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OSTEOMYELITIS

Paula Crossett - HLTH 1020- July 27, 2016

OSTEOMYELITIS- PAULA CROSSETT

What is Osteomyelitis
Osteomyelitis (or OM) is infection and inflammation of the bone and bone marrow. It can be
usefully subclassified on the basis of the causative organism (pyogenic bacteria or
mycobacteria) and the route, duration and anatomic location of the infection. Osteomyelitis
usually begins as an acute infection, but it may evolve into chronic condition

Classification
The definition of OM is broad, and encompasses a wide variety of conditions.
Traditionally, the length of time the infection has been present and whether there is
suppuration (pus formation) or sclerosis (increased density of bone) is used to
arbitrarily classify OM. Chronic OM is often defined as OM that has been present for
more than one month. In reality, there are no distinct subtypes; instead there is a
spectrum of pathologic features that reflect balance between the type and severity of
the cause of the inflammation, the immune system and local and systemic
predisposing factors.
Suppurative osteomyelitis
Acute suppurative osteomyelitis
Chronic suppurative osteomyelitis
Primary (no preceding phase)
Secondary (follows an acute phase)
Non-suppurative osteomyelitis
Diffuse sclerosing
Focal sclerosing (condensing osteitis)
Proliferative periostitis (periostitis ossificans, Garr's sclerosing osteomyelitis)

OSTEOMYELITIS- PAULA CROSSETT

Osteoradionecrosis
OM can also be typed according to the area of the skeleton in which it is present. For
example, osteomyelitis of the jaws is different in several respects from osteomyelitis present
in a long bone. Vertebral osteomyelitis is another possible presentation.

Cause
Age group

Most common organisms

Newborns (younger than 4 mo)

S. aureus, Enterobacter species, and group A and B

Streptococcus species
Children (aged 4 mo to 4 y) S. aureus, group A Streptococcus species, Haemophilus
influenzae, and Enterobacter species
Children, adolescents (aged 4 y to adult) S. aureus (80%), group A Streptococcus
species, H. influenzae, and Enterobacter species
Adult S. aureus and occasionally Enterobacter or Streptococcus species
Sickle cell anemia patients Salmonella species are most common in patients with sickle
cell disease.
In children, the long bones are usually affected. In adults, the vertebrae and the pelvis
are 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, intravenous drug abuse,
infectious root-canaled teeth, or other disease or drugs (e.g., immunosuppressive therapy).
Osteomyelitis is a secondary complication in 13% of patients with pulmonary
tuberculosis. In this case, the bacteria, in general, spread to the bone through the circulatory
system, first infecting the synovium (due to its higher oxygen concentration) before
spreading to the adjacent bone. In tubercular osteomyelitis, the long bones and vertebrae are
the ones that tend to be affected.
Staphylococcus aureus is the organism most commonly isolated from all forms of
osteomyelitis.

OSTEOMYELITIS- PAULA CROSSETT

Bloodstream-sourced osteomyelitis is seen most frequently in children, and nearly 90%


of cases are caused by Staphylococcus aureus. In infants, S. aureus, Group B streptococci
(most common) and Escherichia coli are commonly isolated; in children from one to 16 years
of age, S. aureus, Streptococcus pyogenes, and Haemophilus influenzae are common. In some
subpopulations, including intravenous drug users and splenectomized patients, Gramnegative bacteria, including enteric bacteria, are significant pathogens.
The most common form of the disease in adults is caused by injury exposing the bone
to local infection. Staphylococcus aureus is the most common organism seen in osteomyelitis,
seeded from areas of contiguous infection. But anaerobes and Gram-negative organisms,
including Pseudomonas aeruginosa, E. coli, and Serratia marcescens, are also common.
Mixed infections are the rule rather than the exception.
Systemic mycotic (fungal) infections may also cause osteomyelitis. The two most
common are Blastomyces dermatitidis and Coccidioides immitis.
In osteomyelitis involving the vertebral bodies, about half the cases are due to S. aureus,
and the other half are due to tuberculosis (spread hematogenously from the lungs).
Tubercular osteomyelitis of the spine was so common before the initiation of effective
antitubercular therapy, it acquired a special name, Pott's disease.
The Burkholderia cepacia complex has been implicated in vertebral osteomyelitis in
intravenous drug users.

Symptoms of Osteomyelitis
Acute osteomyelitis develops rapidly over a period of seven to 10 days. The symptoms
for acute and chronic osteomyelitis are very similar and include:
Fever, irritability, fatigue
Nausea
Tenderness, redness, and warmth in the area of the infection

OSTEOMYELITIS- PAULA CROSSETT

Swelling around the affected bone


Lost range of motion
Osteomyelitis in the vertebrae makes itself known through severe back pain, especially
at night.

Pathogenesis
In general, microorganisms may infect bone through one or more of three basic
methods
Via the bloodstream (haematogeneously) - the most common method
Contiguously from local areas of infection (as in cellulitis), or
Penetrating trauma, including iatrogenic causes such as joint replacements or internal
fixation of fractures or secondary periapical periodontitis in teeth.
The area usually affected when the infection is contracted through the bloodstream is
the metaphysis of the bone.Once the bone is infected, leukocytes enter the infected area, and,
in their attempt to engulf the infectious organisms, release enzymes that lyse the 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. Often, the body will try to
create new bone around the area of necrosis. The resulting new bone is often called an
involucrum. On histologic examination, these areas of necrotic bone are the basis for
distinguishing between acute osteomyelitis and chronic osteomyelitis. Osteomyelitis is an
infective process that encompasses all of the bone (osseous) components, including the bone
marrow. When it is chronic, it can lead to bone sclerosis and deformity.
Chronic osteomyelitis may be due to the presence of intracellular bacteria (inside bone
cells). Also, once intracellular, the bacteria are able to escape and invade other bone cells. At
this point, the bacteria may be resistant to some antibiotics. These combined facts may
explain the chronicity and difficult eradication of this disease, resulting in significant costs
and disability, potentially leading to amputation. Intracellular existence of bacteria in
osteomyelitis is likely an unrecognized contributing factor to its chronic form.

OSTEOMYELITIS- PAULA CROSSETT

In infants, the infection can spread to a joint and cause arthritis. In children, large
subperiosteal abscesses can form because the periosteum is loosely attached to the surface of
the bone.
Because of the particulars of their blood supply, the tibia, femur, humerus, vertebra, the
maxilla, and the mandibular bodies are especially susceptible to osteomyelitis. 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 the skin and
mucous membranes. In patients with sickle cell disease, the most common causative agent is
Salmonella, with a relative incidence more than twice that of S. aureus.

Diagnosis
Mycobacterium doricum osteomyelitis and soft tissue infection. Computed tomography
scan of the right lower extremity of a 21-year-old patient, showing abscess formation adjacent
to nonunion of a right femur fracture.
Extensive osteomyelitis of the forefoot
Osteomyelitis in both feet as seen on bone scan
The diagnosis of osteomyelitis is complex and relies on a combination of clinical
suspicion and indirect laboratory markers such as a high white blood cell count and fever,
although confirmation of clinical and laboratory suspicion with imaging is usually necessary.
Radiographs and CT are the initial method of diagnosis, but are not sensitive and only
moderately specific for the diagnosis. They can show the cortical destruction of advanced
osteomyelitis, but can miss nascent or indolent diagnoses.
Confirmation is most often by MRI. The presence of edema, diagnosed as increased
signal on T2 sequences, is sensitive, but not specific, as edema can occur in reaction to

OSTEOMYELITIS- PAULA CROSSETT

adjacent cellulitis. Confirmation of bony marrow and cortical destruction by viewing the T1
sequences significantly increases specificity. The administration of intravenous gadolinium
based contrast enhances specificity further. In certain situations, such as severe Charcot
arthropathy, diagnosis with MRI is still difficult. Similarly, it is limited in distinguishing bone
infarcts from osteomyelitis in sickle cell anemia.
Nuclear medicine scans can be a helpful adjunct to MRI in patients who have metallic
hardware that limits or prevents effective magnetic resonance. Generally a triple phase
technetium 99 based scan will show increased uptake on all three phases. Gallium scans are
100% sensitive for osteomyelitis but not specific, and may be helpful in patients with metallic
prostheses. Combined WBC imaging with marrow studies have 90% accuracy in diagnosing
osteomyelitis.
Diagnosis of osteomyelitis is often based on radiologic results showing a lytic center
with a ring of sclerosis. Culture of material taken from a bone biopsy is needed to identify the
specific pathogen; alternative sampling methods such as needle puncture or surface swabs
are easier to perform, but do not produce reliable results.
Factors that may commonly complicate osteomyelitis are fractures of the bone,
amyloidosis, endocarditis, or sepsis.

Treatment

Osteomyelitis often requires prolonged antibiotic therapy for


weeks or months. A PICC line or central venous catheter can
be placed for long-term intravenous medication
administration. It may require surgical debridement in severe
cases, or even amputation.
Initial first-line antibiotic choice is determined by the patient's history and regional
differences in common infective organisms. A treatment lasting 42 days is practiced in a
number of facilities. Local and sustained availability of drugs have proven to be more

OSTEOMYELITIS- PAULA CROSSETT

effective in achieving prophylactic and therapeutic outcomes. Open surgery is needed for
chronic osteomyelitis, whereby the involucrum is opened and the sequestrum is removed or
sometimes saucerization can be done. Hyperbaric oxygen therapy has been shown to be a
useful adjunct to the treatment of refractory osteomyelitis.
Prior to the widespread availability and use of antibiotics, blow fly larvae were
sometimes deliberately introduced to the wounds to feed on the infected material, effectively
scouring them clean. In 1875, American artist Thomas Eakins depicted a surgical procedure
for osteomyelitis at Jefferson Medical College, in a famous oil painting titled The Gross
Clinic.
There is tentative evidence that bioactive glass may be useful.
Diet-associated changes in the intestinal microbiome, particularly opposing changes in
relative abundance of Prevotella and Lactobacillus species, are a crucial factor regulating the
Inflammasome and Caspase 8-mediated maturation of Interleukin 1 beta and osteomyelitis in
PSTPIP2 mice. This discovery may open new ways to treat osteomyelitis.

Outlook (Prognosis)
With treatment, the outcome for acute osteomyelitis is usually good.
The outlook is worse for those with long-term (chronic) osteomyelitis. Symptoms may
come and go for years, even with surgery. Amputation may be needed, especially in people
with diabetes or poor blood circulation.
The outlook for people with an infection of a prosthesis depends partly on:
The person's health
The type of infection
Whether the infected prosthesis can be safely removed

OSTEOMYELITIS- PAULA CROSSETT

Who Gets Osteomyelitis?


Only 2 out of every 10,000 people get osteomyelitis. The condition affects children and
adults, although in different ways.

Personal Experience
I was diagnosed with Acute Osteomyelitis at the age of 29. It all started with a sore
throat which turned into a Strep throat infection which spread into my bloodstream. I was
hospitalized after 2 days of being almost unconscious. When I was admitted to the hospital I
had 80% of infection in my body, resulting in other illnesses such as gastritis, UTI, bronchitis,
ear infection, and other infectious diseases. I remained in the ICU for about 4 days, it was a
week after my release from the hospital that my primary care doctor diagnosed me with
Osteomyelitis. The treatment consisted of a pelvic bone biopsy, which was very painful, and
an intravenous IV that I carried with me for about 6 weeks. This was to prevent the infection
from damaging important organs like the heart in my case, the IV would spray the antibiotic
above the heart to keep it safe. If I wasnt admitted to the hospital when I did, i probably
would have not be able to share my experience. Although Osteomyelitis is a rare disease that
affects a small percentage of people , I was one of the unlike ones.

OSTEOMYELITIS- PAULA CROSSETT

Strep throat
The cause of strep throat is bacteria known as Streptococcus pyogenes, also known as
group A streptococcus. Streptococcal bacteria are highly contagious. They can spread through
airborne droplets when someone with the infection coughs or sneezes, or through shared
food or drinks.
Complications of streptococcus
Although strep throat isn't dangerous, it can lead to serious complications. Antibiotic
treatment reduces the risk.
Spread of infection
Strep bacteria may spread, causing infection in:
Tonsils
Sinuses
Skin
Blood
Middle ear

Streptococcus bacteria

Not to be confused with Staphylococcus.


Streptococcus is a genus of coccus (spherical)
Gram-positive bacteria belonging to the phylum
Firmicutes and the order Lactobacillales (lactic
acid bacteria). Cell division in this genus occurs
along a single axis in these bacteria, thus they
grow in chains or pairs, hence the namefrom
Greek % streptos, meaning easily bent or twisted, like a chain (twisted chain).
(Contrast this with staphylococci, which divide along multiple axes and generate grape-like
clusters of cells.)
Most are oxidase-negative and catalase-negative, and many are facultative anaerobes.

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Group A
S. pyogenes (GAS) is the causative agent in a wide range of group A streptococcal
infections. These infections may be noninvasive or invasive. The noninvasive infections tend
to be more common and less severe. The most common of these infections include
streptococcal pharyngitis (strep throat) and impetigo. Scarlet fever is also a noninvasive
infection, but has not been as common in recent years.
The invasive infections caused by group A -hemolytic streptococci tend to be more
severe and less common. This occurs when the bacterium is able to infect areas where it is not
usually found, such as the blood and the organs. The diseases that may be caused include
streptococcal toxic shock syndrome, necrotizing fasciitis, pneumonia, and bacteremia.
Additional complications may be caused by GAS, namely acute rheumatic fever and
acute glomerulonephritis. Rheumatic fever, a disease that affects the joints, kidneys, and heart
valves, is a consequence of untreated strep A infection caused not by the bacterium itself.
Rheumatic fever is caused by the antibodies created by the immune system to fight off the
infection cross-reacting with other proteins in the body. This "cross-reaction" causes the body
to essentially attack itself and leads to the damage above. Globally, GAS has been estimated
to cause more than 500,000 deaths every year, making it one of the world's leading
pathogens. Group A Streptococcus infection is generally diagnosed with a rapid strep test or
by culture.

References
Osteomyelitis, Wikipedia, the free encyclopedia.
https://en.wikipedia.org/wiki/Osteomyelitis
Osteomyelitis symptoms, WebMD.
http://www.webmd.com/pain-management/osteomyeltis-treatment-diagnosissymptoms
Osteomyelitis, Prognosis.

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https://medlineplus.gov/ency/article/000437.htm
Strep throat, Streptococcal bacteria, Mayo Clinic.http://www.mayoclinic.org/diseasesconditions/strep-throat/symptoms-causes/dxc-20165964
Streptococcus bacteria, Group A, Wikipedia.
https://en.wikipedia.org/wiki/Streptococcus
Streptococcus A image.
http://app.griffith.edu.au/sciencesimpact/streptococcus-a/
Osteomyelitis, Google images.
https://www.google.com/search?q=osteomyelitis
+treatment&biw=1220&bih=593&espv=2&source=lnms&tbm=isch&sa=X&sqi=2&ved=0ahU
KEwjW0dLkx5XOAhUG-GMKHQWvBBwQ_AUIBigB#tbm=isch&q=osteomyelitis

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