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Salmonella Osteomyelitis of the Pelvis in Healthy Adults: A Case Report
Journal of Orthopaedics, Trauma and Rehabilitation 15 (2011) 27e28
Contents lists available at ScienceDirect
Journal of Orthopaedics, Trauma and Rehabilitation Journal homepages: www.e-jotr.com & www.ejotr.org
Case Report
Salmonella Osteomyelitis of the Pelvis in Healthy Adults: A Case Report 一個健康成人患上盤骨沙門士菌骨髓炎: 病例報告 Ho Wing Hang Angela*, Choi Siu Tong, Chan Wai Lam, Yen Chi Hung, Wong Wing Cheung Department of Orthopaedics and Traumatology, Kwong Wah Hospital, Hong Kong
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted March 2010
We report a case of a healthy 32-year-old patient suffering from Salmonella osteomyelitis of the pelvis. He was treated successfully with surgical debridement and third-generation cephalosporin.
Keywords: infection pelvis Salmonella osteomyelitis
中 文 摘 要 本文報告一名32歲的健康男子患上罕見盤骨沙門士菌骨髓炎，接受清創手術和第三代頭孢菌素抗生素治療後 成功治癒的病例。
Introduction Salmonella osteomyelitis is an uncommon condition, constituting only 0.45% of all types of osteomyelitis.1 The condition is typically associated with haemoglobinopathies, such as sickle cell anaemia; other medical diseases, such as malignancy, liver disease, alcoholism, and diabetes; advanced or very young age; and previous surgery or trauma. It is very rare in healthy persons. Case Report A 32-year-old healthy gentleman presented to us with a discharging wound on his right buttock for 1 month. He enjoyed good past health without significant medical history. Initially, there was a swelling over right buttock. He was told that it was an abscess by a doctor who performed incision and drainage for him subsequently. The wound failed to heal with persistent discharge. No recent or remote history of diarrhoea or abdominal pain could be elicited. On examination, it was found that he was afebrile and had a small purulent discharging wound over his right buttock. Haemoglobinopathy and immune suppression workup were unremarkable. X-rays of the pelvis showed a roundish, welldemarcated sclerotic lesion over the right ilium (Figure 1). Computed tomography of the pelvis confirmed localised bony destruction without intra-pelvic extension (Figure 2). Sinogram revealed that the lesion had no communication with the pelvic cavity (Figure 3). There were mildly elevated C-reactive protein and * Corresponding author. E-mail: [email protected].
Erythrocyte. Wound swab for culture yielded Group D Salmonella typhi. Diagnosis of right ilium Salmonella osteomyelitis was then made. Ceftibutin (a third-generation cephalosporin) was started after consulting a microbiologist. Debridement, sequestretomy, and primary closure of the wound with a local rotational flap were performed. Intra-operatively, sinus tract was noted and traced down to the ilium. Some dark-coloured necrotic tissue was removed from the nidus. The histology confirmed chronic inflammation and sequestrum. Post-operatively, the wound healed well. Antibiotic was given for a total of 6 weeks. Blood parameters returned to normal, and the patient was disease free at 6-month follow-up. Discussion Salmonella are non-sporing gram-negative bacilli. More than 1800 serotypes have been isolated, subdivided into six groups (A, B, C1, C2, D, and E). Transmission occurs through ingestion of contaminated food or water or by direct inoculation. Salmonella infections may present in four different clinical forms: gastroenteritis (70%), carrier condition (15.5%), septic syndrome (8.8%), and focal manifestations (7.4%).2 Osteomyelitis is seen only in 0.8% of all Salmonella infections. Salmonella infection constitutes 0.45% of all types of osteomyelitis.1 It is most commonly associated with sickle cell anaemia and other haemoglobinopathies. Salmonella bacteraemia may occur during episodes of acute enteritis. Organisms are believed to lodge in the bone marrow at the sites of venous stasis and proliferate slowly, producing a chronic form of osteomyelitis. Group B is the most prevalent, followed by Groups D and C.3
2210-4917/$ e see front matter Copyright Ó 2011, The Hong Kong Orthopaedic Association and Hong Kong College of Orthopaedic Surgeons. Published by Elsevier (Singapore) Pte Ltd. All rights reserved. doi:10.1016/j.jotr.2010.11.006
28
W.H.A. Ho et al. / Journal of Orthopaedics, Trauma and Rehabilitation 15 (2011) 27e28
Figure 1. Pelvis X-ray showing roundish sclerotic lesion over right ilium as marked (arrow).
Figure 3. Sinogram showing the lesion (arrow) without intra-pelvic extension.
Specific antibiotic treatment should be based on culture sensitivities. Treatment should be given until there is normalisation of the C-reactive protein values and for 4e6 weeks or more as clinically indicated. Arora et al6 reported a case of early Salmonella osteomyelitis of femur treated with antibiotics alone. We recommend that a combination of radical surgery and intravenous sensitive antibiotics is the most effective treatment of Salmonella osteomyelitis. References
Figure 2. Computed tomography of the pelvis showed localised bony destruction over right ilium, with no intra-pelvic extension.
There were only a few cases of Salmonella osteomyelitis reported in healthy people.1,4e8 It commonly occurred in the diaphyses of long bones, mostly involving the femur and the humerus.9 There were also some cases of involvement of spine,10 hand,8 radius, and ulna.9,11 Multifocal involvement occurs in 15% of the reported cases of Salmonella osteomyelitis.5 Salmonella pelvis osteomyelitis has been reported in adolescents5 only. We are not aware of any literature report on its occurrence in healthy adults. Chronic Salmonella osteomyelitis has been treated conventionally by surgical debridement combined with antibiotics.1 Carlson and Dobozi11 considered that surgical debridement was not adequate and advocated radical debridement of the lesion. Bettin et al4 reported treating a chronic osteomyelitis of the humerus with corticotomy and insertion of gentamycin beads. Radical debridement with delayed bone grafting and reconstruction may be necessary.
1. Sanchez AA, Mazurek MT, Clapper MF. Salmonella osteomyelitis presenting as fibrous dysplasia. A case report. Clin Orthop 1996;330:185e9. 2. Saphra I, Winter JW. Clinical manifestations of salmonellosis in man: an evaluation of 7779 human infections identified at the New York Salmonella Center. N Engl J Med 1957;256:1128e34. 3. Ortiz-Neu C, Marr JS, Cerubin CE, et al. Bone and joint infection due to Salmonella. J Infect Dis 1978;138:820e8. 4. Bettin D, Schaphorn G, Blasius S, et al. A rare case of Salmonella osteomyelitis in the humerus as a differential diagnosis to a malignant bone tumor. Arch Orthop Trauma Surg 2002;122:544e6. 5. Sucato DJ, Gillespie R. Salmonella pelvic osteomyelitis in normal children: report of two cases and a review of the literature. J Pediatr Ortho 1997;17: 463e6. 6. Arora A, Singh S, Aggarwal A, et al. Salmonella osteomyelitis in an otherwise healthy adult maledsuccessful management with conservative treatment: a case report. J Orth Surg 2003;11:217e20. 7. Van Cappelle HG, Veendaal D, de Vogel PL. Salmonella panama osteomyelitis in an otherwise healthy patient. A case report. Clin Orthop 1995;321:235e8. 8. Nobuhiko H, Kazuharu T, Shigeru N, et al. Recurrent Salmonella osteomyelitis of both hands in a child with no signs of haemoglobinopathy: follow-up until 19 years of age. Scad J Plast Reconstr Surg Hand Surg 2003;37:315e7. 9. Declercq J, Verhaegen J, Verbist L, et al. Salmonella typhi osteomyelitis. Arch Orthop Trauma Surg 1994;113:232e4. 10. Gupta SK, Pandit A, White DG, et al. Salmonella osteomyelitis of the thoracic spine: an unusual presentation. Postgrad Med J 2004;80:110e1. 11. Carlson DA, Dobozi WR. Hematogenous Salmonella typhi osteomyelitis of the radius. A case report. Clin Orthop 1994;308:187e91.
Contents lists available at ScienceDirect
Journal of Orthopaedics, Trauma and Rehabilitation Journal homepages: www.e-jotr.com & www.ejotr.org
Case Report
Salmonella Osteomyelitis of the Pelvis in Healthy Adults: A Case Report 一個健康成人患上盤骨沙門士菌骨髓炎: 病例報告 Ho Wing Hang Angela*, Choi Siu Tong, Chan Wai Lam, Yen Chi Hung, Wong Wing Cheung Department of Orthopaedics and Traumatology, Kwong Wah Hospital, Hong Kong
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted March 2010
We report a case of a healthy 32-year-old patient suffering from Salmonella osteomyelitis of the pelvis. He was treated successfully with surgical debridement and third-generation cephalosporin.
Keywords: infection pelvis Salmonella osteomyelitis
中 文 摘 要 本文報告一名32歲的健康男子患上罕見盤骨沙門士菌骨髓炎，接受清創手術和第三代頭孢菌素抗生素治療後 成功治癒的病例。
Introduction Salmonella osteomyelitis is an uncommon condition, constituting only 0.45% of all types of osteomyelitis.1 The condition is typically associated with haemoglobinopathies, such as sickle cell anaemia; other medical diseases, such as malignancy, liver disease, alcoholism, and diabetes; advanced or very young age; and previous surgery or trauma. It is very rare in healthy persons. Case Report A 32-year-old healthy gentleman presented to us with a discharging wound on his right buttock for 1 month. He enjoyed good past health without significant medical history. Initially, there was a swelling over right buttock. He was told that it was an abscess by a doctor who performed incision and drainage for him subsequently. The wound failed to heal with persistent discharge. No recent or remote history of diarrhoea or abdominal pain could be elicited. On examination, it was found that he was afebrile and had a small purulent discharging wound over his right buttock. Haemoglobinopathy and immune suppression workup were unremarkable. X-rays of the pelvis showed a roundish, welldemarcated sclerotic lesion over the right ilium (Figure 1). Computed tomography of the pelvis confirmed localised bony destruction without intra-pelvic extension (Figure 2). Sinogram revealed that the lesion had no communication with the pelvic cavity (Figure 3). There were mildly elevated C-reactive protein and * Corresponding author. E-mail: [email protected].
Erythrocyte. Wound swab for culture yielded Group D Salmonella typhi. Diagnosis of right ilium Salmonella osteomyelitis was then made. Ceftibutin (a third-generation cephalosporin) was started after consulting a microbiologist. Debridement, sequestretomy, and primary closure of the wound with a local rotational flap were performed. Intra-operatively, sinus tract was noted and traced down to the ilium. Some dark-coloured necrotic tissue was removed from the nidus. The histology confirmed chronic inflammation and sequestrum. Post-operatively, the wound healed well. Antibiotic was given for a total of 6 weeks. Blood parameters returned to normal, and the patient was disease free at 6-month follow-up. Discussion Salmonella are non-sporing gram-negative bacilli. More than 1800 serotypes have been isolated, subdivided into six groups (A, B, C1, C2, D, and E). Transmission occurs through ingestion of contaminated food or water or by direct inoculation. Salmonella infections may present in four different clinical forms: gastroenteritis (70%), carrier condition (15.5%), septic syndrome (8.8%), and focal manifestations (7.4%).2 Osteomyelitis is seen only in 0.8% of all Salmonella infections. Salmonella infection constitutes 0.45% of all types of osteomyelitis.1 It is most commonly associated with sickle cell anaemia and other haemoglobinopathies. Salmonella bacteraemia may occur during episodes of acute enteritis. Organisms are believed to lodge in the bone marrow at the sites of venous stasis and proliferate slowly, producing a chronic form of osteomyelitis. Group B is the most prevalent, followed by Groups D and C.3
2210-4917/$ e see front matter Copyright Ó 2011, The Hong Kong Orthopaedic Association and Hong Kong College of Orthopaedic Surgeons. Published by Elsevier (Singapore) Pte Ltd. All rights reserved. doi:10.1016/j.jotr.2010.11.006
28
W.H.A. Ho et al. / Journal of Orthopaedics, Trauma and Rehabilitation 15 (2011) 27e28
Figure 1. Pelvis X-ray showing roundish sclerotic lesion over right ilium as marked (arrow).
Figure 3. Sinogram showing the lesion (arrow) without intra-pelvic extension.
Specific antibiotic treatment should be based on culture sensitivities. Treatment should be given until there is normalisation of the C-reactive protein values and for 4e6 weeks or more as clinically indicated. Arora et al6 reported a case of early Salmonella osteomyelitis of femur treated with antibiotics alone. We recommend that a combination of radical surgery and intravenous sensitive antibiotics is the most effective treatment of Salmonella osteomyelitis. References
Figure 2. Computed tomography of the pelvis showed localised bony destruction over right ilium, with no intra-pelvic extension.
There were only a few cases of Salmonella osteomyelitis reported in healthy people.1,4e8 It commonly occurred in the diaphyses of long bones, mostly involving the femur and the humerus.9 There were also some cases of involvement of spine,10 hand,8 radius, and ulna.9,11 Multifocal involvement occurs in 15% of the reported cases of Salmonella osteomyelitis.5 Salmonella pelvis osteomyelitis has been reported in adolescents5 only. We are not aware of any literature report on its occurrence in healthy adults. Chronic Salmonella osteomyelitis has been treated conventionally by surgical debridement combined with antibiotics.1 Carlson and Dobozi11 considered that surgical debridement was not adequate and advocated radical debridement of the lesion. Bettin et al4 reported treating a chronic osteomyelitis of the humerus with corticotomy and insertion of gentamycin beads. Radical debridement with delayed bone grafting and reconstruction may be necessary.
1. Sanchez AA, Mazurek MT, Clapper MF. Salmonella osteomyelitis presenting as fibrous dysplasia. A case report. Clin Orthop 1996;330:185e9. 2. Saphra I, Winter JW. Clinical manifestations of salmonellosis in man: an evaluation of 7779 human infections identified at the New York Salmonella Center. N Engl J Med 1957;256:1128e34. 3. Ortiz-Neu C, Marr JS, Cerubin CE, et al. Bone and joint infection due to Salmonella. J Infect Dis 1978;138:820e8. 4. Bettin D, Schaphorn G, Blasius S, et al. A rare case of Salmonella osteomyelitis in the humerus as a differential diagnosis to a malignant bone tumor. Arch Orthop Trauma Surg 2002;122:544e6. 5. Sucato DJ, Gillespie R. Salmonella pelvic osteomyelitis in normal children: report of two cases and a review of the literature. J Pediatr Ortho 1997;17: 463e6. 6. Arora A, Singh S, Aggarwal A, et al. Salmonella osteomyelitis in an otherwise healthy adult maledsuccessful management with conservative treatment: a case report. J Orth Surg 2003;11:217e20. 7. Van Cappelle HG, Veendaal D, de Vogel PL. Salmonella panama osteomyelitis in an otherwise healthy patient. A case report. Clin Orthop 1995;321:235e8. 8. Nobuhiko H, Kazuharu T, Shigeru N, et al. Recurrent Salmonella osteomyelitis of both hands in a child with no signs of haemoglobinopathy: follow-up until 19 years of age. Scad J Plast Reconstr Surg Hand Surg 2003;37:315e7. 9. Declercq J, Verhaegen J, Verbist L, et al. Salmonella typhi osteomyelitis. Arch Orthop Trauma Surg 1994;113:232e4. 10. Gupta SK, Pandit A, White DG, et al. Salmonella osteomyelitis of the thoracic spine: an unusual presentation. Postgrad Med J 2004;80:110e1. 11. Carlson DA, Dobozi WR. Hematogenous Salmonella typhi osteomyelitis of the radius. A case report. Clin Orthop 1994;308:187e91.