CLINICAL COMMUNICATION TO THE EDITOR

Stubborn Creatures: Dormant Staphylococcus aureus is the most common cause of

Staphylococcus aureus osteomyelitis and very probably caused the patient’s acute
illness when she was a child by hematogenous spread,
To the Editor: typically involving the metaphysis of a long bone.3 The
associated intense inflammatory response often compro-
mises medullary and periosteal blood supply, leading to
A healthy 70-year-old woman was admitted with a 3-day dead bone (sequestrum) formation, the hallmark of chronic
history of a pus-emitting wound on her left shin, in the osteomyelitis. Within this necrotic ischemic tissue bacteriae
absence of trauma. She was afebrile, and examination was can be hard to eradicate, and intracellular S. aureus persis-
normal excepting a warm, erythematous and tender area tence in osteoblasts has been well documented in vitro,
over her left distal tibia with a central swollen area dis- in vivo, and in chronic osteomyelitis.4 Reactivation can
charging pus. occur after many years as in our patient, whose presenting
Hemoglobin was 11.7 g/dL, white blood cell count feature was extension through cortical bone and sinus tract
17.2  109/L, platelets 480  109/L. Erythrocyte sedi- formation (Figures 1 and 2). Blood tests may appear
mentation rate and C-reactive protein were only mildly misleadingly innocent, but thrombocytosis may be a
elevated (31 mm/h and 37 mg/L, respectively). Results of diagnostic clue.5 Sinus tract cultures may not indicate the
other blood tests were normal. Gram stain of the pus pathogenetic organism, and deep surgical specimen isolates
revealed Gram-positive cocci. Leg x-ray and computed to- are necessary. In our patient they were identical, demon-
mography showed chronic tibial osteomyelitis with cortical strating that a 65-year-old S. aureus can still matter.
perforation and sinus tract formation (Figures 1 and 2).
When asked, she remembered having leg osteomyelitis
when she was a 5-year-old child in Russia.
Pus cultures demonstrated penicillin-sensitive Staphylo-
coccus aureus. Blood cultures were negative. At operation,
debridement of subcutaneous granulation tissue and pus was
done, followed by drilling of the anterior tibial wall. Pus
under pressure came out of the bone marrow, and extensive
debridement and washings were performed. Deep surgical
biopsies grew penicillin-sensitive S. aureus. A peripherally
inserted central catheter (PICC line) was placed, and she
was discharged home for prolonged treatment with intra-
venous cloxacillin (8 g daily).
Our immunocompetent patient’s only risk factor was a
remote history of osteomyelitis that apparently healed 65
years earlier. Her current infection developed in the same
location and involved the same organism; although no re-
cords of her 1951 hospitalization were available, the isolated
S. aureus was sensitive to penicillin G, whereas the vast
majority of strains became resistant to the drug in the 1950s
and 1960s owing to its widespread use and production of b-
lactamases.1,2

Funding: None.
Conflict of Interest: None.
Authorship: AS composed the manuscript with the participation of FB Figure 1 The patient’s lateral calf x-ray on admission,
and MG. showing deformation and thickening of the distal cortex of
Requests for reprints should be addressed to Ami Schattner, MD, He- the tibia and (arrows) overlying bulging of the soft tissues,
brew University-Hadassah, Medical School, 76100 Jerusalem, Israel. with sinus tract and purulent discharge (not shown).
E-mail address: amischatt@gmail.com

0002-9343/$ -see front matter Ó 2016 Elsevier Inc. All rights reserved.
e102 The American Journal of Medicine, Vol 130, No 3, March 2017

Figure 2 (A) Axial view computed tomography scan (soft-tissue window) of distal left tibia, demon-
strating cortical thickening and perforation (arrow). The perforation communicates between the intra-
medullary space and a soft-tissue abscess in the anterior aspect of the thigh. The right leg is normal. (B)
Axial view computed tomography scan (bone window) of distal left tibia, revealing thickening of the
cortex of the tibia with periosteal reaction and anterior cortical foramen (arrow) communicating with soft-
tissue abscess.

Moshe Gelber, MDa http://dx.doi.org/10.1016/j.amjmed.2016.10.012

Frida Babushkin, MDb
Ami Schattner, MDa,c References
a
Department of Medicine 1. O’Grady FW. Twenty-one years of beating beta-lactamases. BMJ.
Laniado Hospital 1982;284:369-370.
Sanz Medical Center 2. Hassam ZA, Shaw EJ, Shooter RA, Caro DB. Changes in antibiotic
Netanya, Israel sensitivity in strains of Staphylococcus aureus, 1952-78. BMJ. 1978;2:
b
Infectious Diseases Unit 536-537.
3. Lew DP, Wadvogel FA. Osteomyelitis. N Engl J Med. 1997;336:
Laniado Hospital
999-1007.
Sanz Medical Center 4. Ellington JK, Harris M, Hudson MC, et al. Intracellular Staphylococcus
Netanya, Israel aureus and antibiotic resistance: implications for treatment of staphy-
c
Faculty of Medicine lococcal osteomyelitis. J Orthop Res. 2006;24:87-93.
Hebrew University-Hadassah, Medical School 5. Schattner A, Dubin I, Gelber M. A new diagnostic clue to osteomyelitis
Jerusalem, Israel in chronic leg ulcers. Am J Med. 2016;129:238-239.