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We report a case of infectious osteitis pubis following a first trimester abortion in a female seropositive for the human immunodeficiency virus (HIV). Joint aspiration yielded Pseudomonas aeruginosa and the patient was successfully treated with oral ciprofloxacin.
The chemotactic response of peripheral blood polymorphonuclear leukocytes (PMNs) to N-formyl-methionyl-leucyl-phenylalanine was determined in four groups of persons (I) 19 patients with pustulosis palmoplantaris (PPP) and skeletal disorder (pustulotic arthro-osteitis); (II) 15 patients with a similar anterior chest wall involvement, but no PPP; (III) 9 patients with PPP, but without skeletal involvement, and (IV) 69 healthy adults (controls). The chemotactic activity of PMNs was found to be significantly increased in groups I-III, and patients with a similar osteoarthropathy, but no PPP compared with the controls. Furthermore the patients with pustulotic arthrosteitis had enhanced chemotactic activity compared with the patients with PPP only. This indicates that both skeletal involvement and PPP are somehow related to the function of PMNs. Colchicine was found of benefit in 2 of 3 group I, and in 6 group II patients, and it normalized their PMN chemotaxis.
Sixty-four cases of acute haematogenous osteitis have been reviewed. The majority of these patients have been treated by high dose intravenous bolus injection of Cloxacillin. With this regime a primary healing rate of 96.8 per cent was achieved with a surgical intervention rate of 4.6 per cent. It is concluded that routine surgery is not required in the treatment of this condition and that the mainstay of treatment should be vigorous antibiotic therapy.
The "gracilis syndrome," a fatigue fracture of traumatic etiology involving the bony origin of the gracilis muscle at the pubic symphysis, is akin to traumatic osteitis pubis and injuries of the adductor longus muscle origin. It is a well-recognized and reported injury in European athletes, but has received less attention in North America. This paper describes a case of this syndrome in a 23-year-old male athlete with a 2-year history of groin, perineal and medial thigh pain, of gradual onset, associated with his participation in rather violent contact sports. The only positive finding on examination was the belated appearance of local tenderness over the symphysis pubis. Radiographically, a bony fragment, including the inferior corner of his left pubis at the symphysis, could be identified. This lesion was surgically excised, and the patient was relieved of his symptoms. The histopathological features of the fragment revealed both viable and nonviable bony trabeculae embedded in fibrous tissue, suggesting that the lesion is an avulsion type of fatigue fracture with the avulsion related to the directional pull of the gracilis muscle.
This study presents the results of treatment of osteitis pubis in 12 intercollegiate athletes. Early in this series, athletes were treated with prolonged rest, oral antiinflammatory medications, and hip-stretching exercises. Of the nine athletes treated in this manner, only one resumed symptom-free activity after 16 weeks of therapy; eight remained symptomatic and subsequently received a corticosteroid injection (1 ml 1% lidocaine, 1 ml 0.25% bupivacaine, and 4 mg dexamethasone) into the pubic symphysis. Of these eight athletes, three returned to full participation within 3 weeks of injection, four required a second injection to alleviate their symptoms, and one was unable to resume athletic activities despite two injections and an inguinal herniorrhaphy. In recent years, we have recommended an injection if treatment. Three athletes received a corticosteroid injection when their symptoms did not resolve. All three returned to full athletic competition within 2 weeks of the injection. The results of our study suggest that a more rapid return to intercollegiate athletics can be achieved through the judicious use of corticosteroid injections.
Serum concentrations of 1,25-dihydroxyvitamin D [1,25-(OH)2D] and immunoreactive parathyroid hormone were measured before and for 7 months after the removal of a 15-g parathyroid adenoma from a 44-yr-old woman with primary hyperparathyroidism and severe osteitis fibrosa cystica. Despite the fall in parathyroid hormone levels from preoperative levels of 20 to 1--2 ng/ml after surgery (normal, up to 1.2 ng/ml), serum 1,25-(OH)2D concentrations remained markedly elevated (156 pg/ml) preoperatively; 124 pg/ml 17 weeks postoperative), approaching the normal range (18--56 pg/ml) only after 5 months (65 pg/ml). Hypocalcemia and hypophosphatemia persisted despite oral 1,25-(OH)2D3 (1 and 2 micrograms/day) and large doses of (oral and iv) calcium gluconate (up to 30 g/day). Healing of the skeletal lesions, reversal of the myopathy, and return of 1,25-(OH)2D circulating levels to normal corresponded to the time when serum phosphate became normal. The stimulus for the persistently elevated serum 1,25-(OH)2D levels may have been hypocalcemia per se, low serum phosphate, or an unidentified signal that paralleled serum phosphate, as serum PTH levels remained in the upper normal range throughout the recovery period.
SAPHO syndrome stands for synovitis, acne, pustulosis, hyperostosis and osteitis. The common site of skeletal lesions in this syndrome is the sternocostoclavicular area. Spondylodiscitis is rarely described in published studies. In general, skin lesions develop before the onset of skeletal lesions. We report a case of SAPHO syndrome in which spondylodiscitis developed more than 1 year before the onset of pustulosis.
Osteoblastic osteitis is a rare kind of bone infection typified by a proliferative reaction of the periosteum and by exuberant bone formation. In the maxillary sinus, it occurs as a consequence of chronic or recurrent sinusitis. It usually manifests with a vague facial discomfort, followed by complications in the deep facial spaces or fossae. The diagnosis is a radiological one. Eradication of this bone infection necessitates removal of the precipitating condition as well as the long-term administration of appropriate anti-biotics. In the case of a deep facial fossae abscess, drainage is mandatory.
We reviewed 16 patients with salmonella osteitis or septic arthritis. All patients were immunologically normal and none had a history of typhoid fever. We discuss the importance of obtaining a bacteriological diagnosis and provide guidelines on the duration of antibiotic treatment.
In an open prospective study, the efficacy and tolerability of ofloxacin in the treatment of chronic post-traumatic osteitis was examined in 83 patients. 103 different pathogens were isolated. More than 75% were Gram-positive bacteria with Staphylococcus aureus occurring in 61% of cases. After ofloxacin treatment bacteriological elimination was more than 90% for both Gram-positive and Gram-negative species, leading to a clinical cure in 85% of patients. Reinfection occurred in 5% of patients. These values were obtained from follow-up examinations which were carried out at least 6 months after the end of therapy. The tolerability of ofloxacin was excellent and no drug-related allergic reactions or side effects were observed. In conjunction with adequate surgical treatment, ofloxacin proved to be a useful antibacterial agent in the therapy of chronic bone infection.
It is estimated that 66% of patients with Paget's disease have involvement of the pelvis and 46% of the proximal femur. Therefore, it is not unexpected that hip pain is one of the major presenting complaints. Analysis of the radiographs of 25 hips with one or more articular sufaces involved by Paget's disease demonstrated narrowing in 24. Unlike the findings in primary degenerative joint disease, the majority of cases had a radiographic pattern characterized by uniform narrowing of the articular cartilage and minimal hypertrophic changes. Pathologic correlation was obtained from specimens of four patients who underwent total hip replacements. The pathogenesis of arthritic changes associated with osteitis deformans is not established. The evidence presented suggest that cartilagenous narrowing results from a disturbance in endochondral bone formation related to the hyperemia of Paget's disease. Secondary deformities of bone produce further derangement of joint mechanics. The secondary degenerative changes which ensue differ mechanically, and therefore radiographically, from primary degenerative joint disease.
Two patients developed osteitis pubis after transrectal aspiration biopsy of the prostate. We recommend that prophylactic antibiotics should be given before all such procedures.
Eight patients with a radiological diagnosis of Osteitis condensans ilii (OCI) had clinical features similar to those of 8 patients with sacro-iliitis (SI). The X-ray appearances may be very difficult to differentiate on standard films and discrimination between the two conditions has to be made from a combination of clinical and radiological findings. The term OCI should be regarded with suspicion when applied to young people with a history of backache.
The synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome is a recently described, currently evolving clinical entity that groups together several idiopathic disorders of bone and skin formerly described under a variety of names. Among the spectrum of possible locations for the bone lesions, there is no previous report in the literature of primary involvement of the skull vault. A patient with primary involvement of the calvaria in the setting of SAPHO syndrome is described here, which, to the authors' knowledge, is the first report of such localization. The clinically and radiologically benign evolution of the different stages of the bone lesions is presented. The authors suggest that the SAPHO syndrome should be considered in the differential diagnosis of lytic, sclerotic, or hyperostotic lesions of the skull, particularly before considering invasive diagnostic procedures.
The SAPHO syndrome is a rare constellation of signs and symptoms characterized by synovitis, acne, pustulosis, hyperostosis, and osteitis. The most common musculoskeletal complaints are hyperostosis, causing pain, tenderness, and swelling of the anterior chest wall, although any part of the axial and appendicular skeleton may be affected. There is a great degree of variability in the dermatologic involvement of this syndrome. A combination of clinical, radiographic, and pathological investigation is required to establish the correct diagnosis. No single treatment has been found to be effective, although nonsteroidal antiinflammatory drugs have been the most frequently used. Because there is no mention of SAPHO syndrome in the English orthopaedic literature, and pediatric orthopaedic surgeons may be the first caregivers to treat these children, we thought it appropriate to share our experience with a 5-year-old boy with SAPHO syndrome recently under our care.
Benign necrotizing osteitis of the external ear canal is a process of unknown origin. This necrotic process with sequestration of the tympanic bone occurs in healthy, non-diabetic patients. It should be differentiated from malignant otitis externa and radionecrosis of the tympanic bone. A case is reported and the literature on this rare clinical entity is discussed.
A 3-year old male presented with a 12-month history of painless scalp swellings associated with cough, fever and night sweats. Physical examination showed tender, fluctuant, pulsatile right frontotemporal and temporoparietal masses. Skull radiographs showed osteolytic skull lesions in the frontal and temporal bones. Microscopy of drained caseous material and histology of biopsies from the affected bone edges confirmed tuberculous osteitis. Though there was an initial response to antituberculous agents, the child died after 5 weeks from hepatic failure. Tuberculosis of the skull bones though rare, may become more common with the recent upsurge of tuberculosis worldwide. A high index of suspicion is necessary for early diagnosis and treatment.
Cortical septic osteitis is defined as a predominant or exclusive infection of the cortex which may lead to diagnosis pitfalls. With the two cases presented here, principal radiological features allowing a correct diagnosis are recalled.