Vol 18 infections


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Vol 18 infections

  1. 1. OrthopedicInfections
  2. 2. Orthopedic Infectious Diseases Hematogenous osteomyelitis Pyogenic spondylitis and discitis Pyarthrosis TBc Arthritis & Sarcoidosis TBc spondylitis Leprosy Luetic infections Viral osteomyelitis Fungus infections Gas forming infections
  3. 3. HematogenousOsteomyelitis
  4. 4. Hematogenous Osteomyelitis Hematogenous osteomyelitis is typically seen in childrenin the metaphyseal ends of long bones in the lower extremities.The proximal end of the tibia is the most common site. Staphaures bacteria arising from a peripheral site such as the skin ornose and throat gain access to the peripheral circulation wherethey travel to the terminal end-arterial circulation just beneaththe growth plate where a primary focal abscess will arise. Theabscess will then increase in size resulting in local thrombosisfollowed by bone necrosis as the purulent mass works its waythru the adjacent cortex gaining access to the subperiostealspace thus lifting the periosteum which then goes on to forma healing involucrum. In the early days prior to antibiotics,osteomyelitis was a very aggressive disease process associatedwith severe local pain, high fevers and septacemia resultingin high white counts and sed rates. The disease was frequently
  5. 5. multi focal in bones as well as in various organs such as thelung, liver and brain resulting in death in a high number ofcases. However, since the advent of antibiotics the modernform of osteomyelitis is far less aggressive and may presentwith minimal symptoms of pain with a minimal elevation ofthe white count or sed rate and for this reason my go onwithout diagnosis or treatment.
  6. 6. 8/17/39 8/26/3910 yr male with acute onset of pain in tibia 4 days before the 1st x-ray with high fever of 104 degrees and a 20,000 WBC
  7. 7. Blood supply to long bones in children
  8. 8. Pathogenesis of primary focus of metaphyseal infection
  9. 9. Early abscess formationand early osteonecrosiswith reparativeinvolucrum formation
  10. 10. Medullary abscess with puss and necrotic bone
  11. 11. 3 mos 8 mos 2.5 yrs Natural course of disease without antibiotics
  12. 12. Another old case ofsevere osteomyelitisof tibia with 2 yr followup
  13. 13. 4 yr female with excessive debreidment of periosteum
  14. 14. 8/93 8/94 1/9611 year old boy who sprained his wrist in early 8/93 for which an X-ray was obtained 2 weeks later because of increasing pain
  15. 15. Biopsy and culture
  16. 16. 9 year old femalewith wrist pain andlow grade fever 6 mos
  17. 17. Modern day Hematogenous Osteomyelitis 4 yr maleEarly mild pain and afebrile (L) with a followup 1 yr later (R)
  18. 18. Osteomyelitis distal femur13 yr male with T-1 coronalMRI and macro section of asimilar case in young adult
  19. 19. Sclerosing osteomyelitis of Garre9 yr old female with low grade pain and slight fever 1 yr
  20. 20. Axial CT scanBone scan
  21. 21. Axial Gad contrast MRI
  22. 22. Ewing’s vs osteomyelitis Bone scan13 yr female with 1 mo pain and onion skin periostitis
  23. 23. Coronal and axial T-2 MRI looks like Ewing’s sarcoma
  24. 24. Purulent responseReactive bone
  25. 25. Multifocal Osteomyelitis5 year old male with painin heel and knee for 6 mos
  26. 26. Sag T-1 T-2 Gad
  27. 27. Cor T-1 Sag T-2 Axial T-2
  28. 28. 10 yr male with contusion to thigh followed with osteo 9 mo later
  29. 29. 13 yr old boy with staph osteo of left humerus 3 mos.
  30. 30. Cor T-1 T-2 Axial T-2
  31. 31. Staph osteo looking like Ewing’s sarcoma Cor Gad13 yr male with slight fever and pain for 2 mos
  32. 32. Osteomyelitis3/06 7/07 7/07 14 year old male with pain right arm for 17 months
  33. 33. Cor T-1 T-2 Gad
  34. 34. Axial T-1 T-2 Gad
  35. 35. Periosteal Osteomyelitis29 yr female with mild intermittent pain left arm for yrs
  36. 36. Cor T-1 T-2 Gad
  37. 37. Axial T-1 T-2 Gad
  38. 38. Staph osteo looking like low grade intramedullary OGS 37 yr male with aching pain in thigh for 1 one yr without fever
  39. 39. Staph osteo looking like osteosarcoma13 year male with knee pain and slight fever for 2 mos
  40. 40. Incisional biopsy
  41. 41. Sequestrum delivery and biopsy specimen
  42. 42. Chronic Staph osteomyelitis of tibia for years60 yr Indian male with 50 yr history of intermittent aching pain R leg
  43. 43. CT Scan
  44. 44. Sag T-1 PD FS Gad
  45. 45. Axial T-1 T-2 Gad
  46. 46. Chronic Osteomyelitis Prox Femur May 2010Oct 09 51 yr male with increasing pain left hip for 9 months
  47. 47. Cor T-2 Sag T-2 Sag Gad
  48. 48. Axial T-2 Gad
  49. 49. Chronic Staph Osteomyelitis distal femur45 yr old male with intermittent pain in right thigh since age 17
  50. 50. Cor T-1 T-2 Sag gad
  51. 51. Axial T-1 T-2 Gad
  52. 52. Chronic staph osteomyelitis distal femur Cor T-216 yr male with dull aching pain in knee for one year
  53. 53. Bone abscess from staph infection 04 07 04 0716 yr male with 3 yr history of intermittent pain and swelling at knee
  54. 54. Bone scan
  55. 55. 07Cor T-1 T-2 Gad
  56. 56. Sag T-1 T-2
  57. 57. Axial T-2 Gad
  58. 58. Soft Tissue Staph Abcess at Elbow31 yr old female with painless lump at elbow for 3 weeks
  59. 59. Cor T-1 T-2 Gad
  60. 60. Axial T-1 T-2 Gad
  61. 61. Staph osteo crossing the growth plateSag T- Cor T-21 10 yr girl with low grade aching pain at ankle for 9 mos
  62. 62. 8 year old male withBrodie’s abscess distaltibia with gopher sign
  63. 63. 13 year male with focalstaph osteo with gophertunnels that could becalled a Brodie’s abscess
  64. 64. Brodie’s abscess13 year male with dullaching pain for 3 mos
  65. 65. Classic gopher tunnelcrossing the growth plate
  66. 66. 42 year old male withthe flue 2 mos agofollowed by acuteonset of pain R thigh
  67. 67. CT scan AP Lat
  68. 68. Axial T-1 Gad
  69. 69. Cor STIR
  70. 70. 17 year old malewith Brodie’sabscess cuboidlooking like anosteoid osteoma
  71. 71. 5 yr female with ring sequestrum 2nd to infected traction pin
  72. 72. Epiphyseal Brodie’s abscessSag T-1 Cor T-27 yr old female with severe pain in knee 1 mo without fever
  73. 73. Epiphyseal Brodie’s abscess CT with gopher tunnel7 yr male with severe pain in knee for 2 mos
  74. 74. Squamous cell CA arising from chronic osteomyelitisMacro section and microscopic of amputated leg of an older patient with a long history of chronic osteo of the tibia
  75. 75. Salmonella Osteomyelitis16 year old black femalewith SS disease and 1 yrhistory of pain left arm
  76. 76. Chronic salmonella osteo for2 years in a 32 year old blackmale with SS disease involvingmultiple limbs
  77. 77. Both arms involved and septic AVN left femoral head
  78. 78. Salmonella Dactylitis hands and feetInfant black male with 3mohistory of SS disease andpainful swelling of handsand feet along with diarrheaand fever
  79. 79. Pyogenic Spondylitis and Discitis
  80. 80. Infectious discitis oflumbar spine in a 3 yrfemale with acute onsetof severe LBP and fevermost likely second tostaph aures spondylitis
  81. 81. Another case of infectiousdiscitis in a 4 yr old male
  82. 82. Infectious discitis young adult male24 yr male shot putter with mild LBP 6 mos without fever
  83. 83. Peudomonas Discitis22 yr male heroin addict with discogram of infected disc space
  84. 84. Pyogenic spondylitis older adult63 yr male with sag T-2 MRI image of severe dorsal spondylitis
  85. 85. Pyogenic Spondylosis with Retropharyngeal Absces 7/83 10/85 64 yr male with progressive neck pain and dysphagia 2 yrs
  86. 86. Pyogenic Sarcroiliac Staph Aures17 year male with LBP for 6 months with fever
  87. 87. Potential drainage sites seen with spinal infections
  88. 88. Pyarthrosis
  89. 89. Staph pyarthosis1.5 yr female with fever andextremely irritable lefthip held in flexion andexternal rotation2 mos following posteriorsurgical drainage andantibiotic therapy
  90. 90. Pathogenesis forpyarthosis of hipor knee joint
  91. 91. Septic necrosis of femoral head Initial 2 mos 6 mos X-ray PO PO 10 yr male with initial diagnosis of rheumatic fever of hiptreated with steroids, ASA and antibiotics without success
  92. 92. Musculoskeletal Tuberculous Infections
  93. 93. Musculoskeletal Tubrculous Infections Tuberculous infection of the musculoskeletal system is seen inabout 5% of patients with pulmonary TBc. The problem is morecommon in Asian and Mexican populations of the world. In theUSA musculoskeletal TBc is rare in children but is more commonin adults with immunodeficiency conditions related to IV drugabuse, alcoholism, HIV disorders and patients on corticosteroidmedication. The most common skeletal site for TBc infection isthe spine followed next by the hip and knee. The TB mico-bacterial organism enters the blood stream in the lung and travelsto a metaphyseal bone site in the spine, hip or knee area whichthen results in discitis or psoas abscess of the spine or tuberculousarthritis of the hip or knee. The tuberculous micobacteriumstimulates the formation of a caseating granulomatous lesionmade up of epithelioid cells, Langhans giant cells and lymphs.A similar granuloma is seen in sarcoidosis which is none infectiousand none caseating. Antituberculous drugs include streptomycin,PAS, INAH, myambutol, and rifampin.
  94. 94. Tuberculous Osteomyelitis9 year old male with knee pain and swelling 1 yr
  95. 95. Pain and swelling in elbow as well
  96. 96. Biopsy shows epithelioid granuloma with Langhans giant cell
  97. 97. 10 yr female with kneepain and swelling 10 moswith dumbell TBcgranuloma crossing thetibial growth plate
  98. 98. 24 yr male with shoulderpain for 1 year with x-rayevidence of tuberculousgranulomas in humeralhead
  99. 99. TBc Arthritis of Hip29 yr Asian male with hip pain for 2 years
  100. 100. TBc Hip Arthritis TBc pannus formation27 yr Asian male withdestructive TBc for 3 yrs
  101. 101. Late TBc Arthritis Hip30 yr Asian male with untreated disease for many yrs
  102. 102. Pediatric TBc Arthritis 4 yr 14 yr 15 yr4 yr Asian male with non treated TBc of hip for 10 years followed with an extra-articular arthrodesis
  103. 103. TBc CarpitisUntreated TBccarpitis in a 73 yrAsian male formany years
  104. 104. TBc Arthritis Elbow 28 yr male 3 yr maleMild adult vs severe pediatric TBc of elbow
  105. 105. TBc osteomyelitis of distal fibula Bone scan76 year male with pain lateral ankle for 4 months
  106. 106. Cor T-2 Gad
  107. 107. Axial T-2 Gad
  108. 108. TBc Dactylitis4 yr Eskimo with TBc dactylitis (spina ventosa)
  109. 109. Tuberculous Tenosynovoitis Epithelioid granuloma27 yr male with 1 yr historyof carpal tunnel syndrome2nd to TBc tenosynovitis
  110. 110. Sarcoidosis Sarcoidosis is a nonspecific noncaseating epithelioid granuloma-tous process that affects the reticuloendothelial system of youngadults that pathologically resembles the histology of TBc, fungusinfections, viruses and even low grade lymphomas such asHodgkin’s disease. In the US it is seen more commonly in thesoutheastern states and is ten times more common in blacks thenwhites. 90% will have pulmonary infiltrates or hialar adenopathyalong with systemic symptoms of fever, coughing, inflammatoryarthropathy and iritis. Other systemic symptoms include weightloss, lymphadenopathy and hepatosplenomegaly as seen inlymphomas. Granulomatous skin lesion similar to erythemanodosum can be seen. Hypercalcemia can be seen in 25% of casesecond to an increase of calcium absorption at the gut level. 70%of cases will have a positive Kveim skin test to help separate outother granulomatous disorders such as TBc. 5% of cases involvethe middle and distal phalanges of the hand (most common) and
  111. 111. feet associated with overlying subcutaneous nodularities thatmight suggest the diagnosis of TBc, gout, Ollier’s disease ortuberous sclerosis. The homeycomb or latticework lytic patternof sarcoidosis will help differentiate from these other diagnosticconsiderations. The bony lesions are asymptomatic unlessassociated with a pathologic fracture. Bony changes in large bonesare very rare and can present with a sclerotic pattern seen in lowgrade lymphomas such as Hodgkin’s disease. The prognosisfor minor lesions of the hands and feet is excellent but withgreater reticuloendothelial involvement of multi organ systemsthe prognosis is more guarded like that of a low gradelymphoma.
  112. 112. Case #1 Sarcoidosis of Hand 46 yr male with recent path fracture ring finger
  113. 113. Biopsy specimenNone caseating epithelioid granuloma with Langhans giant cells Schaumann’s body
  114. 114. Similar cases of bony sarcoidosisA BC D
  115. 115. Sub Q nodularity, lymphadenopathy behind ear and pulmonary lesions in sarcoidosis
  116. 116. Tuberculous Spondylitis
  117. 117. Tuberculous Spondylitis About 60% of all TBc involves the spine and is frequentlyseen in Asian or Mexican patients. In Hong Kong where thisdisease is common they see over 100 cases per year, 70% ofwhich are seen in children. L-1 is the most common vertabrainvolved and from there it can spread up and down the spineunder the anterior longitudinal ligament or thru the Batson’spara vertebral plexes. In China multiple vertabrae are involvedcompared to only one or two vertabrae in mid aged adults inthe USA. As with pyogenic spondylitis it is felt that thetuberculous organism gains access to the vertebral body thruthe blood supply to the spine. Even though there is no primaryinfection of the avascular disc space, extensive destruction ofthe vertebral body with collapse of the disc into the bodyresults in significant gibbus deformity not common in pyo-genic spondylitis.
  118. 118. TBc Spondylitis Dorsal Spine45 yr female with mid dorsal back pain for 6 mos
  119. 119. Thoracotomy Approachaorta TBc granuloma
  120. 120. Surgical clean out and fusionRib strut grafts in place
  121. 121. Post op x-rays
  122. 122. Tuberculous Psoas Abscess47 yr old female with fluid mass in femoral triangle 1 yr
  123. 123. L-3 diseaseX-ray appearance
  124. 124. Saddle bag Abscess over sacrum2 liters of fluid removed
  125. 125. Various sites of psoas abscess drainage
  126. 126. TBc spondylitis with paraplegia (Pott’s dis)63 yr male with gradual onset spastic paraplegia for 6 mos
  127. 127. Autopsy specimen of LD spine
  128. 128. Modern day case of TBc spondylitis MRI28 yr female with LD back pain for 1 yr
  129. 129. Pediatric TBc spondylitis3 yr male 9 yr female
  130. 130. Sacroiliac TBc28 year old male with LBP for 1 year
  131. 131. Brucellar Spondylitis Looks like TBc
  132. 132. Leprosy
  133. 133. Leprosy Leprosy is not very common in the USA but is seen in othercountries such as South America, Africa, southern EuropeIndia and China. There are two clinical types of leprosy. Themore common and non infectious form is the neural ortuberculoid form that is of interest to orthopedic surgeonsbecause of the peripheral neuropathies and neuropathic jointsthat are seen in this form. The lepromatous form which isinfectious because of the draining skin ulcerations has a poorchance for survival. In the neural form of leprosy the micobacterium lepri organ-ism finds its way into periperal nerves causing them to enlargeresulting in a loss of both motor and sensory components. Theloss of sensation results in trophic skin changes including lossof pigmentation, hair and ulcerations. Neuropathic joints areseen in 27% of cases.
  134. 134. Neural or tuberculoid form of leprosy Short fingerNeurotrophic foot ulcers and Gynecomastia 2nd to claw hand deformities testicular leprosy
  135. 135. Neural leprosy Combined median & ulnar N involvement with trophic skin changes, clawing, lack of sweating, and short finger tips from terminal phylangeal osteolysisLoss of skin pigmentation in areas of anesthesia
  136. 136. Neural leprosy Social stigma of eyebrow alopeciaNeuropathic feet with deformityand shortening due to osteolysisand neuropathic joints
  137. 137. Neural leprosyShortening from terminal osteolysis Neuropathic joint shortening
  138. 138. Lepromatous (infectious) form of leprosyDraining facial sores of infectious form of leprosy with micobacterium lepri organisms seen to right
  139. 139. Luetic Infections (Syphilis)
  140. 140. Leutic Infections Syphilis is a disease caused by the treponema pallidumorganism which was first introduced to America by ChristopherColumbus. 50% of cases will involve bone. The two major clinicaltypes include the adult and congenital forms. The acute form ofthe disease is a soft tissue problem and the late or tarda formof the disease is the type that involves bone and joints thatwould be of interest to an orthopedic surgeon . The two mostcommon bones affected with syphilis include the cranium andthe tibia.
  141. 141. Congenital lues3 mo female with luetic metaphysitis & facial snuffles
  142. 142. Congenital lues6 mo. male with luetic metaphysitis
  143. 143. Luetic periostitis 2.5 yr female with saber shin lesion from congenital lues looking like hypervitaminosis A, juvenile Paget’s disease, Englemann’s disease and Caffey’s disease
  144. 144. Luetic periostitis6 year female 26 year male
  145. 145. Associated syphilitic abnormalities Perphorated palateNotched Hutchinson’s teeth 8th nerve hearing defect Luetic keratitis
  146. 146. Heavy metal therapy for syphilis61 year male with incidental finding in pelvis
  147. 147. Viral Osteomyelitis Rubella infection Caffey’s disease
  148. 148. Rubella metaphysitisInfant born with dwarfism,thrombocytopenia, congenitalheart defects, cataracts, enlargedliver & spleen, chorioretinitisand deafness to a mother whohad measles in 1st trimester
  149. 149. Caffey’s disease (viral osteomyelitis ?)8 mo, old infant with 6 weeks of painful swollen forearm
  150. 150. Biopsy specimen thought to be osteosarcoma
  151. 151. Original cortexAmputation specimen showing inflammatory periostitis
  152. 152. Hypertrophic shoulder girdle changes not seen in cong lues
  153. 153. Mandibular hypertrophy seen in Caffey’s and not in lues
  154. 154. Saber shin defect in Caffey,s disease9 mo. old male with tender shin bone for 3 mos.
  155. 155. Fungus Infections
  156. 156. Coccidiomycosis The two most common fungus infections seen by orthopedicsurgeons are coccidiomycosis and blastomycosis. Coccidio-mycosis is most common and seen in the south western part ofthe USA whereas, blastomycosis has no special location.coccidiomycosis is usually seen in the San Joaquin Valley areawhere it starts with an upper respiratory infection and afever known as valley fever followed in a few weeks by anacute pneumonitis which usually heals without recurrence.In a very small percent of cases a granulomatous response isseen in joints, bone, muscle and skin that can lead to the deathof the patient. The granulation tissue is similar to that seen inTBc except for the presence of endospores seen in the cytoplasmof the Langhans type giant cells. Coccidiomycosis replicatesthru a process of endosporulation within the mother cell where-as in blastomycosis the reproduction takes place thru a processof external budding from the mother spore.
  157. 157. Coccidiomycosis of knee 82 yr old farmer from Fresno with mild painful swelling of kneewith lytic epiphyseal lesion like GCT except for anterior breakout
  158. 158. Surgical clean outYellow arrow sinus track lead tonecrotising cavitary abscess spacewith granulomatous granulationtissue revealing Langhans typegiant cells with blue arrowendospore of coccidiomycosis
  159. 159. Coccidiomycosis of Knee Bone scan40 yr old farmer from Stockton with pain and swelling of knee 3 mos
  160. 160. Coccidiomycosis arthritis23 year Asian male with painful swollen knee 2 years
  161. 161. Axial PD Axial T-2
  162. 162. Sag PD Sag T-2
  163. 163. Arthrotomy Cor PDFluconisol treatment
  164. 164. Coccidiomycotic synovial cyst79 yr male with MRI evidenceof a large popliteal cyst arisingfrom the knee joint similar tothe appearance of a rheumatoidsynovitis
  165. 165. Coccidiomycosis of knee Sag T-2 23 yr male with mixed synovial and bony involvement for 1 yr
  166. 166. Coccidiomycosis osteomyelitis3 year old female fromModesto with pain andswelling below the kneefor 2 months
  167. 167. Lateral view
  168. 168. Endospores being phagocytised by a macrophage
  169. 169. Coccidiomycosis osteomyelitis4 year old male with pain and swelling of wrist 3 mo.
  170. 170. Coccidiomycosis dactylitis27 yr old male with pain and swelling of hand 4 mos.
  171. 171. Coccidiomycosis spondylitis29 year male withLPB for 1 year
  172. 172. Sagittal T-2 MRI shows thehigh signal cocci inflammatorytissue extruding anteriorlybeneath the anterior longitudinalligament in order to spread toadjacent vertabrae as we seein TBc spondylitis
  173. 173. Blastomycosis osteomyelitis 32 male with ankle pain and overlying skin sore for 6 mos. Budding spore
  174. 174. Blastomycosis dactylitis24 yr male with painfulthumb with excoriationof overlying skin
  175. 175. Sacroiliac cryptococcosis27 yr male with LBP CT scan Silver stainspores in macrophages
  176. 176. Echinococcus spondylitis Cor T-1 MRI31 yr male from Indiawith LD back pain forone year
  177. 177. Echinococcal osteomyelitis (hydatid disease)35 yr male from Southern Italywith hip pain for 2 yrs with chronicdeformation suggestive of Large calcificfibrous dysplasia cyst in liver
  178. 178. Echinococcal osteomylitisAmputation specimen of femur in adult male
  179. 179. Maduromycosis (Madura foot)41 yr India male with long historyof painless draining sinuses from Biopsy specimenfoot
  180. 180. Gas myositis 21 yr male sailor with recent puncture wound and suddenonset of severe pain and swelling of leg with fever & tachycardia
  181. 181. Gas Fasciaitis62 yr diabetic with gradual onset of mild pain and swellingof calf with no fever or chills - clostridium infection to rt.