Sickle cell disease and osteomyelitis

1. Vertebral Osteomyelitis
and Discitis
Rose-Krystel Hegngi MS 3.
Jayanth H.Keshavamurthy M.D.

2. Case Presentation
• 14-year-old male with hemoglobin SS disease, maintained
on Hydroxyurea 800 mg daily, was recently admitted to the
hospital on 11/14/2017 for one day due to acute pain crisis
with microocclusion/vasooclusive of the back. He had been
having low back pain since 09/27/17 located at the upper
lumbar area, radiating up his spine. The pain is worsened
with breathing and movement and relieved with laying down
and taking Lortab 5.0. He is not able to sleep well at night
and walking has become slightly more difficult due to the
back pain. Mom reports good compliance with his
Hydroxyurea 800mg Qday, Amoxicillin 250mg BID, folic
acid, and Lortab 5.0 every 3-4 hours for pain.

3. MRI 11/14/17
• Impression
1. Pattern of chronic extensive bone marrow changes associated to sickle
cell anemia with combination of old bone infarcts and bone marrow
hematopoietic recruitment throughout thoracic segments.
2. Chronic appearing compression deformities with typical fish mouth
deformity of vertebra, more prominent at T4, T9 and T10 as well as upper
endplates of L2 on L3.
Axial
T2

4. MRI 11/14/17
• Impression
1. Pattern of chronic extensive bone marrow changes associated to sickle
cell anemia with combination of old bone infarcts and bone marrow
hematopoietic recruitment throughout thoracic segments.
2. Chronic appearing compression deformities with typical fish mouth
deformity of vertebra, more prominent at T4, T9 and T10 as well as upper
endplates of L2 on L3.
SAG T2 SAG T1

5. Case Continued
• The patient came in for a follow up visit 3 weeks after
MRI. Since his last visit, he has been at home, not moving
around much, but the pain has been manageable. He
currently wears a back brace as the pain is still worsened
with movements, at a 6/10 at its worst. His appetite has
increased and he is beginning to gain back some weight.
Mom reports good compliance with his Hydroxyurea
800mg Qday, Amoxicillin 250mg BID, folic acid, and
vitamin D. TDC on 9/6/2017 was normal. Mom was told
by Orthopedics that IR will perform bone biopsy of the
spine. She will follow up after the biopsy.

6. CT Guided
Aspiration/Biopsy/Injection
• IMPRESSION
1. Successful CT-guided T10 paraspinal mass biopsy and T10 vertebral
body bone biopsy.
2. As compared with recent MR 11/4/2017, there is progressive
kyphotic deformity and vertebral body compression at T10-T11, with
with early compression of T9.

7. Biopsy Results
• Specimin-Vertebra, Cul Aer/Ana/+Gm
• Prelim:
• 1+ Yellow Colony Further studies in progress
• 1+ White Colony Further studies in progress
• Anaerobe culture in progress
• Gram_Stn_B
• Moderate neutrophils
• No squamous epithelial cells
• Very rare gram positive cocci
• Specimin-Vertebra, Cul Fungus
• Specimen received; culture in progress.
• Presumtive Diagnosis: Vertebral Osteomyelitis/Discitis

8. Differential Diagnosis of Vertebral
Osteomyelitis and Discitis
• Other infections:
• Septicemia
• Cellulitis
• Septic arthritis- given the early decrease in splenic function,
bacterial infections of bone and joints are common in children with
sickle cell disease
• Deep abscess
• Non-Infectious conditions:
• Chronic non-bacterial osteomyelitis,
• Vertebral compression fracture,
• Vaso-occlusive pain episode- local warmth, tenderness, and
swelling are common in both vaso-occlusive pain episodes and
osteomyelitis.
• Malignancy
• Vitamin C deficiency,
• Gaucher disease

9. Vertebral Osteomyelitis and
Discitis: Radiographic Mimics
• (1)Fibrous dysplasia
• (2)Osteoid osteoma and osteoblastoma
• (3)Eosinophilic granuloma and other forms of histiocytosis
https://www.google.com/search?q=fibrous+dyspla
sia+spine&source=lnms&tbm=isch&sa=X&ved=0
ahUKEwjQ5NKdsIfYAhWokOAKHdIHAIMQ_AUI
CigB&biw=2100&bih=1303#imgrc=ZzEyGr3CV4C
-aM:&spf=1513181465605
https://www.google.com/search?biw=2100&b
ih=1303&tbm=isch&sa=1&ei=G1ExWonRMo
m0_Absha6IAw&q=osteoid+osteoma+spine+
radiology&oq=osteod+osteoma+spine&gs_l=
psy-
ab.1.1.0i13k1l4.99094.105104.0.107102.24.
21.2.1.1.0.326.2534.9j10j0j1.20.0....0...1c.1.
64.psy-
ab..1.23.2700...0j0i67k1j0i10k1j0i8i13i30k1.0
.ass7ZA96-
qk#imgrc=tnZH73NCZ6HkeM:&spf=1513181
573645
https://www.google.com/search?biw=2100&bih=
1303&tbm=isch&sa=1&ei=sFIxWuyrJOKkggfXkK
sg&q=eosinophilic+granuloma+vertebra+plana&
oq=eosi&gs_l=psy-
ab.1.0.0i67k1l2j0l2j0i67k1j0l5.9797.10252.0.124
65.4.4.0.0.0.0.156.492.2j2.4.0....0...1c.1.64.psy-
ab..0.4.486....0.NPT07aukngM#imgrc=ENYYUy8
FpA-CjM:&spf=1513181883790
3.1. 2.

10. Vertebral Osteomyelitis and
Discitis: Pathophysiology
• 3 mechanisms
• Hematogenous spread from a distant site or focus of infection
• Most common cause of vertebral osteomyelitis
• Direct inoculation from trauma/invasive spinal diagnostic procedures or
surgery
• Contiguous spread from soft tissue infections
• Location
• Vertebral Bodies-involved in approximately 4% of cases of osteomyelitis in
children (80% occur in the long bones).
• Intervertebral Discs-usually in children younger than 5, occurs almost
exclusively in the lumbar region.

11. Vertebral Osteomyelitis and
Discitis: Clinical Features
• Signs and Symptoms
• Localized neck or back pain, exacerbated by movement and
palpation
• Toxic appearance
• Chronic low-grade fever
• Lab
• Elevated or normal WBC count
• Elevated ESR and CRP in more than 80% of patients

12. Vertebral Osteomyelitis and
Discitis: Diagnosis
• Diagnosis is based on positive culture obtained from computed
tomography (CT)-guided biopsy of the involved vertebra(e) and/or
disc space.
• Microbiology Cultures
• Blood cultures are positive in up to 50% of cases
• Radiographic Imaging
• MRI: most sensitive radiologic technique in the diagnosis of
vertebral osteomyelitis. It is also useful in differentiating between
pyogenic, tuberculous, and fungal infections, and a neoplastic
process.
• CT: acceptable alternative to MRI, optimal for biopsies.
• Plain radiograph: Often normal in early infection. *Chest
radiography is warranted in the clinical suspicion of tuberculosis.
• Radionuclide scanning: useful adjunct to plain film and CT when
there is high suspicion for osteomyelitis in the setting of absent
radiographic changes

13. Treatment
• Combination of antimicrobial therapy and percutaneous drainage of
abscess(es) if present. Routine treatment consists of a minimum of 6
weeks.
• Pathogen-directed therapy (based on blood culture results)
• Staphylococcal spp: if MSSA tx. nafcillin or oxacillin, if MRSA tx
vancomycin
• Streptococcal spp: if fully sensitive to penicillin, tx. ceftriaxone or high
dose penicillin
• Gram-negative bacilli: 3rd or 4th generation cephalosporin, or
fluoroquinolone
• Empiric therapy
• Patients with Gram negative stain and culture results should be
treated empirically, ie. vancomycin + one of the following:
cefotaxime, a 3rd or 4th generation cephalosporin, or ciprofloxacin
• Surgery
• Reserved for patients with neurologic deficits, evidence of
epidural/paravertebral abscess, and or spinal cord compression

14. Works Cited
• Gaillard, F. (2017). Spondylodiscitis | Radiology Reference Article | Radiopaedia.org.
[online] Radiopaedia.org. Available at: https://radiopaedia.org/articles/spondylodiscitis
[Accessed 13 Dec. 2017].
• Uptodate.com. (2017). Bone and joint complications in sickle cell disease. [online]
Available at: https://www.uptodate.com/contents/bone-and-joint-complications-in-sickle-
cell-
disease?source=see_link&sectionName=OSTEOMYELITIS%20AND%20SEPTIC%20A
RTHRITIS&anchor=H12#H12 [Accessed 13 Dec. 2017].
• Uptodate.com. (2017). Hematogenous osteomyelitis in children: Epidemiology,
pathogenesis, and microbiology. [online] Available at:
https://www.uptodate.com/contents/hematogenous-osteomyelitis-in-children-
epidemiology-pathogenesis-and-microbiology?source=see_link [Accessed 13 Dec.
2017].
• Uptodate.com. (2017). Vertebral osteomyelitis and discitis in adults. [online] Available
at: https://www.uptodate.com/contents/vertebral-osteomyelitis-and-discitis-in-
adults#H11 [Accessed 13 Dec. 2017].