Osteomyelitis ( OM) is the infectious inflammation of bone marrow.[ The feet, spine, and hips are the most commonly involved bones in adults.]
The cause is usually a bacterial infection,[ but rarely can be a fungal infection.][ Risks for developing osteomyelitis include diabetes, intravenous drug use, prior splenectomy, and trauma to the area.][ Diagnosis is typically suspected based on symptoms and basic laboratory tests as C-reactive protein and erythrocyte sedimentation rate. This is because plain are unremarkable in the first few days following acute infection.][ Diagnosis is further confirmed by , medical imaging, or bone biopsy.][
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Treatment of bacterial osteomyelitis often involves both antimicrobials and surgery.[ Treatment outcomes of bacterial osteomyelitis are generally good when the condition has only been present a short time.][ Treatment of the relatively rare fungal osteomyelitis as mycetoma infection entails the use of antifungal medications.][ About 2.4 per 100,000 people are affected by osteomyelitis each year.][ Males are more commonly affected than females.]
Signs and symptoms
Symptoms may include pain in a specific bone with overlying redness, fever, and weakness and inability to walk especially in children with acute bacterial osteomyelitis.[ Onset may be sudden or gradual.][ Enlarged lymph nodes may be present.][
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Cause
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| Newborns (younger than 4 mo) | Staphylococcus 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. |
Acute osteomyelitis almost invariably occurs in children who are otherwise healthy, because of rich blood supply to the growing bones. 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 1–3% of patients with pulmonary tuberculosis.[Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Mitchell, Richard N. (2007). Robbins Basic Pathology (8th ed.). Saunders Elsevier. pp. 810–11 ]
Staphylococcus aureus is the organism most commonly isolated from all forms of osteomyelitis.
Osteomyelitis is often caused by Staphylococcus aureus.
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 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 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 ). Tubercular osteomyelitis of the vertebral column 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.
Pathogenesis
In general, microorganisms may infect bone through one or more of three basic methods
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Via the bloodstream ( haematogeneously) – the most common method
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From nearby areas of infection (as in cellulitis), or
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Penetrating Physical trauma, including iatrogenic causes such as joint replacements or internal fixation of Bone fracture, leading to a fracture-related infection,
The area usually affected when the infection is contracted through the bloodstream is the metaphysis of the bone.
Chronic osteomyelitis may be due to the presence of intracellular bacteria.[Ellington. "Microbial Pathogenesis" (1999).] Once intracellular, the bacteria are able to spread to adjacent bone cells.[Ellington Journal of Bone and Joint Surgery (2003).] At this point, the bacteria may be resistant to certain antibiotics.[Ellington. Journal of Orthopedic Research (2006).] These combined factors may explain the chronicity and difficult eradication of this disease, resulting in significant costs and disability, potentially leading to amputation. The presence of intracellular bacteria in chronic osteomyelitis is likely an unrecognized contributing factor in its persistence.
In infants, the infection can spread to a joint and cause arthritis. In children, large subperiosteal 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, vertebrae, maxilla and the Human mandible are especially susceptible to osteomyelitis.
Diagnosis
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.
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 has 90% accuracy in diagnosing osteomyelitis.
Diagnosis of osteomyelitis is often based on radiology results showing a lytic center with a ring of sclerosis.
Factors that may commonly complicate osteomyelitis are fractures of the bone, amyloidosis, endocarditis, or sepsis.
Classification
The definition of osteomyelitis (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 osteosclerosis (pathological increased Bone density) are 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 reflects a balance between the type and severity of the cause of the inflammation, the immune system, and local and systemic predisposing factors.
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Suppurative osteomyelitis
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Acute suppurative osteomyelitis
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Chronic suppurative osteomyelitis
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Primary (no preceding phase)
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Secondary (follows an acute phase)
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Non-suppurative osteomyelitis
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Diffuse sclerosing
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Focal sclerosing (condensing osteitis)
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Proliferative periostitis (periostitis ossificans, Garré's sclerosing osteomyelitis)
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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.
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. Some studies of children with acute osteomyelitis report that antibiotic by mouth may be justified due to PICC-related complications.
Due to insufficient evidence it is unclear what the best antibiotic treatment is for osteomyelitis in people with sickle cell disease as of 2019.
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.[Putland M.D, Michael S., Hyperbaric Medicine, Capital Regional Medical Center, Tallahassee, Florida, personal inquiry June 2008.] Local and sustained availability of drugs have proven to be more effective in achieving prophylactic and therapeutic outcomes.
Before the widespread availability and use of antibiotics, maggot were sometimes maggot therapy to the wounds to feed on the infected material, effectively scouring them clean.
There is tentative evidence that bioactive glass may also be useful in long bone infections.
Hemicorporectomy is performed in severe cases of Terminal Osteomyelitis in the Pelvis if further treatment won't stop the infection.
History
The word is from Greek words ὀστέον osteon, meaning bone, μυελός myelos meaning marrow, and -ῖτις -itis meaning inflammation.
In 1875, American artist Thomas Eakins depicted a surgical procedure for osteomyelitis at Jefferson Medical College, in an oil painting titled The Gross Clinic.
Canadian politician and premier of Saskatchewan Tommy Douglas suffered from osteomyelitis as a child, and in 1910, underwent several surgeries, which the surgeon performed for free in exchange for allowing his medical students to observe the procedures (which Douglas's parents could not have otherwise afforded). This experience convinced him that medical care should be free for everyone.
Fossil record
Evidence for osteomyelitis found in the fossil record is studied by paleopathologists, specialists in ancient disease and injury. It has been reported in fossils of the large carnivorous dinosaur Allosaurus fragilis.
See also
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