Osteomyelitis

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Osteomyelitis

Classification and external resources

Osteomyelitis of thetibiaof a young child. Numerousabscesses in the bone show as radiolucency.

ICD-10

M86.

ICD-9

730

Osteomyelitis

(osteo- derived from the Greek word osteon, meaning bone, myelo- meaningmarrow, and -itis meaning inflammation) simply means aninfectionof the boneor bone marrow.

[1]

It can be usefully subclassified on the basis of the causative organism ( pyogenicbacteria or mycobacteria), the route, duration and anatomic location of the infection.

Pathogenesis

In general, microorganisms may infect bone through one or more of three basic methods: via the bloodstream,contiguously from local areas of infection (as in cellulitis), or penetratingtrauma, including iatrogeniccauses such as joint replacementsor internal fixation of fracturesor root- canaledteeth.

[1]

Once the bone is infected,leukocytes enter the infected area, and, in their attempt toengulf the infectious organisms, release enzymesthat lysethe bone.Pus spreads into the bone's blood vessels, impairing their flow, and areas of devitalized infected bone, known as

sequestra

, form the basis of a chronic infection.

[1]

Often, the body will try to create new bonearound the area of necrosis.The resulting new bone is often called aninvolucrum.

[1]

Onhistologicexamination, these areas of necrotic bone are the basis for distinguishing between

acuteosteomyelitis

and

chronicosteomyelitis

. Osteomyelitis is an infective process whichencompasses all of the bone (osseous) components, including the bone marrow. When it ischronic it can lead to bonesclerosis and deformity. Chronic osteomyelitis may be due to the presence of intracellular bacteria (inside bone cells)

[2]

.Also, once intracellular, the bacteria are able to escape and invade other bone cells

[3]

.In addition,once intracellular, the bacteria becomes resistant to antibiotics

[4]

. These combined facts mayexplain the chronicity and difficult eradication of this disease. This results in significant costsand disability and may even lead to amputation. Intracellular existence of bacteria inosteomyelitis is likely an unrecognized contributing factor to its chronic form.Ininfants, the infection can spread to the jointand causearthritis.Inchildren, large subperiosteal abscessescan form because the periosteumis loosely attached to the surface of the bone.

[1]

Because of the particulars of their blood supply, thetibia, femur , humerus, vertebra, the maxilla, and themandibular bodiesare especially susceptible to osteomyelitis.

[5]

Abscesses of any bone,however, may be precipitated by trauma to the affected area. Many infections are caused by

Staphylococcus aureus

,a member of the normal flora found on theskinandmucous membranes. In patients withsickle celldisease the most common causative agent remainsStaphylococcus aureus,butSalmonellaspecies become proportionally more common pathogens than in healthy hosts.It has been noted that baseball Hall-of-Famer Mickey Mantlehad osteomyelitis, as well asBritish Singer/Songwriter Imogen Heap. During her tour in 2010 she devised an improvisedtrack with the key and tempo voted on by the audience. All proceeds went to the Great OrmondStreet hospital, where a surgeon had successfully performed an operation to save her leg.

[6]

[edit] Cause

Age groupMost common organisms

Newborns (younger than 4mo)

S. aureus

Enterobacter

species, andgroup AandB

Streptococcus

species

Children (aged 4 mo to 4y)

S. aureus

,group A

Streptococcus

species,

Haemophilusinfluenzae

, and

Enterobacter

speciesChildren, adolescents(aged 4 y to adult)

S. aureus

(80%),group A

Streptococcus

species,

, and

speciesAdult

and occasionally

speciesSickle Cell AnemiaPatients

Salmonella

species

In children, thelong bonesare usually affected. In adults, the vertebrae and the pelvisare most commonly affected.Acute osteomyelitis almost invariably occurs in children. When adults are affected, it may be because of compromised host resistance due to debilitation,intravenousdrug abuse, infectiousroot-canaled teeth, or other disease or drugs (

e.g.

immunosuppressivetherapy).Osteomyelitis is a secondary complication in 1-3% of patients with pulmonarytuberculosis

[1]

. Inthis case, the bacteria, in general, spread to the bone through thecirculatory system,first infecting thesynovium(due to its higher oxygenconcentration) before spreading to the adjacent bone

[1]

. In tubercular osteomyelitis, the long bones and vertebrae are the ones which tend to beaffected

[1]

Staphylococcus aureus

is the organism most commonly isolated from all forms of osteomyelitis.

[1]

Bloodstream-sourced osteomyelitis is seen most frequently in children, and nearly 90% of casesare caused by

Staphylococcus aureus

. In infants,

S. aureus

,Group B streptococci(mostcommon

[7]

) and

Escherichia coli

are commonly isolated; in children from 1 to 16 years of age,

S.aureus

Streptococcus pyogenes

, and

Haemophilus influenzae

are common. In somesubpopulations, including intravenous drug users andsplenectomizedpatients,Gram-negative bacteria, includingenteric bacteria, are significant pathogens.

[8]

The most common form of the disease in adults is caused by injury exposing the bone to localinfection.

Staphylococcus aureus

is the most common organism seen in osteomyelitis seededfrom areas of contiguous infection, but anaerobesand Gram-negative organisms, including

Pseudomonas aeruginosa

E. coli

, and

Serratia marcescens

, are also common. Mixed infectionsare the rule rather than the exception.

[8]

Systemicmycotic(fungal) infections may also cause osteomyelitis. The two most common areBlastomyces dermatitidisandCoccidioides immitis. In osteomyelitis involving the vertebral bodies, about half the cases are due to

Staphylococcusaureus

, and the other half are due totuberculosis (spread hematogenously from thelungs