PT CASE: OSTEOMYELITIS

(INSTRUCTOR VERSION)

By Dan Waldman, MD
Department of Family and Community Medicine

GOALS FOR SESSION

At the end of the session, the residents should:

1. Know the basic presentation of osteomyelitis
2. Know which lab tests may be helpful in suspected osteomyelitis, and their
limitations
3. Have a basic understanding of which imaging modalities to use in the
evaluation of osteomyelitis
4. Have a basic understanding of treatment options in osteomyelitis

CASE PRESENTATION WITH QUESTIONS

You are working in clinic, mostly seeing a mix of other providers’ patients, and acute
care visits. You’ve seen 3 URI’s and a few young people with mechanical back pain,
when in walks another patient with back pain. This patient is an 85 year old man
with a history of only “arthritis” in his knees and back. He states that he has had the
new onset of back pain in his mid to low back for the last 3 weeks. He was seen 2
weeks ago, and prescribed Tylenol with codeine and told to follow up in a few weeks.
There was no specific trauma or injury, and the pain does not radiate. He has taken
ibuprofen with only mild improvement. The pain is not relieved by any positional
changes. His pain has been worsening for the last couple weeks.

 Q. What are some of the specific questions you would want to ask
this patient about his back pain?

A. There are many questions at this point since the history was so brief. The
key here is to begin to identify possible “red flags.” Potential red flags in a
back pain history are: age more than 50 years, history of cancer, fever,
unexplained weight loss, pain that is worse at rest, a history of IV drug
use, symptoms of an underlying infection (such as dysuria), incontinence,
or pain that lasts more than 6 weeks.

The patient has no fevers, chills, night sweats or pain anywhere besides his back, He
denies new bowel or bladder symptoms, though he did have dysuria a few weeks ago
that resolved on its own. The patient has a history of “skin cancer” for which he sees
dermatology at the VA and has only needed superficial treatments, such as biopsies
and freezing with liquid nitrogen. He also has a history of BPH, and chronic
symptoms of urinary hesitancy.

1

Hemoglobin is 12. What would be a couple basic tests you could order for the beginning of the workup? A. but nothing more specific. is concerning for chronic infection.  Q. metastatic disease or infection. Other basic tests. strength and sensation testing are normal. The X-ray is helpful. In this case. Additionally. The ESR is elevated at 104 mm/hr. The patient’s age though puts him at risk for some more serious causes of back pain. spinal stenosis.  Q. You notice a recent PSA of 6. What are some potential causes of this patient’s back pain on your differential? A. The radiologist gives a differential for the density that includes disc herniation. the results of the electrophoresis tests are normal. vasculitis or multiple myeloma. You arrange from admission from your clinic.  Q. How do you interpret these findings and the overall picture so far? A. metastatic tumor. The elevated ESR. A CT is obtained and shows an abnormal soft tissue density extending from the midbody of the L3 to L4 vertebra.  Q. The patient’s mildly elevated PSA may not be meaningful.  Q. Straight leg raising does not worsen the patient’s pain. as well as blood and urine cultures. The patient’s back exam is notable for tenderness of the paraspinal muscles at about T5. osteoporosis with a resulting compression fracture would be high on the differential. Your prostate exam reveals a diffusely enlarged prostate without nodules. Compression fractures. and otherwise normal vital signs. and infection. such as metastatic disease. The patient has a normal temperature. You also obtain a CBC which shows a white count of 9400 with 70% neutrophils. What are some other imaging modalities that can be attempted for further evaluation? 2 . Given the patient’s age. to facilitate continued workup. and the chem.-7 and LFT results are normal. A serum and urine protein electrophoresis should be ordered as well. but non-diagnostic in this case. Reflexes. An ESR and X-Ray would be a good place to start.0 ng/ml. such as chemistry panels and LFT’s could also be helpful. however. What are the next steps in the workup? A. The X-ray shows degenerative changes in the T1-T6 vertebra.5. metastatic lesions from prostate cancer are usually blastic and visible on X-ray. Further imaging is probably the next step. are usually seen on plain films. if present. Mechanical back pain from an unperceived strain is also possible.

If the second attempt yields no organism. and shows destruction of the endplates of the L3 and L4 vertebral bodies. Oral treatment of acute osteomyelitis in children has been accepted for many years. What should you do next? A. the use of illicit drugs contaminated by candida species and prolonged neutropenia. An MRI is obtained. The differential remains infectious or metastatic. S. and from patients with urinary catheters in place (Lew DP W. F. which typically involves two adjacent vertebras and the disc space between them. The specific organisms encountered vary depending on the clinical scenario and the age of the patient. but may not be able to differentiate between soft tissue infection. with destruction of the disc space between them.  Q. Fungal osteomyelitis is a complication of catheter-related fungemia. degenerative joint disease. If the cultures from the first biopsy are negative another biopsy can be performed. Cytology is negative for malignant cells. Cultures obtained of the fluid are pending. How long should antibiotics be given for? Traditionally. Cultures can be negative. though the treatment in adults has traditionally been 3 .  Q. aureus is found later in life. 4-6 weeks of antimicrobial therapy are used for treatment of osteomyelitis. and gram-negative rods are found in the elderly. the options are then empiric treatment or open surgical biopsy. especially involving the spine. and can give help delineate the extension of anatomic abnormalities caused by the disease process.  Q. aureus and streptococci are typical in neonates. most likely staph aureus. A fine-needle aspiration biopsy of the L3-L4 disc space reveals blood-tinged. What are the most likely organisms to gear empiric therapy towards?  A. A guided biopsy performed by interventional radiology should be performed next. 2004). 1997). slightly cloudy fluid. but no organisms. The rationale for this duration is based on the results of animal studies and the observation that revascularization of bone after debridement takes about four weeks (Lazzarini L MD. In this case.. Bone scans can be helpful in the diagnosis of many conditions that have increased bone metabolic activity. What would be the best next step in diagnosis? A.  Q. S. healing fractures or stress fractures. What about using oral antibiotics? A. MRI can be helpful in unclear situations.  Q. A. The combination of the MRI findings and the negative cytology suggest vertebral infection. so multiple specimens should be obtained on biopsy. Gram staining shows numerous white cells. Pseudomonas can be isolated from injection-drug addicts.

and 6% of patients with nonspecific mechanical low back pain who do not have a spinal infection (Deyo. Osteomyelitis and diskitis are rare causes for back pain presenting to a primary care physician’s office. 1986). Hematogenous spread is more common in children and elderly patients. “Subacute” osteomyelitis is often used for the middle ground of a few weeks of mild symptoms (see below). or even years. the lack of fever and white count is not uncommon for vertebral osteomyelitis.” as signs for more than 10 days can correlate roughly with the development of necrotic bone (Lew DP. The important points with this case are recognizing that this patient had some warning signs (age. warranted an aggressive workup. and chronic to be evolving over weeks to months. which when combined with the patient’s age and symptoms. Chronicity: Acute vs.. Most consider “acute” to be evolving over several days to weeks. One study estimated that fever was present in only 52% of patients with pyogenic osteomyelitis and only 4% of patients with diskitis (Deyo. This has been best studied in the use of quinolone antibiotics (Mader JT. 1986). Leukocytosis is present in only about 43% of patients with spinal infection. 4 . F. but the absence does not substantially decrease the odds. The hallmark of chronic osteomyelitis is the presence of dead bone. Classification There are a few different ways to classify osteomyelitis. including the chronicity of the infection and the amount of inflammation present. and 2) the underlying pathogenesis. with cure rates of 92% being seen for enterobacter. Likewise an ESR greater than 100 is also significantly associated with a serious underlying cause of back pain. though in one review the success rates may differ by organism. There are many differences of opinion. aureus (Lew DP W. 72% for pseudomonas and 75% for staph. 1990). “Sequential treatment” involves starting a patient with intravenous antibiotics for a week or two. Additionally. OSTEOMYELITIS REVIEW Introduction Osteomyelitis is a difficult disease to diagnose. or local inoculation following surgery or trauma. and presence of pain in all positions) for further workup. In general. some state that more than 10 days of symptoms means “chronic. worsening over a few weeks. it should be categorized by 1) the chronicity of the infection. Thus the presence of elevated white count and fever increase the odds of spinal infection significantly. This is not helped by the lack of good quality studies that evaluate different clinical criteria for the diagnosis of osteomyelitis. Pathogenesis: hematogenous spread of bacteria. contiguous spread from soft tissue infection. Osteomyelitis after injury is the most prevalent type and is usually associated with open fractures or after orthopedic surgery to repair injured bones. 1995). as many factors can affect the accuracy of tests. intravenous for most acute and chronic cases. 1997). and then switching to oral antibiotics for completion of treatment. chronic. Diagnostic tests must be tailored to the specific clinical scenario.

in patients with a foot ulcer and diabetes (in the absence of end stage renal disease). ESR greater than 100 mm/hr is highly sensitive. significant elevation of the periosteum and thickening of the periosteum. Blood cultures are positive in 50% of cases in acute osteomyelitis. The pain occurs with and without movement. but bone changes take 2-3 weeks to be evident. These include elevated ESR and elevated white counts.  CT (with and without contrast): Can detect cortical destruction. In fact. bone infarcts or healed osteomyelitis.Symptoms  Typical acute osteomyelitis presents with bone pain. As an example.  MRI: Especially useful in imaging the vertebra and the infected foot. The difficulty arises in the unfortunately not uncommon cases of suspected osteomyelitis associated with orthopedic prosthesis. or exclude other conditions. tenderness.  Osteomyelitis of the hip. 1991). though patients often have no constitutional symptoms. warmth and swelling developing over several days to a week. but the sensitivity and specificity of this modality needs further evaluation. A positive blood culture and radiologic evidence of osteomyelitis obviates the need for a bone biopsy. Also helps in providing pre-op detail for surgical debridement. MRI can have false positive results in fractures. Some situations may be complicated by bone changes from other processes. and rigors are occasionally present. periosteal new bone formation and sequestra (piece of dead bone separated from the bone in the process of necrosis). Osteomyelitis cannot be excluded if plain films are negative.  Ultrasound: Can reveal fluid collections adjacent to bone. but non-specific for diagnosing osteomyelitis (Newman.  Bone Scan: Three phase bone scan can differentiate cellulitis from osteomyelitis. Many patients are febrile. The three phase technetium bone scan is considered by many the test of choice in evaluating for acute osteomyelitis in cases 5 . Labs  Routine labs are non-specific. decubitus ulcers and foot ulcers from diabetes and/or vascular insufficiency. Radiologic Evaluation  Plain films: inexpensive but insensitive. May help diagnose or choose further studies. periosteal reaction and soft tissue extension. vertebrae and pelvis are known for presenting with very few symptoms  Chronic osteomyelitis is easy to diagnose in patients with previously diagnosed and treated osteomyelitis who then have the recurrence of pain or inflammation in the same place. Chronic osteo can be seen on plain films with bone sclerosis. Soft tissue swelling + bone destruction + periosteal reaction is fairly specific for osteomyelitis. including diabetic feet. MRI may be the best modality for evaluating the foot for osteomyelitis. intraosseous gas.

 Dual Tracer Scans: Combine an inflammation imaging tracer (indium or gallium) with an “anatomic” tracer (a technetium labeled bone scan or marrow scan). 1996). diabetic feet. 1996). The following clinical findings were noted in a review of 35 patients with limb-threatening diabetic foot ulcers (Newman. of normal plain films.  Osteomyelitis associated with infected overlying wounds can present a challenge for biopsy. The bone scan portion provides good sensitivity. though needle biopsy is commonly used for practical reasons. (the whole process can take 2-3 days from the time ordered). Bone biopsy may be warranted as well in patients with decubitus ulcers and clinical suspicion of osteomyelitis. is the gold standard. such as after a traumatic injury. The quality of the studies available for the meta-analysis was generally variable (Termaat MF. repeating the needle biopsy. while the indium labeled cell scan helps localize infection to bone or soft tissue (Ghiorzi. so if the clinical suspicion is high and the needle biopsy is negative. Correlation of the microbiology of the overlying wound and that of the causative organism of the osteomyelitis is generally poor. Note that open biopsy. even with normal labs and imaging. Bone Biopsy  Gold standard for the diagnosis of osteomyelitis. inflammatory bone diseases. septic arthritis. 1991): 6 . avoiding the wounded tissue. cancer. This test is time consuming as it takes time to obtain the tracer and tag the patient’s cells. 2006).  Indium labeled leukocyte scan: Useful at evaluating for osteo at sites of fracture nonunion. following surgery. 2001). or performing an open biopsy should be done. 2005). healed osteo and Paget’s disease (Schauwecker. are at high risk for osteomyelitis. but still relatively unspecific. False positive results though can be seen in any situation that causes increased bone turnover.  PET Scan: Recent meta-analysis shows PET scanning to be the most accurate single test to diagnose chronic osteomyelitis. Similar results were seen in the combination of bone scans and white cell scans (dual tracer scans). especially if they are located over bony prominences. Sampling error reduces the sensitivity and specificity of needle biopsy somewhat. with a sensitivity and specificity near 95% (Schauwecker. so biopsy of the bone should still be attempted (Khatri G. Better than bone scans in evaluation of diabetic feet. Diabetic Foot Ulcers Associated with Osteomyelitis Patients with diabetes and soft tissue infections for more than two weeks.

After the biopsy is obtained. Early antibiotics limit the development of bone destruction or necrosis. but often 6 weeks. compared to four of 26 (15 percent) without osteomyelitis. In the past this meant nafcillin plus cefotaxime or ceftriaxone. but nafcillin is being replaced more and more with vancomycin with increasing MRSA prevalence. In another report of 76 patients with infected diabetic foot ulcers. especially when the chances for success with antibiotics alone are slim. Treatment of Osteomyelitis Few studies have investigated the optimal treatment for osteomyelitis. A clear discussion regarding the pros and cons of antibiotics versus surgical debridement should be undertaken with the patient.  All patients with ulcers that exposed bone were associated with underlying osteomyelitis. A probe could be passed directly to bone in 33 of these patients (66 percent). and must be parenterally administered for at least 4. Most recommendations are therefore based on expert opinion. debridement may be necessary as well. 1995). amputation of the limb may be required.  An erythrocyte sedimentation rate greater than 70 mm/h had a sensitivity of 28 percent and specificity of 100 percent for diagnosing osteomyelitis. Obtaining a biopsy sample is essential for proper antibiotic selection. MRI is the best imaging choice in cases of suspected osteomyelitis in cases of diabetic foot infections. 50 had contiguous osteomyelitis (Grayson. patients would need to be followed for years. removing the devitalized bone and soft tissue. As mentioned above. or in cases complicated by poor vascular supply or chronic infection. debridement complicates the utility of antibiotics. If antibiotics fail. Also. especially in cases where the pathogen has not been adequately identified.  Lesions larger than 2 cm x 2 cm had a sensitivity of 56 percent and specificity of 92 percent for osteomyelitis. In order to measure treatment success. and clinical situations and pathogens are heterogeneous.  Ulcers deeper than 3 mm were significantly more likely to overlie infected (osteomyelitic) bone than shallower ulcers (82 versus 33 percent). empiric antibiotics should be started. In the absence of good oxygen delivery to a limb with chronic osteomyelitis. by situation (in addition to plain films): Clinical Scenario Radiologic test of choice Diabetic foot infection MRI Evaluation of acute Three phase technetium bone scan 7 . These can be completed as an outpatient as appropriate. Imaging of choice in suspected osteomyelitis.

A clinical sign of underlying osteomyelitis in diabetic patients. VAMC (111). present that may degrade most materials used in orthopedics. W. R. (1991). (2005). (2001). UpToDate . Ghiorzi. D. 1:328-38. JAMA . M. T. NEJM . Grayson. AM J Med Sci . Termaat MF. (1990). Quinolones and osteomyelitis: state-of-the-art. (1986). (1995). M. J Bone Joint Surg Am . The Journal of Bone and Joint Surgery . 343(10):723-726. JAMA . 8 . patients with neuropathy. F. proceed to biopsy is either an ulcer larger than 2x2cm or bone is palpable on probing x “complicated” = complicating a fracture. vasculopathy B IB LI O GRAPHY Carek PJ. W. Diagnosis and monitring by leukocyte scanning with indium In-111 oxyquinoline. F. Osteomyelitis in Long Bones. 72:104 -10. Lew DP. or combination of bone scan and white cell scan Diabetic ulcer where there Consider no further imaging. (1995). Early diagnostic evaluation of low back pain. 266:1246. G. Schauwecker. Skeletal Nuclear Medicine. Diagnosis and Management of Osteomyelitis. Drugs . such as titanium. Lurie JD. Diagnosis of Osteomyelitis in Adults. 87:2464-71. (2004). The accuracy of diagnostic imaging for the assessment of chronic osteomyelitis: a systemic review and meta-analysis. J. CT or MRI images do not interfere with MRI. 336: 16. J Gen Intern Med . J Bone Joint Surg Am . P. Sack J (2001). NEJM. Collier. L. Sox H (2000). M. Osteomyelitis. Newman. In D. Gerber PD. Am Fam Phys.osteomyelitis in uncomplicated* cases Ferromagnetic material is Nuclear study: indium scan or dual tracer exam. Lazzarini L MD. Unsuspected osteomyelitis in diabetic foot ulcers. D. St Louis: Mosby. Lew DP. (1997). (2006). Note. Post Module Evaluation Please place completed evaluation in an interdepartmental mail envelope and address to Dr. W. Mader JT. 999-10073. Deyo. Effect of bone biopsy in guiding antimicrobial therapy for osteomyletis complicating open wounds. Department of Medicine. Probing to bone in infected pedal ulcers. 273:721. Evaluation of the spine for MRI ostei Chronic osteomyelitis PET scan if available. 63(12):2413-2420. R. Wendy Gerstein. C. Dickerson L. Khatri G. (1996). A pain in the back. Suppl 2:100-101. postop. The role of nuclear imaging in osteomyelitis. W. 86:2305- 2318 . Oral ciprofloxacin compared with standard parenteral antibiotic therapy for chronic osteomyelitis in adults. 321(6):367-71. J.

5) Please provide any further comments/feedback about this module. confusing data. or omissions? Please list/comment below: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________ 4) Was the attending involved in the teaching of this module? Yes/no (please circle). how effective was this module for learning this topic? _________ (1= not effective at all.1) Topic of module:__________________________ 2) On a scale of 1-5. 5 = extremely effective) 3) Were there any obvious errors. or the inpatient curriculum in general: 6) Please circle one: Attending Resident (R2/R3) Intern Medical student 9 .