Emphysematous Osteomyelitis

Abstract

DesCripTionA 56-year-old man with a known history of type 2 diabetes mellitus, hypertension, nephrolithiasis and gout presented with fatigue and flank pain for 3 days. The above symptoms were associated with fevers and chills. On admission, the patient's vitals were remarkable for fever with maximum temperature (T max) 39.1°C, hypotension requiring pressor support and tachycardia. On auscultation, he had reduced air entry at lung bases, distended abdomen, bipedal oedema and petechial rash over the upper extremities and the trunks. In addition, there was purplish discolouration over the left medial sacral area. Laboratory work-up was remarkable for elevated white cell count 21.4x10 9 /L (4.0-12.0x10 9 /L), creatinine 7.98 mg/dL (0.60-1.40 mg/dL), anion gap of 25, erythrocyte sedimentation rate of 70 mm/hour (0-20 mm/hour), total bilirubin of 4.9 mg/dL (0.2-1.2 mg/dL) and lipase 422 U/L (0-140 U/L). Platelet count was 31×10 3 /µL (150-400 10 3 /µL), aspartate aminotransferase of 71 U/L (10-40 U/L) and alanine aminotransferase of 37 U/L (3-45 U/L). Septic shock was suspected, and the patient was placed on empiric coverage with piperacillin-tazobactam and vancomycin. His CT scan of the abdomen (figures 1 and 2) showed left emphysematous pyelonephritis and a 4 mm obstructing proximal left ureteral stone (figure 3). Urology was consulted, and the patient underwent cystoscopy with left ureteral stent placement. Interval CT abdomen and pelvis on the fourth day of antibiotic treatment showed resolution of air from the left pelvicalyceal system; however, it showed air bubbles within L5/S1 vertebral bodies and L5-S1 disc which was suggestive of emphysematous osteomyelitis (EO) (figures 4 and 5). The patient developed acute kidney injury, so antibiotics were switched to intravenous meropenem and linezolid. Blood cultures grew Escherichia coli (E. coli), linezolid (5 days) was then discontinued and meropenem (7 days) was then switched to ceftriaxone. Soon, he developed hives, it was attributed to ceftriaxone and was shifted to aztreonam which was renally dosed. Transoesophageal echo was performed since he had prolonged E. coli bacteraemia and was negative for vegetations. The blood cultures also cleared up, and he showed clinical improvement. He was subsequently discharged on aztreonam. A follow-up MRI of the back was recommended in 8 weeks.

Osteomielitis enfisematosa en el pie: una localización inusual

“…La osteomielitis enfisematosa es una patología infrecuente y grave, caracterizada por la presencia de gas intraóseo 4 . Este hallazgo en las vértebras puede estar relacionado con fenómenos degenerativos, pero su localización extraaxial es patognomónica de osteomielitis [5][6][7][8][9] . Figura 3.…”

Emphysematous Pyelonephritis and Emphysematous Osteomyelitis: A case report

“…It should, therefore, be treated intensively with antibiotics for 4 to 6 weeks to avoid necrosis and bone destruction. Surgery should be reserved for complicated situations such as abscess formation or necrosis, and for patients who do not respond to antibiotics [10].…”

A Rare Case of Emphysematous Osteomyelitis of Femur in an Intravenous Drug User

“…The spread of infection is usually hematogenous, though contiguous spread from skin or soft tissue, or following orthopedic or intraabdominal surgery [ 10 ] have also been described in the literature.…”