bone infection notes only
TRANSCRIPT
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Infectious Disease of Bone
Jeffrey R. Thompson, D.C. DACBRAssoc. Prof. Diag. ImagingTexas Chiropractic College
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General concepts• Osteomyelitis = infection of bone• Septic Arthritis = specifically involves joint• Pyogenic and granulomatous infectious agents
both may occur• Staphylococcus is most common agent
– Others include strep, tuberculosis, brucella, coccoidiomycosis, syphilis.
• Mechanism of infection typically hematogenous– Direct extension from soft tissue or direct
implantation from puncture wound or surgery
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Acute Pyogenic Osteomyelitis• Etiology: most common is staphylococcus• Age: most common age infant – 12 yrs• Clincal- child
– Elevated WBC with 80% PMN’s– Fever, chills– Local pain, swelling
• Clinical- adult– Often chronic before detection
• WBC count and fever not as dramatic until later
– More common to involve joints in adults than children
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Bone infection - imaging• Plain film– Significant “latent” period = no
change!– Appendicular skeleton 7-10 days– Spine 2 – 4 weeks!– Negative plain film does not rule out infection!
• Radionuclide bone scan– Technetium most (often used)– Gallium citrate– Indium (esp. for soft tissue infection)
• MR very sensitive to bone and/or soft tissue changes
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Bone infection – x-ray
• Metaphyseal area typically first area involved– Sluggish blood flow and “end” arterioles present
• Soft tissue swelling and blurring of fascial plane lines early (difficult to detect)
• Permeative or motheaten bone destruction– chronic bone abscess geographic
• Reactive sclerosis of adjacent bone common• Periosteal reaction typically parallel
– More periostitis in children than adult– Laminated pattern may develop more chronically
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Osteomyelitis• In the child, infection
will typically not cross the physeal plate
• Periostitis is marked• Involucrum = shell of
periosteal new bone around infected bone
• Sequestrum = island of (dead) bone surrounded by infected bone Unremarkable AP shoulder.
Two weeks later….
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Acute osteomyelitis• Note sparing of epiphysis despite extensive involvement of
metaphysis and shaft
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Acute osteomyelitis• Earliest plain film finding is soft
tissue swelling (June 28) 2 weeks later (Aug 11)
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Acute osteomyelitis• Parallel periostitis and permeative
bone destruction Progression
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Acute osteomyelitis• Parallel periostitis and permeative
bone destruction With treatment
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Chronic Osteomyelitis• Characterized by prominent reactive sclerosis
superimposed on evidence of bone destruction.• Irregular cortical outline and “bone expansion”
common due to chronic periostitis/new bone formation.
• Brodies Abscess = A localized focus of chronic bone infection.– May mimic osteoid osteoma both clinically and
radiographically, although the nidus may be bigger.– Geographic lucency with reactive sclerosis.
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Chronic Osteomyelitis of Garre• Osteomyelitis characterized by dense sclerosis/hypertrophic
change and little to no destruction = Garre’s Osteomyelitis
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Chronic Osteomyelitis
• Areas of isolated bone abscess
• Can produce laminated periostealrx’n (arrowheads at top of slide)
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Brodies Abscess
Two different cases
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Brodies AbscessNote the track-like pattern of the radiolucency affecting the metaphysis
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Septic Arthritis• Pyogenic or granulomatous etiologies possible
– 50-80% of skeletal tuberculosis affects joints• Rapid joint destruction possible; early dx needed!
– Consider infection in any patient with acute onset of monoarthritic pain and swelling without a probable etiology
– Joint aspiration is definitive for dx of infection and also useful in d/dx of crystal deposition arthropathy
• Elevated ESR, rubor, calor, dolor, etc.
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Septic Arthritis• Age: most common < age 30, but range is wide• Staph aureus is most common, but TB, strep,
gonorrhea, brucellosis, etc. may also cause• Large joints (hip and knee) are common sites for
TB joint infection• TB may mimic radiographic appearance of RA in
a joint (but does not show RA distribution)
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Septic Arthritis• Spine is common site • IVD space narrowing and
indistinct endplates on both sides
• Pott’s disease = spinal tuberculosis– Chronic TB often shows
Ca++ paraspinal– Fusion of bodies maybe
• Vertebral body collapse = kyphosis
Lateral next slide….
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Septic Arthritis• Indistinct endplates on
lateral and oblique
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Spine TB
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Spine TBParavertebral soft tissue calcifications consistent with granulomatous infection- TB
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• Marked thoracic gibbus formation from chronic TB of the spine
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Chronic TB spineChronic TB with dramatic kyphosis of spine
Note the soft tissue calcification, consistent with paravertebral TB abscess
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Infectious discitisInitial film 55yr male One month after facet injection for pain
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Septic Arthritis• Sacroiliac joint infection may mimic appearance of Reactive
arthritis, Psoriatic, RA, etc.• SI joint location more common in IV drug users than individuals
infected under other circumstances
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Septic Arthritis
Note the asymmetry of the acetabulae due to subtle loss of cortical margin at lateral margin of roof. Next slide shows progression…
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Septic Arthritis
1 month later 2 months later 1 year later
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TB of the hip
Chronic infection may result in bony ankylosis of the joint
Age 10 yrs
Age 13 yrs Age 14 yrs
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Septic ArthritisNote the rapid, symmetrical loss of joint space over 2 week period
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Osteomyelitis - Complications include
• Cloaca = A draining sinus may develop in soft tissues thru the skin to expelled necrotic tissue
• Marjolin’s ulcer = at the site of a chronic cloaca, squamous cell carcinoma may develop due to chronic inflammation
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Hydatid Disease - Echinococcosis• A parasitic infection, usually transmitted to
humans by dogs (intermediate host) that have consumed entrails of infected sheep (definitive host).
• Infection of humans occurs through oral contamination; ova penetrate gut and enter blood stream– Most filtered out in vascular beds of liver (75%), lung
(15%) or spleen, where most hydatid cysts are found– Only about 1% of all hydatid disease is skeletal
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Hydatid Disease of bone• Sites: Spine and pelvis
are most common• X-ray
– Expansile, “bubbly”appearance
– Mimics neoplasm• Giant Cell• Plasmacytoma• ABC • chordoma
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Cysticercosis• Larval stage of parasite taenia solium (pork tapeworm) may be
deposited in subcutaneous tissue, muscles and various organs• Foreign-body response occurs when larvae die
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Cysticercosis• Cigar-shaped calcifications are characteristic (up to 23mm long)