The challenge of differentiating vaso-occlusive crises from osteomyelitis in children with sickle cell disease and bone pain: A 15-year retrospective review

Fontalis, Andreas; Hughes, Kendall L.; Nguyen, My-Linh; Williamson, Mike; Yeo, Andrea; Lui, Darren F; Gelfer, Yael

doi:10.1302/1863-2548.13.180094

Cited by 12 publications

(13 citation statements)

References 37 publications

(53 reference statements)

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“…BJI commonly occurs in primarily healthy children without clear predisposing conditions. However, a higher prevalence is described in patients affected by immunodeficiencies and haemoglobinopathies, particularly sickle cell disease (SCD) and chronic granulomatous disease (CGD) [ 13 , 14 ]. Previous experimental studies on animal models have suggested that minor trauma may increase the susceptibility of bone and joint tissues to bacterial seeding [ 15 ].…”

Section: Aetiology and Pathogenesismentioning

confidence: 99%

Update on Acute Bone and Joint Infections in Paediatrics: A Narrative Review on the Most Recent Evidence-Based Recommendations and Appropriate Antinfective Therapy

2020

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Acute bone and joint infections (BJIs) in children may clinically occur as osteomyelitis (OM) or septic arthritis (SA). In clinical practice, one-third of cases present a combination of both conditions. BJIs are usually caused by the haematogenous dissemination of septic emboli carried to the terminal blood vessels of bone and joints from distant infectious processes during transient bacteraemia. Early diagnosis is the cornerstone for the successful management of BJI, but it is still a challenge for paediatricians, particularly due to its nonspecific clinical presentation and to the poor specificity of the laboratory and imaging first-line tests that are available in emergency departments. Moreover, microbiological diagnosis is often difficult to achieve with common blood cultures, and further investigations require invasive procedures. The aim of this narrative review is to provide the most recent evidence-based recommendations on appropriate antinfective therapy in BJI in children. We conducted a review of recent literature by examining the MEDLINE (Medical Literature Analysis and Retrieval System Online) database using the search engines PubMed and Google Scholar. The keywords used were “osteomyelitis”, OR “bone infection”, OR “septic arthritis”, AND “p(a)ediatric” OR “children”. When BJI diagnosis is clinically suspected or radiologically confirmed, empiric antibiotic therapy should be started as soon as possible. The choice of empiric antimicrobial therapy is based on the most likely causative pathogens according to patient age, immunisation status, underlying disease, and other clinical and epidemiological considerations, including the local prevalence of virulent pathogens, antibiotic bioavailability and bone penetration. Empiric antibiotic treatment consists of a short intravenous cycle based on anti-staphylococcal penicillin or a cephalosporin in children aged over 3 months with the addition of gentamicin in infants aged under 3 months. An oral regimen may be an option depending on the bioavailability of antibiotic chosen and clinical and laboratory data. Strict clinical and laboratory follow-up should be scheduled for the following 3–5 weeks. Further studies on the optimal therapeutic approach are needed in order to understand the best first-line regimen, the utility of biomarkers for the definition of therapy duration and treatment of complications.

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Section: Aetiology and Pathogenesismentioning

confidence: 99%

Update on Acute Bone and Joint Infections in Paediatrics: A Narrative Review on the Most Recent Evidence-Based Recommendations and Appropriate Antinfective Therapy

2020

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“…ESR and CRP are commonly utilized in the clinical setting to support the diagnosis of OM in children and for evaluating the response to therapy 10,11 . Data on their utility for diagnosis of OM in children with SCD are limited 9,12,13 . Of note, we found that patients who were treated for OM had a higher CRP and ESR compared to patients evaluated but not treated for OM and when the comparison was limited to patients with probable/confirmed OM, ESR but not CRP remained significantly higher.…”

Section: Discussionmentioning

confidence: 73%

“…10,11 Data on their utility for diagnosis of OM in children with SCD are limited. 9,12,13 Of note, we found that patients who were Note: Other includes scapula, clavicle, hand, rib, and mandible sites of involvement infarction. 12 Furthermore, SCD is a chronic inflammatory state.…”

Section: Discussionmentioning

confidence: 77%

Characteristics and outcomes of osteomyelitis in children with sickle cell disease: A 10‐year single‐center experience

Weisman

Nickel

Darbari

et al. 2020

Pediatric Blood & Cancer

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Background Patients with sickle cell disease (SCD) are at increased risk for osteomyelitis (OM). Diagnosis of OM in SCD is challenging as the clinical presentation is similar to a vasoocclusive crisis (VOC) with no diagnostic gold standard. We report characteristics and outcomes of OM in SCD patients treated at our center over 10‐year period. Design/Method We conducted a retrospective analysis of patients with SCD who were treated for OM at our center over a 10‐year period (2006‐2016). Cases were identified utilizing radiology data mining software. Radiology reports and medical charts of potential OM cases were reviewed. Results Twenty‐eight children with SCD were treated for OM at our institution. Patients treated for OM were largely similar to patients treated for a VOC. However, patients treated for OM had significantly higher C‐reactive protein (10 mg/dL vs 5.58 mg/dL, P = 0.03) and erythrocyte sedimentation rate (60 mm/h vs 47 mm/h, P = 0.02). Magnetic resonance imaging (MRI) findings were consistent with OM in 18 (64%) patients and indeterminate in the remaining. Based on clinical, laboratory, and radiological findings, the diagnosis of OM was considered confirmed in 3 patients, probable in 6 patients, and presumed in 19 patients. Nontyphoidal Salmonella was isolated from cultures in 9 (32%) patients, while no organism was identified in 19 (67%) patients. All patients were treated with antibiotics. Six patients (21%) required surgical interventions. Conclusions OM continues to pose diagnostic challenges. Most patients are treated for OM without definitive confirmation. Nontyphoidal Salmonella was the only organism identified in our cohort.

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“…OM is an acute or chronic inflammatory process in the bone caused by bacterial infection. The cumulative occurrence of OM in children with SCD has been reported to range broadly from 1.4 to 12% in different series 4‐6 …”

Section: Introductionmentioning

confidence: 99%

“…Differentiating OM from VOC may pose a diagnostic challenge, as several clinical, radiological, and laboratory features overlap. However, early recognition and treatment of OM is necessary to prevent long‐term morbidity such as chronic OM or recurrent relapses 2,4,7 . While there are no standard diagnostic criteria for OM, isolation of a bacterial pathogen from the suspected site of infection or from blood in a patient with clinical and radiographic findings consistent with OM is highly suggestive 8 .…”

Section: Introductionmentioning

confidence: 99%

Microbiology and radiographic features of osteomyelitis in children and adolescents with sickle cell disease

Kao

Yee

Maillis

et al. 2020

Pediatric Blood & Cancer

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Background Children with sickle cell disease (SCD) are at increased risk for bacterial infections including osteomyelitis (OM). Fever and bone pain, key presenting symptoms of OM, are common in SCD, thus complicating diagnosis. We reviewed presentation, imaging features, and microbiologic etiologies of children with SCD treated for OM. Methods The comprehensive SCD clinical database of children and adolescents with SCD followed at a single, large tertiary pediatric center were searched to identify all diagnostic coding for potential cases of osteomyelitis in children ages 6 months to 21 years from 2010 to 2019. Medical charts were reviewed to determine OM diagnostic probability based on radiographic and microbiologic findings and the duration of prescribed antibiotic treatment for OM. Results Review of 3553 patients (18 039 person‐years) identified 20 episodes of probable OM in 19 children. Magnetic resonance imaging (MRI) findings to support OM were definitive in 4/19 (21%), probable in 10/19 (53%), suspected in 5/19 (26%), based on blinded radiologist review. Blood and/or operative cultures from bone and tissue debridement isolated Salmonella species in seven (35%) cases and methicillin‐susceptible Staphylococcus aureus (MSSA) in two (10%). Six patients received antibiotic treatment prior to obtainment of cultures. Of culture‐positive cases, MRI findings for OM were definitive or probable in six of nine (67%), suspected in three of nine (33%). Conclusions Distinction between OM and sickle‐related bone infarct or vasoocclusion is difficult based on imaging findings alone. Early attainment of blood and operative cultures increases the likelihood of identifying and adequately treating OM.

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The challenge of differentiating vaso-occlusive crises from osteomyelitis in children with sickle cell disease and bone pain: A 15-year retrospective review

Cited by 12 publications

References 37 publications

Update on Acute Bone and Joint Infections in Paediatrics: A Narrative Review on the Most Recent Evidence-Based Recommendations and Appropriate Antinfective Therapy

Update on Acute Bone and Joint Infections in Paediatrics: A Narrative Review on the Most Recent Evidence-Based Recommendations and Appropriate Antinfective Therapy

Characteristics and outcomes of osteomyelitis in children with sickle cell disease: A 10‐year single‐center experience

Microbiology and radiographic features of osteomyelitis in children and adolescents with sickle cell disease

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