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Inadvertent self-healing in desperate times
Case Report
Inadvertent self-healing in desperate times Sean X Leng, Thomas Finucane, Lisa Boult, Larry Zheng, William B Greenough III Lancet 2007; 370: 1458 Johns Hopkins University School of Medicine, Baltimore, MD, USA (S X Leng MD, Prof T Finucane MD, L Boult MD, L Zheng MD, Prof W B Greenough III MD) Correspondence to: Dr Sean X Leng, Johns Hopkins University School of Medicine, 5505 Hopkins Bayview Circle, Baltimore, MD 21224, USA [email protected]
In February, 2007, a 47-year-old woman was admitted to our hospital, with stage IV pressure ulcers. She had become paraplegic in 1999, after a bullet damaged the spine at the level of the 9th thoracic vertebra. Pressure ulcers developed in 2006. In December, 2006, the patient developed a high fever and was found to have worsening pressure ulcers and meticillin-resistant Staphylococcus aureus bacteraemia. Her condition improved with intravenous vancomycin and wound debridement. Because she was doubly incontinent, a Foley catheter was inserted, and a colostomy was done to reduce wound contamination. The patient was transferred to a nursing home, but developed intermittent fever, anorexia, and severe left hip pain. After several weeks, she was transferred to our hospital. On admission, she was cachectic, at 48·2 kg, and had five large stage IV pressure ulcers on the lower back and hips (figure). Her white-blood-cell count, and serum
A
B
C
Figure: Severe osteomyelitis in a paraplegic woman (A) The ulcers that are likely to have led to osteomyelitis. (B) Radiography showing displacement of the femoral head and neck. (C) The fragment of bone that fell out of an ulcer.
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concentration of C-reactive protein (CRP) were 14·2×109 per L, and 167 mg/L, respectively. Her serum concentrations of haemoglobin and albumin were only 87 g/L and 19 g/L, respectively. We started to treat her with vancomycin. For wound care, we used an antimicrobial gel. CT showed erosion of the femoral head and neck, inferior pubic ramus, and acetabulum, with fluid and air in the left hip joint. CT-guided aspiration yielded clear liquid, cultures of which were negative. Despite treatment, the patient’s condition worsened. The hip pain and fever continued; the white-blood-cell count and serum concentration of CRP rose as high as 18·5×109 per L and 257 mg/L, respectively; the serum albumin concentration fell to 13 g/L, and the patient’s weight to 43·6 kg. 6 weeks after admission, radiography showed that the femoral head and neck were separated from the rest of the femur, and medially displaced. Hours later, a bone fragment fell out of a pressure sore, while the dressing was being changed. The patient’s condition then started to improve. The fever and pain ceased immediately, and the pressure ulcers began to heal. 8 weeks after the fragment fell out, the patient’s weight had increased to 58·2 kg; the serum concentrations of haemoglobin and albumin were 128 g/L and 32 g/L, respectively; the white-blood-cell count and serum concentration of CRP were 8·25×109 per L and 22 mg/L, respectively. At the end of August, 2007, the patient remained in hospital; she had no fever, her weight was stable at 59 kg, and her wounds continued to heal. Pressure ulcers are common in elderly people, and people with spinal-cord injuries.1,2 For several years after being shot, our patient had been cared for by relatives and had been able to live at home. When a close relative died, the standard of care provided by her family decreased substantially, and a fragmented health system did not fully meet her needs. We think that the osteomyelitis was caused by infection spreading from an ulcer, either directly or through the bloodstream.3 The infected proximal femur developed avascular necrosis. Because the blood supply to the proximal femur was so poor, intravenous antibiotics were largely ineffective. Ordinarily, we would have done an excision arthroplasty, known as the Girdlestone procedure,4 to remove the infected bone. However, the patient was so ill that surgery was judged to be unacceptably risky. Fortunately, the necrotic bone dropped off, eerily mimicking the Girdlestone procedure. References 1 Byrne DW, Salzberg CA. Major risk factors for pressure ulcers in the spinal cord disabled: a literature review. Spinal Cord 1996; 34: 255–63. 2 Bates-Jensen BM. Quality indicators for prevention and management of pressure ulcers in vulnerable elders. Ann Intern Med 2001; 135: 744–51. 3 Lew DP, Waldvogel FA. Osteomyelitis. Lancet 2004; 364: 369–79. 4 Horan FT. Robert Jones, Gathorne Girdlestone and excision arthroplasty of the hip. J Bone Joint Surg Br 2005; 87: 104–06.
www.thelancet.com Vol 370 October 20, 2007
Inadvertent self-healing in desperate times Sean X Leng, Thomas Finucane, Lisa Boult, Larry Zheng, William B Greenough III Lancet 2007; 370: 1458 Johns Hopkins University School of Medicine, Baltimore, MD, USA (S X Leng MD, Prof T Finucane MD, L Boult MD, L Zheng MD, Prof W B Greenough III MD) Correspondence to: Dr Sean X Leng, Johns Hopkins University School of Medicine, 5505 Hopkins Bayview Circle, Baltimore, MD 21224, USA [email protected]
In February, 2007, a 47-year-old woman was admitted to our hospital, with stage IV pressure ulcers. She had become paraplegic in 1999, after a bullet damaged the spine at the level of the 9th thoracic vertebra. Pressure ulcers developed in 2006. In December, 2006, the patient developed a high fever and was found to have worsening pressure ulcers and meticillin-resistant Staphylococcus aureus bacteraemia. Her condition improved with intravenous vancomycin and wound debridement. Because she was doubly incontinent, a Foley catheter was inserted, and a colostomy was done to reduce wound contamination. The patient was transferred to a nursing home, but developed intermittent fever, anorexia, and severe left hip pain. After several weeks, she was transferred to our hospital. On admission, she was cachectic, at 48·2 kg, and had five large stage IV pressure ulcers on the lower back and hips (figure). Her white-blood-cell count, and serum
A
B
C
Figure: Severe osteomyelitis in a paraplegic woman (A) The ulcers that are likely to have led to osteomyelitis. (B) Radiography showing displacement of the femoral head and neck. (C) The fragment of bone that fell out of an ulcer.
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concentration of C-reactive protein (CRP) were 14·2×109 per L, and 167 mg/L, respectively. Her serum concentrations of haemoglobin and albumin were only 87 g/L and 19 g/L, respectively. We started to treat her with vancomycin. For wound care, we used an antimicrobial gel. CT showed erosion of the femoral head and neck, inferior pubic ramus, and acetabulum, with fluid and air in the left hip joint. CT-guided aspiration yielded clear liquid, cultures of which were negative. Despite treatment, the patient’s condition worsened. The hip pain and fever continued; the white-blood-cell count and serum concentration of CRP rose as high as 18·5×109 per L and 257 mg/L, respectively; the serum albumin concentration fell to 13 g/L, and the patient’s weight to 43·6 kg. 6 weeks after admission, radiography showed that the femoral head and neck were separated from the rest of the femur, and medially displaced. Hours later, a bone fragment fell out of a pressure sore, while the dressing was being changed. The patient’s condition then started to improve. The fever and pain ceased immediately, and the pressure ulcers began to heal. 8 weeks after the fragment fell out, the patient’s weight had increased to 58·2 kg; the serum concentrations of haemoglobin and albumin were 128 g/L and 32 g/L, respectively; the white-blood-cell count and serum concentration of CRP were 8·25×109 per L and 22 mg/L, respectively. At the end of August, 2007, the patient remained in hospital; she had no fever, her weight was stable at 59 kg, and her wounds continued to heal. Pressure ulcers are common in elderly people, and people with spinal-cord injuries.1,2 For several years after being shot, our patient had been cared for by relatives and had been able to live at home. When a close relative died, the standard of care provided by her family decreased substantially, and a fragmented health system did not fully meet her needs. We think that the osteomyelitis was caused by infection spreading from an ulcer, either directly or through the bloodstream.3 The infected proximal femur developed avascular necrosis. Because the blood supply to the proximal femur was so poor, intravenous antibiotics were largely ineffective. Ordinarily, we would have done an excision arthroplasty, known as the Girdlestone procedure,4 to remove the infected bone. However, the patient was so ill that surgery was judged to be unacceptably risky. Fortunately, the necrotic bone dropped off, eerily mimicking the Girdlestone procedure. References 1 Byrne DW, Salzberg CA. Major risk factors for pressure ulcers in the spinal cord disabled: a literature review. Spinal Cord 1996; 34: 255–63. 2 Bates-Jensen BM. Quality indicators for prevention and management of pressure ulcers in vulnerable elders. Ann Intern Med 2001; 135: 744–51. 3 Lew DP, Waldvogel FA. Osteomyelitis. Lancet 2004; 364: 369–79. 4 Horan FT. Robert Jones, Gathorne Girdlestone and excision arthroplasty of the hip. J Bone Joint Surg Br 2005; 87: 104–06.
www.thelancet.com Vol 370 October 20, 2007