2. NONTUBERCULOUS MYCOBACTERIAL
INFECTIONS
• Multiple case reports impli-cate at least 15 different species of
Mycobacteriumas causes
• of osteoarticular and tenosynovial infections.
• The most common causative organisms are Mycobacterium avium
• complex, Mycobacterium marinum,and Mycobacterium kansasii.
3. • The clinical, radiographic, and histopathologic manifestations of
musculoskeletal nontuberculous Mycobacterium
• species may be indistinguishable from those in tubercu-losis, often
requiring an initial antibiotic regimen that covers M. tuberculosis
• Nonstandard chemotherapeutic agents have been developed, such as
rifabutin and clarithro-mycin for treatment of M. avium complex
• The operative principles and techniques that apply to musculoskeletal
tuberculosis also are appropriate for musculoskeletal infections
caused by nontu-berculous Mycobacterium species.
4. • BRUCELLOSIS
• Brucellosis, or undulant fever, is a zoonotic disease most com-monly
caused by the gram-negative coccobacillus Brucella Melitensis and is
usually found in goats. Almost all infections
• result from direct or indirect exposure to animals. The pri-mary mode
of transmission is the ingestion of unpasteurized
• milk or milk products. Occupations that
• place individuals at risk include farming, veterinary medi-cine, meat
handling, and laboratory work.
5. • osteoarticular involvement, normally occur-ring as sacroiliitis,
spondylitis, or spondylodiscitis
• A diagnosis of brucellosis is best made with a combina-tion of
serology with a Brucella agglutinin titer greater than 1:160 and a
positive blood culture
• For patients with osteo-articular involvement, a bone scan is
recommended. If there
• are axial symptoms, then spinal MRI is also appropriate
6. • A 6-month three-drug course of rifampin, doxycycline,
• and streptomycin is recommended for patients with osteoarticular
involvement
7. • TYPHOID FEVER
• Typhoid fever is caused by Salmonella typhi,a gram-negative
• anaerobic bacillus that is rarely seen in developed countries.
• Because the primary mode of transmission is oral-fecal, it
• occurs in individuals who have ingested contaminated food or
• fluids.
8. • Symptoms include fever, abdominal pain with diarrhea,
• dehydration, weight loss, headaches, fatigue, and, at times,
• altered consciousness. Multiple systems may be affected, with
• cardiopulmonary involvement, hepatosplenomegaly, and
• gastrointestinal infiltration. Approximately 30% of patients
• with typhoid fever may have arthralgias and myalgias
9. • Septic sacroiliitis and osteomyelitis of multiple regions have been
Described
• Diagnosis is confirmed by isolating S. typhifrom one
• of multiple sites (e.g., blood, fecal or intestinal samples, and
• bone marrow); measurement of agglutinating antibodies is
• also helpful
10. • chloramphenicol has been used, although third-generation
cephalosporins may be as effective.
11. SYPHILIS
• Syphilis is caused by a spirochete, Treponema pallidum,
• that is transmitted transplacentally, by sexual contact, or
• through blood products. Bone can become involved at any
• stage of the disease or at any age.
• In congenital syphilis, peri-ostitis of the temporal bone and palate and
cortical thicken-ing of the upper one half of the tibia (“saber shins”) may be
• seen. Vascular extension to bone (e.g., sternum or vertebral
• body) has been described. Early osseous involvement may be
• noted on bone scans in relatively asymptomatic areas, such
• as the hands, feet, forearms, clavicle, or tibias.
12. • Chronic arthralgias may develop and,
• because of neuropathic or vascular involvement, may lead to the
development of a “Charcot joint
13. • Diagnosis is made primarily by darkfield microscopy with
identification of the pathogen from the sampled fluid.
• Antibody assays such as Venereal Disease Research Laboratory
• (VDRL), rapid plasma reagin (RPR), or the more specific tests,
• microhemagglutination T. pallidum and syphilis IgG antibody
• by electroimmune assay (EIA) are frequently included as part
• of the workup.
14. • Although treat-ment may vary depending on the stage of the disease,
the
• mainstay of treatment is penicillin G benzathine.
15. • VIRAL OSTEITIS AND ARTHRITIS
• Viral infections of bone remain as a diverse group of diseases.
• Virus strains, such as varicella, rubella, and vaccinia, have been
isolated from synovitic joints. Osteomyelitis variolosa
• was recognized by joint swelling and lytic lesions before the
• suppression of smallpox.
16. • ACTINOMYCOSIS
• Actinomycosis is a chronic granulomatous disease charac-terized by
external sinuses. It is most commonly caused by
• Actinomyces israelii. Actinomycesare gram-positive anaerobic
• filamentous bacteria
17. • Diagnosis is usually made by identifying
• sulfur granules or branching mycelia. Image-guided aspiration
• of infected regions is helpful in obtaining appropriate samples.
• Actinomycotic osteomyelitis most typically affects the
• cervicofacial regions, particularly the mandible.
18. • Diagnosis is made by identification of the pathogen from
• an image-guided aspirant of infected tissue. Penicillin typi-cally is
used for treatment, although tetracycline, erythromy-cin, and
chloramphenicol can be used.
19. LYME DISEASE
• Lyme disease is the most common tick-borne illness in the
• United States. The Ixodes tick family is the primary vector for
• the spirochete bacteria Borrelia burgdorferi that causes the
• disease.
20. • Most patients with Lyme disease present with a character-istic bull’s-eye rash
(erythema migrans) within 1 month of the
• tick bite although up to 20% of patients may not
• display this associated rash. Normally, the rash is accompanied
• by viral-like symptoms of fever, chills, fatigue, and headaches.
• Arthralgia, usually polyarthralgia involving both large and small
• joints and potentially the neck and back, typically accompanies
• the viral-like symptoms and characteristic bull’s-eye rash.
• A total of 60% of patients who are not treated appropri-ately initially will develop
intermittent arthritis
• The knee is the most commonly involved joint, followed by the ankle and wrist.
21. • the intermit-tent arthritis often is described as “migratory arthritis.”
• The CDC recommends using enzyme-linked immuno-sorbent assay (ELISA)
followed by the Western immunoblot test for diagnosis .
• The Western immunoblot test will diagnose most patients with Lyme disease if
performed at
• least 4 weeks after tick contact. Synovial fluid analysis is usually nonspecific with
mildly elevated white blood cell count
• (normally <50,000 cells/mm
• 3). Genomic DNA of B. burgdorferican be found in the synovial fluid by using
polymerase
• chain reaction (PCR). Successful treatment with antibiotics for Lyme arthritis can
be documented by the transforma-tion of a positive PCR to a negative PCR.
typical
22. • erythema migrans should be diagnosed clinically and does
• not need laboratory testing. First-line antibiotic therapy employs
doxycycline orally
• for 30 to 60 days for Lyme disease–associated arthritis.
• Second-line antibiotic treatment uses amoxicillin for the same
• duration. If a patient does not respond to a 30- to 60-day
• course of oral antibiotics, then a 30-day course of intravenous
• ceftriaxone is recommended.
23.
24.
25. FUNGAL INFECTION
• Fungal osteomyelitis generally develops slowly, and diagnosis and
treatment may be delayed.
• Immunocompromised individuals are more
• susceptible.
• Treatment plans for these unusual infections should be made in
collaboration with an infectious disease consultant
26. COCCIDIOIDOMYCOSIS
• Transmission primarily is by inhalation of air-borne Coccidioides
immitis. Most of these infections do not
• cause symptoms; infections that do usually are confined to the
• lungs. A more disseminated presentation can occur with kid-ney, liver,
spleen, pericardium, and bone. A hypersensitivity arthritis, which is
self-limited to 2 to 4 weeks, can occur.
27. • Bone involvement is noted in 20% to 50% of extrapul-monary
coccidioidal infections.
• The axial skeleton is more commonly affected than the appendicular
skeleton, and the vertebral column is the most susceptible location of
bony involvement for the disease. The infection can spread into
adjacent soft tissues, causing paraspinal abscesses.
28. • Diagnosis of long-standing skeletal coccidioidomyco-sis can be
assisted by radiographic evaluation. Normally, a chronic infection will
display single or multiple lytic punched-out lesions with osteopenia
and ill-defined borders. A moth-eaten appearance may be noted in
small bones.
• Some studies have noted 100% sensitivity for identifying skeletal
coccidi-oidomycosis using bone scans. Diagnostic confirmation
29. • depends on histopathologic examination of a bone culture specimen,
which demonstrates granulomatous inflammation and often
spherules.
• Itraconazole has been shown superior to fluconazole in treat-ing
skeletal coccidioidomycosis.
• Additional surgical methods may be required for antibiotic refractory
infections. This
• may include debridement and removal of infected bone or synovium.
Relapses are also common.
30. BLASTOMYCOSIS
• Infection usually occurs after the inhalation of the spores of
Blastomyces dermatitidis,a dimorphic soil-dwelling fungus.
• frequently found in immunocompromised patients. Definitive
diagnosis is made by showing the characteristic broad-based budding
yeast on microscopic examination of
• a joint or bone aspirate. Culture of the yeast or mold form establishes
the diagnosis but may take 1 to 5 weeks to grow.
• Amphotericin B is the antibiotic of choice, with ketoconazole or
itraconazole being effective alternative drugs.
31. HISTOPLASMOSIS
• histoplasmosis is caused by Histoplasma capsulatum.It is usually a mild
pulmonary infection that
• occurs after inhalation of the infecting particle Although pulmonary
involvement is most predominant, bone and soft
• tissues can be affected, usually manifesting as a self-limited
hypersensitivity arthritis.
• Recommendation is use of prolonged antibiotic treatment after
debridement and resection of grossly involved tissue.
• Antifungal agents, such as ketoconazole or itraconazole, are effective for
the treatment of mild disseminated histo-plasmosis involving bones or
joints. For more resistant cases,
32. • especially in immunocompromised patients, amphotericin B is
recommended.
33. CRYPTOCOCCOSIS
• Cryptococcosis, caused by Cryptococcus neoformans,is a rare fungal
disease that is being increasingly found in immunologically compromised
patients.
• isolated bone lesions have been reported in 10% of patients. These may
mimic primary bone neoplasms or have a presentation similar to other
fungal
• bone lesions. The spine and long and flat bones also may be
• involved. The diagnosis is established by biopsy, and anti-gen titers are
used. Treatment of the bone lesions consists of curettage. In the absence of
neurologic involvement, keto-conazole can be effective. In more severe
cases, amphoteri-cin B should be used.
34. SPOROTRICHOSIS
• Sporotrichosis is usually produced by inoculation of Sporothrix
schenckii through a minor cut or abrasion. This fungus is found in
many environments, but infection is rare.
• Although a suppurative granulomatous lesion with an ulcer-ated
appearance develops on the skin, there may be lymph,
hematogenous, or contiguous spread to other structures. This disease
can affect the bones, joints, and periarticular soft tissues. The gold
standard for diagnosis is isolation of the fungus in culture.
35. • Cultures can take 2 weeks to be positive.
• Operative intervention may include debridement and chemotherapy
with amphotericin.
• Other chemotherapeutic regimens, including ketoconazole,
itraconazole, or fluconazole, have been used. Oral potassium iodide is
used to treat skin lesions and, at times, osseous lesions.
36. • ECHINOCOCCOSIS
• Echinococcosis, also called unilocular or human hydatid disease, is caused by the larval stage of
Echinococcus granulosus
• Sheeps act as intermediate hosts. Although the liver is the
• most frequently involved, other organ systems can be affected (e.g., kidneys, intestines, central
nervous system, and bone). Bone involvement is usually seen in less than
• 1% of cases and is exhibited by cystic or lytic lesions in the trabecular bone that can extend into
other subcortical areas.
• The most commonly affected areas in bone are the vertebrae, pelvis, and the skull. Long bones
may also be affected.
• Progressive changes may resemble tumor formation with an
• expansile cystic appearance.. Antigen or antibody titers are helpful in making the diagnosis, and
imaging studies (CT and ultrasonography) may delineate the characteristics
• of the cyst and guide treatment.
37. • The best treatment for a bone infection resulting from
• echinococcosis is to resect the involved bone or to ampu-tate.
Operative manage-ment should include careful planning and
meticulous tech-nique to avoid spillage of the cyst contents, which
may cause
• spread of the disease. If spillage occurs, application of cetyl-
trimethylammonium bromide (Cetrimide), 2% formalin, or
• 1% iodine can reduce the danger of spreading. Albendazole
• or mebendazole can also be used chemotherapeutically but
resolution varies.
38. Acenatobacter
• Acinetobacter is a genus of gram-negative bacteria belonging to the
wider class of Gammaproteobacteria. Acinetobacter species are
oxidase-negative, exhibit twitching motility,[7] and occur in pairs under
magnification.
• Acinetobacter species are a key source of infection in debilitated
patients in the hospital, in particular the species Acinetobacter
baumannii.
•
39. • A. baumannii has also been identified as an ESKAPE pathogen
(Enterococcus faecium, Staphylococcus aureus, Klebsiella
pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa,
and Enterobacter species), a group of pathogens with a high rate of
antibiotic resistance that are responsible for the majority of
nosocomial infections
40. • A. baumannii is an opportunistic pathogen with a range of different
diseases, each with their own symptoms. Some possible types of A.
baumannii infections include:[citation needed]
• Pneumonia
• Bloodstream infections
• Meningitis
• Wound and surgical site infections, including necrotizing fasciitis
• Urinary tract infections
41. • Being referred to as an opportunistic infection, A. baumannii infections are highly
prevalent in hospital settings. A. baumannii poses very little risk to healthy
individuals;[39] however, factors that increase the risks for infection include:
• Having a weakened immune system
• Chronic lung disease
• Diabetes
• Lengthened hospital stays
• Illness that requires use of a hospital ventilator
• Having an open wound treated in a hospital
• Treatments requiring invasive devices like urinary catheters
• A. baumannii can be spread through direct contact with surfaces, objects, and the
skin of contaminated persons
42. • A. baumannii has also been reported to infect skin and soft tissue in
traumatic injuries and postsurgical wounds. A. baumannii commonly
infect burns and may result in complications owing to difficulty in
treatment and eradication
• Recently sulbactam-durlobactam, a new antibacterial combination
undergoing phase 3 trial, has demonstrated good in vitro activity also
against carbapenem-resistant A. baumannii isolates (92%
susceptibility)
43. • In November 2004, the CDC reported an increasing number of A.
baumannii bloodstream infections in patients at military medical facilities
in which service members injured in the Iraq/Kuwait region during
Operation Iraqi Freedom and in Afghanistan during Operation Enduring
Freedom were treated.[23] Most of these were multidrug-resistant. Among
one set of isolates from Walter Reed Army Medical Center, 13 (35%) were
susceptible to imipenem only, and two (4%) were resistant to all drugs
tested. One antimicrobial agent, colistin (polymyxin E), has been used to
treat infections with multidrug-resistant A. baumannii; however,
antimicrobial susceptibility testing for colistin was not performed on
isolates described in this report. Because A. baumannii can survive on dry
surfaces up to 20 days, they pose a high risk of spread and contamination
in hospitals, potentially putting immunocompromised and other patients at
risk for drug-resistant infections that are often fatal and, in general,
expensive to treat.
