Presented in API Kerala chapter 2010- Dr.Jithesh.K,MD ,Consultant physician

1. Antibiotic Eluting Implant –Antibiotic Eluting Implant –
A unique treatment modality forA unique treatment modality for
chronic melioidotic osteomyelitischronic melioidotic osteomyelitis
Dr.Jithesh.K,MDDr.Jithesh.K,MD
Consultant PhysicianConsultant Physician
Department of General MedicineDepartment of General Medicine
Baby Memorial HospitalBaby Memorial Hospital
CalicutCalicut
(Presented in API Kerala chapter 2009)(Presented in API Kerala chapter 2009)

2. Clinical HistoryClinical History
• 60 year farmer with CAD (old q AWMI) and type 260 year farmer with CAD (old q AWMI) and type 2
Diabetes mellitus on OHA and insulin for five years.Diabetes mellitus on OHA and insulin for five years.
C/0C/0
• Fever - 7 daysFever - 7 days
• Rigor and chills - 7daysRigor and chills - 7days
• History of Pulmonary tuberculosis for which he receivedHistory of Pulmonary tuberculosis for which he received
empirical ATT 2 years back from another tertiary centre.empirical ATT 2 years back from another tertiary centre.
• Sputum and BAL for AFB were negative.Sputum and BAL for AFB were negative.
• CT guided FNAC was suggestive of abscess.CT guided FNAC was suggestive of abscess.
• Mantoux test was strongly positive then.Mantoux test was strongly positive then.

3. Clinical featuresClinical features
• Febrile and looked toxicFebrile and looked toxic
• Hepatomegaly – predominantly the leftHepatomegaly – predominantly the left
lobe of liver was enlargedlobe of liver was enlarged
• Splenomegaly – 3 cm below costal marginSplenomegaly – 3 cm below costal margin
along its long axis.along its long axis.
• Chest was clear.Chest was clear.
• Cardiovascular and nervous systemCardiovascular and nervous system
examination was unremarkable.examination was unremarkable.

4. Clinical courseClinical course
• Routine investigations likeRoutine investigations like
CBC+ESR,Urine R/E,LFT,CXR,RFT,BloodCBC+ESR,Urine R/E,LFT,CXR,RFT,Blood
C&S,Blood Widal were sent.C&S,Blood Widal were sent.
• USG abdomen showedUSG abdomen showed
hepatosplenomegaly.hepatosplenomegaly.
• He was started on Inj.CeftriaxoneHe was started on Inj.Ceftriaxone
suspecting enteric fever clinically.suspecting enteric fever clinically.

5. Clinical courseClinical course
• Third day onwards patient complained ofThird day onwards patient complained of
a nagging pain in left hip for which ana nagging pain in left hip for which an
orthopaedic opinion was obtained.orthopaedic opinion was obtained.
• PROM and AROM of Hip joint werePROM and AROM of Hip joint were
normal.normal.
• X ray hip was unremarkable.X ray hip was unremarkable.
• Was advised NSAIDS and patientWas advised NSAIDS and patient
improved symptomatically.improved symptomatically.

7. Clinical CourseClinical Course
• Patient was running high grade intermittentPatient was running high grade intermittent
fever.fever.
• Meanwhile we got a call from our microbiologyMeanwhile we got a call from our microbiology
department that his blood culture was positivedepartment that his blood culture was positive
for Pseudomonas pseudomallei, and a diagnosisfor Pseudomonas pseudomallei, and a diagnosis
of Melioidosis was made.of Melioidosis was made.
• Patient was changed over to Inj. Ceftazidime 2Patient was changed over to Inj. Ceftazidime 2
gm iv 8gm iv 8thth
hourly with chloramphenicol 500mg qidhourly with chloramphenicol 500mg qid
(iv followed by oral) ,followed by(iv followed by oral) ,followed by
chloramphenicol and cotrimoxazole.chloramphenicol and cotrimoxazole.

10. Clinical courseClinical course
• Patient gradually became afebrile.Patient gradually became afebrile.
• Liver and spleen gradually decreased inLiver and spleen gradually decreased in
size.size.
• However patient restarted complaining ofHowever patient restarted complaining of
nagging pain in the left hip with inability tonagging pain in the left hip with inability to
stand and walk.stand and walk.
• Orthopaedics review was obtainedOrthopaedics review was obtained

11. Clinical courseClinical course
• Patient had tenderness in thePatient had tenderness in the
subtrochanteric area.subtrochanteric area.
• He was lying in bed in pain with flexionHe was lying in bed in pain with flexion
deformity of left hip.deformity of left hip.
• Inability to do active SLR on left side.Inability to do active SLR on left side.

12. Clinical courseClinical course
• X ray hip was reviewed.X ray hip was reviewed.
• Left trochanter had relative osteoporoticLeft trochanter had relative osteoporotic
changes compared to right.changes compared to right.
• Consensual decision was to take a MRIConsensual decision was to take a MRI
hip.hip.

13. Clinical courseClinical course
• MRI showedMRI showed

17. MRI reportMRI report
• Cystic signals in upper third of both femurCystic signals in upper third of both femur
with sub periosteal fluid collection andwith sub periosteal fluid collection and
edema of muscles near upper one third ofedema of muscles near upper one third of
left femur.left femur.

18. PossibilitiesPossibilities
• ? Chronic meliodotic osteomyelitis? Chronic meliodotic osteomyelitis
• ?Was the pulmonary disease for which the patient?Was the pulmonary disease for which the patient
received ATT an acute infection of melioidosis.received ATT an acute infection of melioidosis.
• ? How to treat the chronic osteomyelitis – Conservatively? How to treat the chronic osteomyelitis – Conservatively
with antibiotics/ Surgical drainage.with antibiotics/ Surgical drainage.
• Antibiotic impregnated bone grafting.Antibiotic impregnated bone grafting.

19. 99 m Tcm Bone scan99 m Tcm Bone scan
• To rule out other foci of active disease.To rule out other foci of active disease.
• If disease was active in hip joint alone - SingleIf disease was active in hip joint alone - Single
site drainage preferably with antibioticsite drainage preferably with antibiotic
impregnated bone grafting.impregnated bone grafting.
• Multiple sites of active foci of infection whereMultiple sites of active foci of infection where
localised surgery may not give muchlocalised surgery may not give much
symptomatic relief to the patient.symptomatic relief to the patient.

21. 99 m Tcm bone scan99 m Tcm bone scan
• Active tracer uptake in upper one third ofActive tracer uptake in upper one third of
left femur.left femur.
• Right femur was not showing any activeRight femur was not showing any active
uptake (quiescent).uptake (quiescent).
• Increased tracer uptake in right 3Increased tracer uptake in right 3rdrd
and 4and 4thth
ribs (? benign uptake)ribs (? benign uptake)

22. Debridement with antibioticDebridement with antibiotic
impregnated Calciumimpregnated Calcium
hydroxyapatitehydroxyapatite

23. Advantages of antibioticAdvantages of antibiotic
impregnated Calciumimpregnated Calcium
hydroxyapatite implanthydroxyapatite implant
• Gentamicin impregnated cement fails to prevent relapseGentamicin impregnated cement fails to prevent relapse
of the disease as the organism is resistant.of the disease as the organism is resistant.
• Ceftazidime impregnated calcium hydroxyapatite doesCeftazidime impregnated calcium hydroxyapatite does
not need a reopening to remove.not need a reopening to remove.
• It is based on the principle of antibiotic elution at the siteIt is based on the principle of antibiotic elution at the site
of infection, where parentral antibiotics fail to reach dueof infection, where parentral antibiotics fail to reach due
to poor vascularity.to poor vascularity.

30. Bone biopsy reportBone biopsy report
• ““Starry” or “Garland” GranulomasStarry” or “Garland” Granulomas
suggestive of chronic melioidosissuggestive of chronic melioidosis

32. Take home pointsTake home points
• Treatment with systemic antibiotics alone in avascular sites ofTreatment with systemic antibiotics alone in avascular sites of
melioidotic infection is wrought with the risk of relapse.melioidotic infection is wrought with the risk of relapse.
• Simple debridement of the osteomyelitic site is significantlySimple debridement of the osteomyelitic site is significantly
associated with relapse.associated with relapse.
• Gentamicin impregnated cement which is commonly used for fillingGentamicin impregnated cement which is commonly used for filling
osteomyelitic bone defects is ineffective in melioidosis as theosteomyelitic bone defects is ineffective in melioidosis as the
organism is resistant to gentamicin.organism is resistant to gentamicin.
• Ceftazidime impregnated calcium hydroxyapatite implant works onCeftazidime impregnated calcium hydroxyapatite implant works on
the principle of antibiotic elution, cures melioidotic osteomyelitis andthe principle of antibiotic elution, cures melioidotic osteomyelitis and
has the advantage of not requiring a reopening surgery to removehas the advantage of not requiring a reopening surgery to remove
the cement.the cement.
• Only a hand full of case reports are available in world literatureOnly a hand full of case reports are available in world literature
where this modality of treatment has been appliedwhere this modality of treatment has been applied..