteract the challenging problems.
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Affiliation(s)
- Enrico Maria Zardi
- Internistic Ultrasound Service, Department of Medicine and Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Álvaro del Portillo 200, 00128 Rome, Italy
| | - Massimo Chello
- Unit of Cardiovascular Surgery, Department of Medicine and Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Álvaro del Portillo 200, 00128 Rome, Italy
| | - Domenico Maria Zardi
- Interventional Cardiology Unit, Castelli Hospital (NOC), RM 00040 Ariccia, Italy
| | - Raffaele Barbato
- Unit of Cardiovascular Surgery, Department of Medicine and Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Álvaro del Portillo 200, 00128 Rome, Italy
| | - Omar Giacinto
- Unit of Cardiovascular Surgery, Department of Medicine and Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Álvaro del Portillo 200, 00128 Rome, Italy
| | - Ciro Mastroianni
- Unit of Cardiovascular Surgery, Department of Medicine and Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Álvaro del Portillo 200, 00128 Rome, Italy
| | - Mario Lusini
- Unit of Cardiovascular Surgery, Department of Medicine and Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Álvaro del Portillo 200, 00128 Rome, Italy
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Maxillary Fungal Osteomyelitis Mimicking and Treated as Endodontic Pathosis. Case Rep Dent 2022; 2022:1976352. [PMID: 35846181 PMCID: PMC9287005 DOI: 10.1155/2022/1976352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/01/2022] [Accepted: 06/27/2022] [Indexed: 12/02/2022] Open
Abstract
Fungal osteomyelitis is a lethal opportunistic infection that affects only a small percentage of patients present to endodontists. It is a highly contagious infection that requires urgent treatment. We discuss three cases in which endodontic pathology was initially recognized but subsequent follow-up revealed severe osteolytic fungal infection of the maxilla manifesting as acute apical abscesses in the maxillary canine region. CBCT demonstrated osteolytic abnormalities, and further histology confirmed the illness was caused by mucormycosis in patients with uncontrolled diabetes mellitus and exposure to COVID-19.
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15
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Systematic review: investigating the added diagnostic value of gadolinium contrast agents for osteomyelitis in the appendicular skeleton. Skeletal Radiol 2022; 51:1285-1296. [PMID: 34643771 DOI: 10.1007/s00256-021-03915-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 09/13/2021] [Accepted: 09/17/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Osteomyelitis is an infection of the bone marrow. MRI with gadolinium-based contrast is frequently performed for cases of suspected osteomyelitis. The objective of this systematic review is to examine the diagnostic accuracy of contrast-enhanced vs non-contrast-enhanced MRI for osteomyelitis in the appendicular skeleton. MATERIALS AND METHODS We conducted a systematic review of MRI in the diagnosis of osteomyelitis by searching MEDLINE and EMBASE from January 2000 to March 2020. There were 21 studies that met the inclusion criteria for the systematic review for a total of 1095 patients. Analytic methods were based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Evidence was evaluated using the STARD criteria for evaluation of completeness and transparency of reporting. RESULTS For diagnosing osteomyelitis in the appendicular skeleton, MRI with gadolinium-based contrast has 89% sensitivity (95% CI, 86-92%), 79% specificity (95% CI, 75-83%), and 90% overall diagnostic accuracy ([SE] = 0.03). For diagnosing osteomyelitis in the appendicular skeleton, MRI without gadolinium-based contrast has a 92% sensitivity (95% CI, 87-96%), 89% specificity (95% CI, 84-93%), and 96% overall diagnostic accuracy ([SE] = 0.03). The median score of included studies was 85% utilizing the STARD criteria with excellent interobserver agreement of 83.4%. Limitations included small sample size of studies, with retrospective designs. CONCLUSION No evidence was found to suggest an added diagnostic value of gadolinium contrast for the diagnosis of osteomyelitis in the appendicular skeleton. For routine cases of suspected non-spinal osteomyelitis, non-contrast MRI of the area of interest is the next most appropriate study after radiographs.
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16
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Ibrahim A, Berkache M, Morency-Potvin P, Juneau D, Koenig M, Bourduas K, Freire V. Diabetic foot infections: how to investigate more efficiently? A retrospective study in a quaternary university center. Insights Imaging 2022; 13:88. [PMID: 35536462 PMCID: PMC9086415 DOI: 10.1186/s13244-022-01228-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 04/20/2022] [Indexed: 11/10/2022] Open
Abstract
Background Diabetic foot infections are frequent and associated with substantial morbidity and substantial cost to the healthcare system. Up to 34% of diabetic patients will develop an ulcer potentially leading to osteomyelitis. Imaging plays a crucial role in the diagnostic process. Imaging modalities to investigate the diabetic foot infection are many and imaging prescription habits remain heterogeneous across physicians. We aimed to improve the appropriateness of imaging examination requested, and performed, for diabetic foot osteomyelitis and we aimed to reduce the overall imaging-related cost. Methods Local committee was created to develop an algorithm for suspected diabetic foot osteomyelitis. Best practices were defined by the local algorithm. The algorithm was shared with our physicians. Pre- and post-intervention analysis was conducted retrospectively. All adult diabetic patients with suspected foot osteomyelitis were included. Adherence to best practices was measured. Statistical analysis with Chi-Square and two tailed unpaired t-test was performed. Results Pre-intervention cohort had 223 patients (mean age: 63; 168 men). Adherence to best practice was 43%. Scintigraphy (48%) preferred over MRI (44%) and performed simultaneously in 15 patients. Post-intervention cohort had 73 patients (mean age: 66; 62 men). Adherence to best practice was 78%, improved by 35% (p < 0.001). MRI (51%) preferred over scintigraphy (23%) and performed simultaneously in three patients. Scintigraphy examinations decreased by 25% (p < 0.001). MRI examinations increased by 7% (p = 0.32). Hospital imaging related fees decreased by 22% per patient (p = 0.002). Conclusion Interval improvement in adequate adherence while reducing unnecessary examinations for patients and decreasing costs for the healthcare system was observed.
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Affiliation(s)
- Aisin Ibrahim
- Department of Diagnostic Radiology, McGill University, 1650 Cedar Avenue (Rm C5-118), Montreal, QC, H3G 1A4, Canada.
| | - Moncef Berkache
- Faculty of Medicine, Laval University, 1050 Avenue de la Médecine, Quebec, QC, G1V 0A6, Canada
| | - Philippe Morency-Potvin
- Department of Microbiology and Infectious Disease, Centre hospitalier de L'Université de Montréal, 1051 Rue Sanguinet, QC, H2X 3E4, Montreal, Canada
| | - Daniel Juneau
- Department of Nuclear Medicine, Centre hospitalier de L'Université de Montréal, 1051 Rue Sanguinet, QC, H2X 3E4, Montreal, Canada
| | - Martial Koenig
- Department of Internal Medecine, Centre hospitalier de L'Université de Montréal, 1051 Rue Sanguinet, QC, H2X 3E4, Montreal, Canada
| | - Karine Bourduas
- Department of Surgery, Orthopedics Division, Centre hospitalier de L'Université de Montréal, 1051 Rue Sanguinet, QC, H2X 3E4, Montreal, Canada
| | - Véronique Freire
- Department of Diagnostic Radiology, Centre hospitalier de L'Université de Montréal, 1051 Rue Sanguinet, QC, H2X 3E4, Montreal, Canada
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Spellberg B, Aggrey G, Brennan MB, Footer B, Forrest G, Hamilton F, Minejima E, Moore J, Ahn J, Angarone M, Centor RM, Cherabuddi K, Curran J, Davar K, Davis J, Dong MQ, Ghanem B, Hutcheon D, Jent P, Kang M, Lee R, McDonald EG, Morris AM, Reece R, Schwartz IS, So M, Tong S, Tucker C, Wald-Dickler N, Weinstein EJ, Williams R, Yen C, Zhou S, Lee TC. Use of Novel Strategies to Develop Guidelines for Management of Pyogenic Osteomyelitis in Adults: A WikiGuidelines Group Consensus Statement. JAMA Netw Open 2022; 5:e2211321. [PMID: 35536578 PMCID: PMC9092201 DOI: 10.1001/jamanetworkopen.2022.11321] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE Traditional approaches to practice guidelines frequently result in dissociation between strength of recommendation and quality of evidence. OBJECTIVE To construct a clinical guideline for pyogenic osteomyelitis management, with a new standard of evidence to resolve the gap between strength of recommendation and quality of evidence, through the use of a novel open access approach utilizing social media tools. EVIDENCE REVIEW This consensus statement and systematic review study used a novel approach from the WikiGuidelines Group, an open access collaborative research project, to construct clinical guidelines for pyogenic osteomyelitis. In June 2021 and February 2022, authors recruited via social media conducted multiple PubMed literature searches, including all years and languages, regarding osteomyelitis management; criteria for article quality and inclusion were specified in the group's charter. The GRADE system for evaluating evidence was not used based on previously published concerns regarding the potential dissociation between strength of recommendation and quality of evidence. Instead, the charter required that clear recommendations be made only when reproducible, prospective, controlled studies provided hypothesis-confirming evidence. In the absence of such data, clinical reviews were drafted to discuss pros and cons of care choices. Both clear recommendations and clinical reviews were planned with the intention to be regularly updated as new data become available. FINDINGS Sixty-three participants with diverse expertise from 8 countries developed the group's charter and its first guideline on pyogenic osteomyelitis. These participants included both nonacademic and academic physicians and pharmacists specializing in general internal medicine or hospital medicine, infectious diseases, orthopedic surgery, pharmacology, and medical microbiology. Of the 7 questions addressed in the guideline, 2 clear recommendations were offered for the use of oral antibiotic therapy and the duration of therapy. In addition, 5 clinical reviews were authored addressing diagnosis, approaches to osteomyelitis underlying a pressure ulcer, timing for the administration of empirical therapy, specific antimicrobial options (including empirical regimens, use of antimicrobials targeting resistant pathogens, the role of bone penetration, and the use of rifampin as adjunctive therapy), and the role of biomarkers and imaging to assess responses to therapy. CONCLUSIONS AND RELEVANCE The WikiGuidelines approach offers a novel methodology for clinical guideline development that precludes recommendations based on low-quality data or opinion. The primary limitation is the need for more rigorous clinical investigations, enabling additional clear recommendations for clinical questions currently unresolved by high-quality data.
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Affiliation(s)
- Brad Spellberg
- Los Angeles County+University of Southern California (USC) Medical Center, Los Angeles
| | - Gloria Aggrey
- Montgomery Medical Associates PC, Rockville, Maryland
| | - Meghan B. Brennan
- University of Wisconsin Hospital and Clinics, William S. Middleton Memorial Veterans Hospital, Madison
| | - Brent Footer
- Providence Portland Medical Center, Portland, Oregon
| | | | | | - Emi Minejima
- Los Angeles County+University of Southern California (USC) Medical Center, Los Angeles
- Department of Clinical Pharmacy, University of Southern California School of Pharmacy, Los Angeles
| | - Jessica Moore
- Providence Little Company of Mary Medical Center, San Pedro, California
| | - Jaimo Ahn
- Department of Orthopaedic Surgery, Michigan Medicine, University of Michigan, Ann Arbor
| | | | - Robert M. Centor
- Department of Medicine, Birmingham Veterans Affairs (VA) Medical Center, Birmingham, Alabama
| | | | - Jennifer Curran
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, Ann Arbor
| | - Kusha Davar
- Los Angeles County+University of Southern California (USC) Medical Center, Los Angeles
| | - Joshua Davis
- Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Mei Qin Dong
- New York Health and Hospitals Bellevue Hospital, New York, New York
| | | | - Doug Hutcheon
- Los Angeles County+University of Southern California (USC) Medical Center, Los Angeles
| | - Philipp Jent
- Department of Infectious Diseases, Inselspital Bern University Hospital, Bern, Switzerland
| | - Minji Kang
- University of Texas Southwestern, Dallas
| | - Rachael Lee
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham
| | - Emily G. McDonald
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal, Canada
| | - Andrew M. Morris
- Department of Medicine, Division of Infectious Diseases, Sinai Health, University Health Network, and University of Toronto, Toronto, Canada
| | - Rebecca Reece
- Section of Infectious Diseases, Department of Medicine, West Virginia University School of Medicine, Morgantown
| | - Ilan S. Schwartz
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Miranda So
- Sinai Health System-University Health Network Antimicrobial Stewardship Program, UHN and Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Steven Tong
- Victorian Infectious Diseases Service, Royal Melbourne Hospital and University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Christopher Tucker
- Hospital Medicine, Magnolia Regional Health Center, Corinth, Mississippi
| | - Noah Wald-Dickler
- Los Angeles County+University of Southern California (USC) Medical Center, Los Angeles
| | - Erica J. Weinstein
- Division of Infectious Diseases, Department of Medicine and Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Riley Williams
- Pharmacy Service, Oklahoma City VA Health Care System, Oklahoma City, Oklahoma
| | | | - Shiwei Zhou
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, Ann Arbor
| | - Todd C. Lee
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal, Canada
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Yan YY, Ouellette HA, Saththianathan M, Munk PL, Mallinson PI, Sheikh A. The Role of a Virtual Noncalcium Dual-Energy CT Application in the Detection of Bone Marrow Edema in Peripheral Osteomyelitis. Can Assoc Radiol J 2022; 73:549-556. [PMID: 35006011 DOI: 10.1177/08465371211065181] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Purpose: To determine the sensitivity and specificity of dual-energy CT (DECT) virtual noncalcium images (VNCa) with bone and soft tissue reconstructions in the diagnosis of osteomyelitis. Materials & Methods: Between December 1, 2014 to December 1, 2020, 91 patients who had 99 DECT performed for a clinical indication of osteomyelitis with corresponding MRI, triphasic bone scan and/or white blood cell scintigraphy with CT/SPECT performed either 2 weeks before or 1 month after the DECT were retrospectively identified. The presence or absence of osteomyelitis was established using a second imaging test, bone biopsy or surgery. Two radiologists interpreted VNCa images alone and with bone and soft tissue reconstructions for osteomyelitis. Fleiss k statistics was used to assess inter-level agreement. Results: Osteomyelitis was present in 26 cases (26.2%), of which 4 cases (4%) had co-existing septic arthritis. DECT was performed at the following sites: ankle/foot (n = 59), calf (n = 12), knee (n = 3), thigh (n = 7), hip (n = 9), pelvis (n = 6), wrist/hand (n = 1), and shoulder (n = 2). Sensitivity with VNCa images alone was 53.8% and 73.1% and specificity was 84.9% and 71.2%. Sensitivity with VNCa images and bone and soft tissue reconstructions was 80.8% and 80.8% and specificity was 80.8% and 72.6%. Interobserver agreement was 76.7% (76 of 99 cases), for VNCa images alone (k = .487), and 66.7% (66 of 99 patients) for bone and soft tissue reconstructions with VNCa images together (k = .390). Conclusion: When VNCa images were combined with bone and soft tissue reconstructions, there is improved sensitivity in the diagnosis of osteomyelitis.
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Affiliation(s)
- Yet Yen Yan
- Musculoskeletal Section, Department of Radiology, 8167Vancouver General Hospital, Vancouver, BC, Canada.,Department of Radiology, 469851Changi General Hospital, Singapore
| | - Hugue A Ouellette
- Musculoskeletal Section, Department of Radiology, 8167Vancouver General Hospital, Vancouver, BC, Canada
| | - Mayuran Saththianathan
- Musculoskeletal Section, Department of Radiology, 8167Vancouver General Hospital, Vancouver, BC, Canada
| | - Peter L Munk
- Musculoskeletal Section, Department of Radiology, 8167Vancouver General Hospital, Vancouver, BC, Canada
| | - Paul I Mallinson
- Musculoskeletal Section, Department of Radiology, 8167Vancouver General Hospital, Vancouver, BC, Canada
| | - Adnan Sheikh
- Musculoskeletal Section, Department of Radiology, 8167Vancouver General Hospital, Vancouver, BC, Canada
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Rubitschung K, Sherwood A, Crisologo AP, Bhavan K, Haley RW, Wukich DK, Castellino L, Hwang H, La Fontaine J, Chhabra A, Lavery L, Öz OK. Pathophysiology and Molecular Imaging of Diabetic Foot Infections. Int J Mol Sci 2021; 22:11552. [PMID: 34768982 PMCID: PMC8584017 DOI: 10.3390/ijms222111552] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 10/16/2021] [Accepted: 10/20/2021] [Indexed: 12/27/2022] Open
Abstract
Diabetic foot infection is the leading cause of non-traumatic lower limb amputations worldwide. In addition, diabetes mellitus and sequela of the disease are increasing in prevalence. In 2017, 9.4% of Americans were diagnosed with diabetes mellitus (DM). The growing pervasiveness and financial implications of diabetic foot infection (DFI) indicate an acute need for improved clinical assessment and treatment. Complex pathophysiology and suboptimal specificity of current non-invasive imaging modalities have made diagnosis and treatment response challenging. Current anatomical and molecular clinical imaging strategies have mainly targeted the host's immune responses rather than the unique metabolism of the invading microorganism. Advances in imaging have the potential to reduce the impact of these problems and improve the assessment of DFI, particularly in distinguishing infection of soft tissue alone from osteomyelitis (OM). This review presents a summary of the known pathophysiology of DFI, the molecular basis of current and emerging diagnostic imaging techniques, and the mechanistic links of these imaging techniques to the pathophysiology of diabetic foot infections.
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Affiliation(s)
- Katie Rubitschung
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.R.); (A.S.); (A.C.)
| | - Amber Sherwood
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.R.); (A.S.); (A.C.)
| | - Andrew P. Crisologo
- Department of Plastic Surgery, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA;
| | - Kavita Bhavan
- Department of Internal Medicine, Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.B.); (L.C.)
| | - Robert W. Haley
- Department of Internal Medicine, Epidemiology Division, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA;
| | - Dane K. Wukich
- Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA;
| | - Laila Castellino
- Department of Internal Medicine, Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.B.); (L.C.)
| | - Helena Hwang
- Department of Pathology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA;
| | - Javier La Fontaine
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (J.L.F.); (L.L.)
| | - Avneesh Chhabra
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.R.); (A.S.); (A.C.)
| | - Lawrence Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (J.L.F.); (L.L.)
| | - Orhan K. Öz
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.R.); (A.S.); (A.C.)
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20
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Rubitschung K, Sherwood A, Crisologo AP, Bhavan K, Haley RW, Wukich DK, Castellino L, Hwang H, La Fontaine J, Chhabra A, Lavery L, Öz OK. Pathophysiology and Molecular Imaging of Diabetic Foot Infections. Int J Mol Sci 2021; 22:ijms222111552. [PMID: 34768982 DOI: 10.3390/ijms222111552.pmid:34768982;pmcid:pmc8584017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 10/16/2021] [Accepted: 10/20/2021] [Indexed: 05/27/2023] Open
Abstract
Diabetic foot infection is the leading cause of non-traumatic lower limb amputations worldwide. In addition, diabetes mellitus and sequela of the disease are increasing in prevalence. In 2017, 9.4% of Americans were diagnosed with diabetes mellitus (DM). The growing pervasiveness and financial implications of diabetic foot infection (DFI) indicate an acute need for improved clinical assessment and treatment. Complex pathophysiology and suboptimal specificity of current non-invasive imaging modalities have made diagnosis and treatment response challenging. Current anatomical and molecular clinical imaging strategies have mainly targeted the host's immune responses rather than the unique metabolism of the invading microorganism. Advances in imaging have the potential to reduce the impact of these problems and improve the assessment of DFI, particularly in distinguishing infection of soft tissue alone from osteomyelitis (OM). This review presents a summary of the known pathophysiology of DFI, the molecular basis of current and emerging diagnostic imaging techniques, and the mechanistic links of these imaging techniques to the pathophysiology of diabetic foot infections.
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Affiliation(s)
- Katie Rubitschung
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Amber Sherwood
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Andrew P Crisologo
- Department of Plastic Surgery, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA
| | - Kavita Bhavan
- Department of Internal Medicine, Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Robert W Haley
- Department of Internal Medicine, Epidemiology Division, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Dane K Wukich
- Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Laila Castellino
- Department of Internal Medicine, Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Helena Hwang
- Department of Pathology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Javier La Fontaine
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Avneesh Chhabra
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Lawrence Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Orhan K Öz
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
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21
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Tiwari P, Bera RN, Kanojia S, Chauhan N, Hirani MS. Assessing the optimal imaging modality in the diagnosis of jaw osteomyelitis. A meta-analysis. Br J Oral Maxillofac Surg 2021; 59:982-992. [PMID: 34503859 DOI: 10.1016/j.bjoms.2020.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 11/23/2020] [Indexed: 12/26/2022]
Abstract
Osteomyelitis is an inflammatory infectious disease that affects bone and bone marrow. Histopathology remains the gold standard method for diagnosis, but imaging modalities also play an important role. We systematically reviewed five articles with comparative studies on plain films, computed tomography (CT) scan, magnetic resonance imaging (MRI), cone beam computed tomography (CBCT), positron emission tomography (PET), single photon-emission computed tomography (SPECT), scintigraphy, and SPECT/CT. Scintigraphy and SPECT/CT has the highest sensitivity of 100%. PET is only to be used in cases of follow up. Orthopantomography (OPG) is the most common initial diagnostic tool despite its low sensitivity. CT provides the necessary specificity needed for radionuclide imaging, which has the highest negative predictive value of 100% and a positive predictive value >95%. SPECT/CT with 100% sensitivity and 85% specificity can be considered as the imaging modality of choice for initial diagnosis and follow up.
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Affiliation(s)
- P Tiwari
- Unit of Oral and Maxillofacial Surgery, Faculty of Dental Sciences, Institute of Medical Sciences.
| | - R N Bera
- Unit of Oral and Maxillofacial Surgery, Faculty of Dental Sciences, Institute of Medical Sciences, Room No 142 Sushruta Hostel Trauma Centre BHU, Banaras Hindu University, Varanasi, Uttar Pradesh 221005, India.
| | - S Kanojia
- Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, India.
| | - N Chauhan
- Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, India.
| | - M S Hirani
- Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, India.
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22
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Titanium implant coating based on dopamine-functionalized sulphated hyaluronic acid: in vivo assessment of biocompatibility and antibacterial efficacy. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2021; 128:112286. [PMID: 34474837 DOI: 10.1016/j.msec.2021.112286] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 06/11/2021] [Accepted: 06/25/2021] [Indexed: 11/20/2022]
Abstract
The number of total knee and/or hip replacements are expected to exceed 5 million a year by 2030; the incidence of biofilm-associated complications can vary from 1% in primary implants to 5.6% in case of revision. The purpose of this study was to test the ability of sHA-DA, a partially sulphated hyaluronic acid (sHA) functionalized with a dopamine (DA) moiety, to prevent acute bacterial growth in an in vivo model of an intra-operatively highly contaminated implant. Previously, in vitro studies showed that the DA moiety guarantees good performance as binding agent for titanium surface adhesion, while the negatively charged sHA has both a high efficiency in electrostatic binding of positively charged antibiotics, and bone regenerative effects. The in vitro testing also highlighted the effectiveness of the sHA-DA system in inhibiting bacterial spreading through a sustained release of the antibiotic payload from the implant coating. In this study the chemical stability of the sHA-DA to β-ray sterilization was demonstrated, based on evaluation by NMR, SEC-TDA Omnisec and HPLC-MS analysis, thus supporting the approach of terminal sterilization of the coated implant with no loss of efficacy. Furthermore, an in vivo study in rabbits was performed according to UNI EN ISO 10993-6 to assess the histocompatibility of titanium nails pre-coated with sHA-DA. The implants, placed in the femoral medullary cavity and harvested after 12 weeks, proved to be histocompatible and to allow bone growth in adhesion to the metal surface. Finally, an in vivo model of bacterial contamination was set up by injecting 1 mL of bacterial suspension containing 104 or 106 CFU of methicillin-resistant Staphylococcus aureus (MRSA) into the femoral medullary cavity of 30 rabbits. Titanium nails either uncoated or pre-coated with sHA-DA and loaded directly by the surgeon with 5% vancomycin were implanted in the surgical site. After 1 week, only the animals treated with pre-coated nails did not show the presence of systemic or local bacterial infection, as confirmed by microbiology and histology (Smeltzer score). Further insights into the animal model setup are crucial, however the results obtained suggest that the system can be effective in preventing the onset of the bacterial infective process.
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Qian M, Wang J, Li J, Wang S, Wang Z, Chen X, Ou H, Liang Y, Peng X. Role of ultrasound and CT in the early diagnosis and surgical treatment of primary sternal osteomyelitis caused by Salmonella: Case reports. Exp Ther Med 2021; 21:189. [PMID: 33488798 PMCID: PMC7812590 DOI: 10.3892/etm.2021.9620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 10/16/2020] [Indexed: 12/22/2022] Open
Abstract
Primary sternal osteomyelitis (PSO) caused by Salmonella is a rare condition and most commonly associated with sickle cell disease. Only one such case has been previously reported in an infant (age, <1 year) worldwide. The present study reported on two infantile cases of PSO caused by Salmonella in the absence of any hematological diseases. A total of two male infants (age, ≤1 year) were referred to our hospital for fever and rapid breathing accompanied by a chest wall mass involving the lower end of the sternum. Imaging findings on CT and ultrasound, which included sternal segment dislocation, lytic destruction and periosteal elevation, confirmed the diagnosis of PSO. Blood and purulent material cultures confirmed that the causative pathogen was Salmonella. The infants were completely cured by sequential intravenous and oral antibiotics followed by surgical debridement. The infants remained symptom-free and local recurrence of PSO was not detected at follow-up. PSO caused by Salmonella in the absence of any hematological diseases is a rare condition. Unfamiliarity with this disease may lead to a delay in diagnosis and serious complications. The current case report presents two cases of PSO along with a brief overview of the characteristics and management modalities for this condition, and it provides a comprehensive reference for pediatricians regarding this rare disease, particularly in infants.
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Affiliation(s)
- Mengjiao Qian
- Department of Cardiothoracic Surgery, The First People's Hospital of Honghe Prefecture, Mengzi, Yunnan 661100, P.R. China
| | - Jing Wang
- Department of Cardiothoracic Surgery, The First People's Hospital of Honghe Prefecture, Mengzi, Yunnan 661100, P.R. China
| | - Jun Li
- Department of Cardiothoracic Surgery, The First People's Hospital of Honghe Prefecture, Mengzi, Yunnan 661100, P.R. China
| | - Sibo Wang
- Department of Cardiothoracic Surgery, The First People's Hospital of Honghe Prefecture, Mengzi, Yunnan 661100, P.R. China
| | - Zhongyin Wang
- Department of Cardiothoracic Surgery, The First People's Hospital of Honghe Prefecture, Mengzi, Yunnan 661100, P.R. China
| | - Xiao Chen
- Department of Cardiothoracic Surgery, The First People's Hospital of Honghe Prefecture, Mengzi, Yunnan 661100, P.R. China
| | - Haibo Ou
- Department of Cardiothoracic Surgery, The First People's Hospital of Honghe Prefecture, Mengzi, Yunnan 661100, P.R. China
| | - Yuanzhong Liang
- Department of Radiology, The First People's Hospital of Honghe Prefecture, Mengzi, Yunnan 661100, P.R. China
| | - Xuguan Peng
- Department of Cardiothoracic Surgery, The First People's Hospital of Honghe Prefecture, Mengzi, Yunnan 661100, P.R. China
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A Comparison of the Epidemiology, Clinical Features, and Treatment of Acute Osteomyelitis in Hospitalized Children in Latvia and Norway. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57010036. [PMID: 33406590 PMCID: PMC7824191 DOI: 10.3390/medicina57010036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/16/2020] [Accepted: 12/30/2020] [Indexed: 02/06/2023]
Abstract
Background and objectives: Paediatric acute osteomyelitis (AO) may result in major life-threatening and limb-threatening complications if not recognized and treated early. The management of AO may depend on local microbial prevalence and virulence factors. This study compares the approach to paediatric AO in hospitals in two countries—Latvia and Norway. Materials and Methods: The study includes patients with AO hospitalized in the paediatric department in the Norwegian hospital Sørlandet Sykehus Kristiansand (SSK), in the period between the 1st of January 2012 and the 31st of December 2019. The results from SSK are compared to the results of a published study of AO in patients hospitalized at the Children’s Clinical University Hospital (CCUH) in Riga, Latvia. Results: The most isolated pathogen from cultures in both hospitals was S. aureus (methicillin-sensitive). The lower extremity was the most affected body part (75% in CCUH, 95% in SSK), the main clinical symptom was pain (CCUH 92%, SSK 96.6%). Deep culture aspiration was most often taken intraoperatively in CCUH (76.6%) and percutaneously in SSK (44.8%). Oxacillin was the most applied antibiotic in CCUH (89.4%), and Cloxacillin in SSK (84.6%). Combined treatment with anti-Staphylococcal penicillins and Clindamycin was administered in 25.5% and 33.8% of CCUH and SSK patients, respectively. The median duration of the intravenous antibacterial treatment in CCUH and SSK was 15 and 10 days, respectively, and a switch to oral therapy was mainly made at discharge in both hospitals. The median total duration of antibiotic treatment was 25 days in CCUH and 35 days in SSK. 75% of CCUH and 10.3% of SSK patients were treated surgically. Complications were seen in 47% of patients in CCUH and in 38% in SSK. Conclusions: The transition to oral antibacterial treatment in both hospitals was delayed, which suggests a lack of criteria for discontinuation of intravenous therapy and could potentially contribute to longer hospitalization, higher cost of treatment and risk of complications. The use of more invasive techniques for deep culturing and significantly more common surgical interventions could possibly be linked to a higher complication rate in AO patients treated at the Latvian hospital.
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Lindegaard C, Galen G, Aarsvold S, Berg LC, Verwilghen D. Haematogenous septic arthritis, physitis and osteomyelitis in foals: A tutorial review on pathogenesis, diagnosis, treatment and prognosis. Part 1. EQUINE VET EDUC 2020. [DOI: 10.1111/eve.13394] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- C. Lindegaard
- Department of Veterinary Clinical Sciences Faculty of Health Sciences University of Copenhagen Taastrup Denmark
| | - G. Galen
- School of Veterinary Sciences Faculty of Science University of Sydney Sydney New South Wales Australia
| | - S. Aarsvold
- Puchalski Equine Imaging Petaluma California USA
| | - L. C. Berg
- Department of Veterinary Clinical Sciences Faculty of Health Sciences University of Copenhagen Taastrup Denmark
| | - D. Verwilghen
- School of Veterinary Sciences Faculty of Science University of Sydney Sydney New South Wales Australia
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Imaging for detection of osteomyelitis in people with diabetic foot ulcers: A systematic review and meta-analysis. Eur J Radiol 2020; 131:109215. [PMID: 32862106 DOI: 10.1016/j.ejrad.2020.109215] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/09/2020] [Accepted: 08/08/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Osteomyelitis is an infection of the bone which can occur in people with diabetic foot ulcers. It can be diagnosed using X-rays, ultrasound, scintigraphy, magnetic resonance imaging (MRI), single photon emission computed tomography (SPECT) and positron emission tomography (PET). OBJECTIVES To review the evidence on the diagnostic accuracy of imaging tests to diagnose osteomyelitis in people with diabetic foot ulcers. METHODS We conducted a systematic review and meta-analysis. MEDLINE, EMBASE and other databases were searched to July 2018. Risk of bias was evaluated. Diagnostic accuracy was estimated using bivariate meta-analyses. RESULTS Thirty-six studies were included in the meta-analysis. Eight studies were at high risk of bias MRI had high diagnostic accuracy (22 studies: 96.4 % sensitivity (95 % CI 90.7-98.7); 83.8 % specificity (76.0-89.5)). PET scans also had high accuracy (6 studies: 84.3 % sensitivity (52.8-96.3); 92.8 % specificity (75.7-98.2)), and possibly also SPECT, but with few studies (3 studies: 95.6 % sensitivity (76.0-99.3); 55.1 % specificity (19.3-86.3)). Scintigraphy (17 studies: 84.2 % sensitivity (76.8-89.6); 67.7 % specificity (56.2-77.4)), and X-rays (16 studies: 61.9 % sensitivity (50.5-72.1); 78.3 % specificity (62.9-88.5)) had generally inferior diagnostic accuracy. CONCLUSIONS MRI and PET both reliably diagnose osteomyelitis in diabetic foot ulcer patients. SPECT may also have good diagnostic accuracy, although evidence is limited. This review confirms most current guidelines, showing that MRI may be the preferable test in most cases, given its wider availability and the lack of potentially harmful ionising radiation.
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Kaziz H, Amine Triki M, Chermiti W, Mouelhi T, Naouar N, Laziz Ben Ayeche M. Acute osteomyelitis of the distal fibula in children: Treatment options and long-term follow-up. Arch Pediatr 2020; 27:342-347. [PMID: 32736914 DOI: 10.1016/j.arcped.2020.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 03/31/2020] [Accepted: 06/23/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Acute osteomyelitis of the distal fibula is a rare disease in children and is characterized by special features compared with other sites. The objective of this study was to report the functional outcome at long-term follow-up. METHODS We reviewed retrospectively, between January 2000 and December 2010, all cases of acute osteomyelitis of the distal fibula. Epidemiological and bacteriological data as well as therapy and outcome factors were analyzed. At the last follow-up, functional outcome was studied based on ankle motion, growth disturbance, and radiological sequelae. RESULTS Seven cases of acute osteomyelitis of the distal fibula were found. The mean age was patients was 7.71 years and the sex ratio was 2.5. The portal of entry of the pathogen was a skin injury in 57% of cases. Staphylococcusaureus was identified in 71% of cases. The mean duration of antibiotic therapy was 33.2 days. At a mean of 12.85 years of follow-up, no growth disturbance was found. The mean plantar and dorsal flexion was 41° and 27.7°, respectively. The mean postoperative American Orthopedics Foot and Ankle score (AOFAS) was 96.71 points. CONCLUSION Acute osteomyelitis of the distal fibula in children is scarce and rarely reported in the literature. It occurs more often in boys at an average age of 7 years. Local symptoms are usually more obvious than general symptoms. Surgical debridement of the subperiosteal abscess without bone trepanation seems to lead to a satisfactory outcome. LEVEL OF EVIDENCE Level IV - case series. IRB: Sahloul Hospital Human Research Ethics Committee.
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Affiliation(s)
- H Kaziz
- Orthopaedics department, Hospital Sousse, Sahloul University, city 4000 9, Sousse, Tunisia.
| | - M Amine Triki
- Orthopaedics department, Hospital Sousse, Sahloul University, city 4000 9, Sousse, Tunisia
| | - W Chermiti
- Orthopaedics department, Hospital Sousse, Sahloul University, city 4000 9, Sousse, Tunisia
| | - T Mouelhi
- Orthopaedics department, Hospital Sousse, Sahloul University, city 4000 9, Sousse, Tunisia
| | - N Naouar
- Orthopaedics department, Hospital Sousse, Sahloul University, city 4000 9, Sousse, Tunisia
| | - M Laziz Ben Ayeche
- Orthopaedics department, Hospital Sousse, Sahloul University, city 4000 9, Sousse, Tunisia
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Langsjoen J, Neuwelt A, Eberhardt S, Mlady G, Shukla U, Murali S, Pizanis C, Sillerud LO. A comparison of ferumoxytol with gadolinium as contrast agents for the diagnostic magnetic resonance imaging of osteomyelitis. Magn Reson Imaging 2020; 71:45-54. [PMID: 32439428 DOI: 10.1016/j.mri.2020.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 04/16/2020] [Accepted: 04/19/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Ferumoxytol, an FDA-approved superparamagnetic iron oxide nanoparticle (SPION) preparation used for the treatment of iron deficiency anemia, is also known to be taken up by macrophages in areas of infection or inflammation, where it produces negative contrast changes on T2-weighted MR images. PURPOSE We sought to compare Ferumoxytol-induced MRI contrast changes with those observed using standard-of-care Gadolinium in patients presenting with symptoms suggestive of osteomyelitis. SUBJECTS Out of eighteen enrolled patients, 15 had MR imaging with both ferumoxytol and gadolinium. Based on clinical and/or pathologic criteria, 7 patients were diagnosed with osteomyelitis, 5 patients had osteomyelitis ruled out, and in 3 patients a definitive diagnosis could not be made. FIELD STRENGTH 1.5 Tesla. SEQUENCES Used included STIR, T1-weighted and T2-weighted spin echo. ASSESSMENT The mean contrast changes upon ferumoxytol and gadolinium administration were measured from lesion regions of interest and compared with control regions. STATISTICAL TESTS Student's t-test, propagation of errors. Data are reported as means ± S.E. RESULTS The mean contrast changes, ΔC, associated with a diagnosis of osteomyelitis were found to be ΔCFe = -2.7 ± 0.7 when Ferumoxytol and T2w imaging sequences were used and ΔCGd = +3.1 ± 1.1 (P < 0.001) when Gadolinium and a T1w imaging sequence was used. The MRI contrast changes for both agents correlated with systemic markers of inflammation, such as the erythrocyte sedimentation rate. In patients without osteomyelitis, no significant contrast changes were observed in T2-weighted, Ferumoxytol-contrasted MRI. The macrophages in osteomyelitic lesions were found to take up at least 16 times as much iron as benign bone marrow. DATA CONCLUSION We conclude that in terms of its MRI diagnostic accuracy for osteomyelitis Ferumoxytol-contrasted MRI is a promising approach for diagnosing osteomyelitis that merits further study.
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Affiliation(s)
- Jens Langsjoen
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States of America
| | - Alex Neuwelt
- Department of Medical Oncology, Department of Veterans Affairs, Richmond, VA 23249, United States of America
| | - Stephen Eberhardt
- Department of Radiology, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States of America
| | - Gary Mlady
- Department of Radiology, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States of America
| | - Utkarsh Shukla
- University of New Mexico School of Medicine, Albuquerque, NM 87131, United States of America
| | - Sowmiya Murali
- University of New Mexico School of Medicine, Albuquerque, NM 87131, United States of America
| | - Charles Pizanis
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States of America
| | - Laurel O Sillerud
- Department of Neurology, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States of America.
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Ertuğrul B, Uçkay I, Schöni M, Peter-Riesch B, Lipsky BA. Management of diabetic foot infections in the light of recent literature and new international guidelines. Expert Rev Anti Infect Ther 2020; 18:293-305. [PMID: 32052672 DOI: 10.1080/14787210.2020.1730177] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: In May 2019 the International Working Group on the Diabetic Foot (IWGDF) launched their quadrennially updated guidelines on the management of diabetic foot infections (DFIs). Concomitantly, the number of new publications regarding DFI increased.Areas covered: The IWGDF committee developed and addressed key questions and produced evidence-based recommendations related to diagnosing and treating DFIs. This narrative review provides an overview of this new guideline and also of other recently published literature in the field of DFIs.Expert opinion: The 2019 IWGDF guidelines provide an authoritative, international, evidence-based approach to diagnosing and treating DFIs. The 27 recommendations are supported by systematic reviews of both diagnosis and interventions. Our review of this guideline, along with other recent publications in the field, allows us to offer state-of-the-art guidance for caring for these difficult infections. As the evidence base for management of DFIs remains suboptimal, we need further research to improve the management of DFIs.
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Affiliation(s)
- Bülent Ertuğrul
- Infectious Diseases and Clinical Microbiology, Adnan Menderes University, Aydın, Turkey
| | - Ilker Uçkay
- Infectiology, Balgrist University Hospital, Zurich, Switzerland
| | - Madlaina Schöni
- Orthopedic Department, Balgrist University Hospital, Zurich, Switzerland
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