Atypical Musculoskeletal InfectionArushka NaidooSAPOS ICL 2017

• Syphilis• Brucella• Salmonella• Hydatid Disease

Treponema Pallidum• Sphirochaete gram

negative bacterium • Obligate human

parasite• Transmission ØSexualØTransplacentalØPercutaneousØBlood transfusion –no

cases since 1964

Stages of SyphillisSTAGE CLINICAL  PRESENTATIONPrimary  Syphilis Chancre  – single   ,firm,   round  

painless  sore

Secondary  Syphilis Non  itchy,  reddish  brown  skin  rash,  mucous  membrane   lesionsSystemic  symptoms-­‐ fever,  pharyngitis,   headache,  arthralgia

Tertiary  Syphilis Gumma formation  – non  specific  granulomatous   lesion   infiltrates  skin,  bone,   organs

Latent  Syphilis Positive  serological  test,  asymptomaticEarly-­‐ within  1  year  of  overt  infection  Late  -­‐ >  1  year  of  overt  infection

Neurosyphillis – central  nervous  system  infection  that  can  occur  in  any  stage

• Transplacental transmission • Can also occur perinatal • Associated with Ø Intrauterine deathØ Intrauterine growth retardationØHepatosplenomegalyØCNS : hydrocephalus, optic atrophy ,

seizuresØMusculocutaneous lesionsØLymphadenopathy

Congenital Syphilis

Congenital Syphilis

Arnold  S,  Ford-­‐Jones  EL  :Congenital  Syphilis   :  A  guide   to  Management  and  diagnosis

• identification of syphilis in the mother• adequacy of maternal treatment• presence of clinical, laboratory, or

radiographic evidence of syphilis in the neonate

• comparison of maternal (at delivery) and neonatal nontreponemal serologic titers(RPR/VDRL) using the same test, by the same laboratory.

• Any neonate at risk for congenital syphilis should receive a full evaluation and testing for HIV infection.

Management – CDC 2015

• Recommended Regimes • Aqueous Crystalline Penicillin G 100 000 –

150000 units/kg/dose IV every 12 hours during the first 7 days of life and every 8 hours thereafter for a total of ten days OR

• Procaine Penicillin G 50 000units/kg/dose IM in a single daily dose for ten days OR

• Benzathine Penicillin G 50000 units/kg/dose IM in a single dose

• Azithromycin • Ceftriaxone

Management

• Gram negative bacilli• Brucellosis Melitensis• Reservoir – goats and sheep • B Abortis -cattle, B Canis –Dogs, B Suis –

swine

Brucellosis

Transmission

• Multisystemic disease• Broad spectrum clinical manifestations

• Adults – spine is commonly affected• Children – arthralgia , osteitis

• Subclinical brucellosisasymptomatic, incidentally after serologic

screening of persons at high risk of exposure.

• Acute and subacute brucellosis• Disease can be mild and self-limited (eg, B

abortus) or fulminant with severe complications (eg, B melitensis)

• acute brucellosis occurs without focal abnormalities.

• Nonfocal weakness • the tissues overlying the spine or peripheral

nerves may be tender to percussion. • Tenderness, swelling, or effusion of joints

• Brucella organism localises in the synovium

• Synovitis with a sterile serosanguinous fluid

• Similar process occurs in muscle and tendons

• Bone marrow infiltrated = osteomyelitis

Mona  et  al  Radiographs  1994  :Imaging   features  of  Brucellosis  

• Chronic - symptoms for more than a year• Relapsing – symptoms 2-3 months after

treatment

• Background: Brucellosis is a systemic infection with a various clinical manifestations ranging from asymptomatic infection to serious and fatal diseases. In endemic area, one-third of all cases of human brucellosis have been reported in children.

• Objectives: This study aimed to evaluate epidemiology, clinical presentation, and treatment outcome of brucellosis among children in Zahedan City.

• Patients and Methods: During 36 months, from December 2008 through October 2011, we evaluated all patients younger than 19 years old who were referred to Infectious Diseases Clinic in Boo-Ali Hospital (Zahedan City, southeastern Iran). The patients were referred because of fever, myalgia, and arthralgia, chronic low-back pain, bone pain, and other signs or symptoms consistent with brucellosis and had a positive results for serology test. Titers > 1:80 were considered as positive results.

• Results: Among 32 patients with brucellosis (24 male and 8 female; age range, 7-19 years), 83% had chronic bone pain. Fever was reported in 39% and the least frequent complication was osteomyelitis (3%). Patients were treated medically and all the patients survived.

• Conclusions: Our study showed that the clinical manifestations and complication in children with brucellosis are similar to that in the adults; however, treatment can be different according to age of patients. In endemic areas, every patient with low-back pain in any age group should be evaluate for brucellosis.

• Demonstration of the agent: blood cultures in tryptose broth, bone marrow cultures.

• Demonstration of antibodies against the agent either with the classic Huddleson, Wright, and/or Bengal Rose reactions,

either with ELISA or the 2-mercaptoethanol assay for IgM antibodies associated with chronic disease• Histologic evidence of granulomatous hepatitis on

hepatic biopsy• Radiologic alterations in infected vertebrae: the

Pedro Pons sign (preferential erosion of the anterosuperior corner of lumbar vertebrae) and marked osteophytosis are suspicious of brucellicspondylitis.

Diagnosis

• Drugs that display clinical activity with low relapse rates include the following:

• Doxycycline• Gentamicin• Streptomycin• Rifampin• Trimethoprim-sulfamethoxazole (TMP-SMZ)Other agents with potential roles include the following:• Chloramphenicol• Imipenem-cilastatin• Tigecycline• Fluoroquinolones

Treatment

• Surgery – only for pyogenic collections

• Rare cause of infection • < 10% of all osteomyelitis• Associated withImmunocompromised ØSickle cell anaemiaØHIVØSLEØHaemoglobinopathy ØNeoplasms

Salmonella

• Bone infarction + sluggish microcirculation • 60-80% of osteomyelitis caused by

Salmonella• Multi site involvement• Septic arthrithis – poore prognosis –

requires surgical management

Salmonella in sickle cell disease

Salmonella   typhi Spondylitis.Govender,  S;  Parbhoo,  A;  Rasool,  M;  Maharaj,  J

Journal  of  Pediatric  Orthopaedics.  19(6):710,  November/December  1999.

• Two patients were seen at the Children's Hospital of Buffalo with an insidious onset of hip pain who were found to have salmonella osteomyelitis of the pelvis. Both patients were healthy without predisposing medical conditions and initially had normal white blood cell counts and radiographs. The purpose of this report is to alert others to the possibility of having salmonella osteomyelitis in a normal child and to provide recommendation for diagnosis and treatment.

Salmonella Pelvic Osteomyelitis in Normal Children: Report of Two Cases and a Review of the LiteratureSucato, Daniel J. M.D.; Gillespie, Robert M.B., Ch.B.

• FIG.  2  .  Case  2.  A:  Bone  scan  of  the  pelvis  performed   10  days  after  the  onset  of  symptoms  on  the  first  admission  at  our   institution  demonstrating  no  focal  uptake.  B:  Gallium  scan  of  the  pelvis  1  week  after  the  bone  scan,  demonstrating  exuberant  uptake  in  the  region  of   the  right  hip.  C:  A  T2-­‐weighted  MRI  coronal  image  taken  3  days  after  the  gallium  scan,  demonstrating   a  signal  change  in  the  anterior  column  of  the  right  acetabulum,  which  extends  anteriorly  into  the  soft  tissues  (dark  arrow).  D:  A  coronal  CT  image  performed   on  the  same  day  as  the  MRI,  demonstrating   destruction  of  the  anterior  column  of  the  acetabulum.

©  Lippincott-­‐Raven  Publishers.    Published  by  Lippincott  Williams  &  Wilkins,  Inc. 2

FIG.  3Salmonella   Pelvic  Osteomyelitis  in  Normal  Children:  Report  of  Two  Cases  and  a  Review  of  the  Literature.Sucato,  Daniel;  Gillespie,  Robert

Journal  of  Pediatric  Orthopaedics.  17(4):463-­‐466,  July/August  1997.

FIG.  3  .  Case  2.  An  anteroposterior  roentgenogram  taken  on  the  second  admission  at  our  institution,  17  days  after  the  onset  of  symptoms,  demonstrating  a  soft-­‐tissue  shadow  along  the  iliopectineal   line  of  the  right  pelvis  (dark  arrow).

FIG.  3  .  Case  2.  An  anteroposterior  roentgenogram   taken  on  the  second  admission  at  our  institution,   17  days  after  the  onset  of  symptoms,  demonstrating  a  soft-­‐tissue  shadow  along  the  iliopectineal line  of   the  right  pelvis  (dark  arrow).

Diagnosis • Blood, pus, urine cultures• Widal test • Surgery • Medical – chloramphenicol , ceftriaxone,

ampicillin

• Larval form of the cestode worm Echinococcus granulosis

• E Granulosis – cystic form• E multilocularis – alveolar form

Hydatid

• Spine• Long bones• Illium• Skull• Ribs• Scapula• Sternum

Sites involved

• Embryos are deposited in bone• Destruction by mechanical pressure

without an inflammatory response• No pericyst formation • Parasite expands along path of least

resistance• Can be latent for years

Unusual cause of paraplegia in a child of 5 years

Nausheen Khan; Irma VandewerkeDepartment of Radiology, Kalafong Hospital and University of Pretoria, South Africa

©  2007  Lippincott  Williams  &  Wilkins,  Inc. 2

Fig  1Intermittent  Leg  Pain  and  Swelling  in  a  30-­‐year-­‐old  Man.Alemdaroglu,  Kadir;   Iltar,  Serkan;  Pulat,  Haluk;  Atlhan,  Dogan

Clinical  Orthopaedics  &  Related  Research.  462:248-­‐254,  September   2007.DOI:  10.1097/BLO.0b013e31803bbae7

Fig  1  A-­‐B.  (A)  Anteroposterior  and  (B)  lateral  radiographs  of  the  left  tibia  taken  preoperatively   reveal   the  multiloculated,  or  bunch  of  grapes,  appearance  of  the  lesion.

Intermittent  Leg  Pain  and  Swelling  in  a  30-­‐year-­‐old  Man.Alemdaroglu,  Kadir;   Iltar,  Serkan;  Pulat,  Haluk;  Atlhan,  Dogan

Clinical  Orthopaedics &  Related  Research.  462:248-­‐254,  September   2007.DOI:  10.1097/BLO.0b013e31803bbae7

Xray• CT, MRI, and ultrasound • The presence of hydatid sand in aspirated

cyst fluid is diagnostic.• Serologic tests (enzyme immunoassay,

immunofluorescent assay, indirect hemagglutination assay) are variably sensitive but are useful if positive and should be done.

• eosinophilia

Diagnosis

• Tuberculosis• Fibrous dysplasia• Enchondroma• Metastatic disease• Plasmacytoma• Mutiple myeloma• Haemangioma• Giant cell tumour

Differential diagnosis

• Surgical debridement• Chemical sterilization -Scolices –

hypertonic saline, formalin or 0.5% silver nitrate

• Albendazole

Management