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An 18-month-old boy presented with lytic lesion of skull and recurrent abscesses with Serratia marcescens The extensive work up revealed a gene mutation confirming the diagnosis of chronic granulomatous disease (CGD). This case scenario underscores the importance of exploring the possibility of immunodeficiency if there is a history of recurrent abscesses with atypical organism. The case also demonstrates that CGD can present as lytic lesion of skull., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Five patients with segmental irregular-shaped bone defect of the femur were recruited in this study from 2017.12 to 2018.11. All patients were treated by customized design and 3D printed micro-porous prosthesis. And the procedure was divided into stages: radical debridement and temporary fixation (the first stage); the membrane formation and virtual surgery (intervening period for 6-8 weeks); definite reconstruction the defects (the second stage). Routine clinical follow-up and radiographic evaluation were done to assess bone incorporation and complications of internal fixation. The weight-bearing time and the joint function of the patients were recorded. The patients were followed up for an average of 16.4 months. The average length of bone defect and the distal residual bone was 12 cm and 6.5 cm. The average time of partial weight-bearing and full weight-bearing was 12.7 days and 2.6 months. X-ray demonstrated good osseous integration of the implant/bone interface. No complications occurred such as implant loosening, subsidence, loss of correction and infection. At the last follow-up, Harris score of hip joint was excellent in 2 cases, good in 2 cases, fair in 1 case; HSS score of knee joint was good in 4 cases, middle in 1 case. From our study, we concluded that meticulous customized design 3D printed micro-porous prosthesis combined with intramedullary nail may be a promising and an alternative strategy to treat metaphyseal segmental irregular-shaped femoral bone defect, especially for cases with massive juxta-articular bone loss.

A direct-from-source rapid musculoskeletal diagnostic panel (MDP) was validated recently. We compared clinical measures to theoretical time points had MDP results been available. The MDP would have significantly decreased the time to pathogen identification (7 hours), time to definitive antimicrobial therapy (22 hours), and hospital length of stay (26.4 hours)., (© The Author(s) 2019. Published by Oxford University Press on behalf of The Journal of the Pediatric Infectious Diseases Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The characteristics and clinical consequences of pyogenic bone and joint infections in older children and adolescents have received little attention. This study evaluated the presentation and complications of musculoskeletal infections involving the pelvis and extremities in children older than 10 years. Thirty patients 10 to 17 years old (mean, 12.7 years old) were treated for musculoskeletal infections. Mean time to diagnosis was 9.2 days. Prior to correct diagnosis, 83% were assessed by at least 1 outpatient provider. At the time of admission, 55% were weight bearing and 93% were afebrile. Twenty-eight percent had a multifocal infection. More than one-third had serious medical complications or orthopedic sequelae; compared with patients without complications, this group had a significantly higher admission C-reactive protein and longer hospital stay. Symptoms of musculoskeletal infection common among young children may be absent in adolescents. Axial imaging is recommended to identify adjacent or multifocal disease. The Kocher criteria are less sensitive for septic hip arthritis in the adolescent population. Prompt recognition and treatment are critical to avoid medical and musculoskeletal complications. [Orthopedics. 2020;43(4):e291-e298.]., (Copyright 2020, SLACK Incorporated.)

Introduction: Infections of enterobacteria producing extended-spectrum -lactamases place a heavy burden on health systems. Little is known in osteoarticular infections, so this work studied the prevalence of these infections in a third-level hospital., Material and Methods: Prevalence study in patients of a Traumatology Service during 2016, with infection criteria provided by the CDC in Atlanta, Georgia. The VITEK® 2 AST-N272 (bioMérieux) system was used for bacterial identification at the species level and for antimicrobial susceptibility tests., Results: 7.85% (n = 86) were reported with osteoarticular infections; 22.09% (n = 19) were by enterobacteria BLEEs. An average of 77.1 days of hospitalization (SD 37.7) (46-200 days); isolation of the microorganism occurred 15 days after entry. Sixteen (84.2%) patients had osteomyelitis, three (15.8%) had a prosthetic knee or hip infection. The average number of treatment days was 60 days (21-129 days). Eighteen patients (94.7%) were discharged with resolution of their infectious picture; one patient died with infection over aggregated pneumonia due to carbapenem-resistant K. pneumoniae., Discussion: The prevalence of osteoarticular infections by enterobacteria BLEEs could not be accurately calculated, but we consider it to be within what is expected, infection control measures require higher standards and there is a lack of development programs to use antimicrobials rationally to control the emergence of these pathologies.

Rationale: Spinal epidural abscess (SEA) is a rare condition that shows a high prevalence in immunocompromised patients. The clinical presentation of SEA includes the "classic triad" of pain, fever, and neurological dysfunction. However, these nonspecific features can lead to a high rate of misdiagnosis. SEA may lead to paralysis or even death; thus, prognosis of these patients remains unfavorable., Patient Concerns: We report a case of a multilevel (T6-T12) SEA in a 22-year-old woman., Diagnosis: The patient was initially diagnosed with spinal tuberculosis at a local hospital based on a history of tuberculosis exposure, as well as radiography and computed tomography. Histopathological examination of the tissue resected during laminectomy confirmed the diagnosis of SEA in this patient., Interventions: The patient underwent multilevel laminectomy combined with long-term antibiotic therapy., Outcomes: Physical examination performed 16 months postoperatively revealed that superficial and deep sensation was restored to normal levels in the lower extremities with improvement in the patient's motor function (muscle strength 2/5)., Lessons: This case report indicates that whole spine magnetic resonance imaging is warranted in patients with SEA and that prompt surgical intervention is important at symptom onset. Long-term antibiotic therapy is also essential postoperatively.

Background: Sphingomonas paucimobilis is an emerging opportunistic bacterium with a particular tropism toward bones and soft tissues. It is a gram-negative rod that can infect immunosuppressed or immunocompetent individuals in the community or hospital settings. Prognosis of infected patients is generally good, but morbidity and mortality cases have both been documented., Objectives: To present and discuss all reported Sphingomonas paucimobilis-mediated bone and soft-tissue infections, and shed light upon the relevance of this organism in orthopaedic surgery., Data Sources: Pubmed and Cochrane Library., Study Eligibility Criteria: Studies reporting at least one human bone or soft-tissue infection due to Sphingomonas paucimobilis., Results: Ten articles describing 19 patients met the inclusion criteria. Common infections included osteomyelitis, cellulitis, and septic arthritis. Fifteen patients (78.9%) had community-acquired diseases. All patients were successfully treated with antibiotic therapy and only one (5.3%) had a residual complication., Limitations: The study included a small sample size presenting with bone or soft-tissue infections. Some cases had lacking data., Conclusion: Despite being associated with a good prognosis in most cases, Sphingomonas paucimobilis-related orthopaedic infections may exhibit some complications., (Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Bone and joint infections include septic arthritis, prosthetic joint infections, osteomyelitis, spinal infections (discitis, vertebral osteomyelitis and epidural abscess) and diabetic foot osteomyelitis. All of these may present through the acute medical take. This article discusses the pathogenesis of infection and highlights the importance of taking a careful history and fully examining the patient. It also emphasises the importance of early surgical intervention in many cases. Consideration of alternative diagnoses, appropriate imaging and high-quality microbiological sampling is important to allow appropriate and targeted antimicrobial therapy. This article makes some suggestions as to empiric antibiotic choice; however, therapy should be guided by local antimicrobial policies and infection specialists. Involvement of a multidisciplinary team is essential for optimal outcomes., (© Royal College of Physicians 2018. All rights reserved.)

Advantages of MALDI-TOF MS (MS) were evaluated for diagnosis of bone and joint infections after enrichment of synovial fluid (SF) or crushed osteoarticular samples (CSs). MS was performed after enrichment of SF or crushed osteoarticular samples CS (n = 108) in both aerobic and anaerobic vials. Extraction was performed on 113 vials (SF: n = 47; CS: n = 66), using the Sepsityper ® kit prior identification by MS. The performances of MS, score and reproducibility results on bacterial colonies from blood agar and on pellets after enrichment in vials, were compared. MS analysis of the vial resulted in correct identification of bacteria at a species and genus level (80.5% and 92% of cases, respectively). The reproducibility was superior for aerobic Gram-positive bacteria (Staphylococci and Gram-positive bacilli: 100% colonies), as compared to aerobic Gram-negative bacilli (89.7%), anaerobes (83.3%) and Streptococcus/Enterococcus (58.8%). MS performance was significantly better for staphylococci than for streptococci on all identification parameters. For polymicrobial cultures, identification (score>1.5) of two species by MS was acceptable in 92.8% of cases. Use of MS on enrichment pellets of bone samples is an accurate, rapid and robust method for bacterial identification of clinical isolates from osteoarticular infections, except for streptococci, whose identification to species level remains difficult., (Copyright © 2016 Institut Pasteur. Published by Elsevier Masson SAS. All rights reserved.)

Biofilms are complex communities of microorganisms embedded in an extracellular matrix and adherent to a surface. The development was described as a four-stage process leading to the formation of a mature biofilm which was resistant to immune system and antibiotic actions. In bone and joint infections (BJIs), the formation of biofilms is a leading cause of treatment failure. Here we study the capacity of 11 antibiotics commonly used in the treatment of BJIs to inhibit the biofilm formation on 29 clinical Staphylococcus aureus isolates by a new test called Antibiofilmogram(®) The minimal inhibitory concentration (MIC) and biofilm MIC (bMIC) were determined in vitro and showed similar values for clindamycin, fusidic acid, linezolid and rifampin. Reversely, daptomycin, fosfomycin, gentamicin and ofloxacin showed a bMIC distribution different from MIC with bMIC above breakpoint. Finally, cloxacillin, teicoplanin and vancomycin revealed an intermediate bMIC distribution with a strain-dependent pattern. A murine in vivo model of catheter-associated S. aureus infection was made and showed a significant reduction, but not total prevention, of catheter colonization with cloxacillin at bMIC, and no or limited reduction with cloxacillin at MIC. Antibiofilmogram(®) could be of great interest after surgical operations on contaminated prostheses and after bacteremia in order to prevent the colonization of the device., (© FEMS 2016. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Here, we report the diagnosis and treatment of an extraoral cutaneous sinus tract originating in a mandibular second molar with a C-shaped root canal system. The patient was referred to our department by a dermatologist after a series of unsuccessful treatments, including antibiotics. Diffuse radiolucency on a preoperative radiograph revealed that earlier root canal treatment had been only partially successful. Consequently, we performed retreatment of the root canal comprising removal of the former restoration and gutta-percha, cleaning and shaping, and passive irrigation with sodium hypochlorite. The patient responded well, and the cutaneous lesion completely resolved uneventfully within 1 month postoperatively. Preoperative recognition and thorough knowledge of the root canal anatomy and conventional methods of obturation are necessary in performing successful endodontic treatment.

Background: Bone and joint infection in adults arises most commonly as a complication of joint replacement surgery, fracture fixation and diabetic foot infection. The associated morbidity can be devastating to patients and costs the National Health Service an estimated £20,000 to £40,000 per patient. Current standard of care in most UK centres includes a prolonged course (4-6 weeks) of intravenous antibiotics supported, if available, by an outpatient parenteral antibiotic therapy service. Intravenous therapy carries with it substantial risks and inconvenience to patients, and the antibiotic-related costs are approximately ten times that of oral therapy. Despite this, there is no evidence to suggest that oral therapy results in inferior outcomes. We hypothesise that, by selecting oral agents with high bioavailability, good tissue penetration and activity against the known or likely pathogens, key outcomes in patients managed primarily with oral therapy are non-inferior to those in patients treated by intravenous therapy., Methods: The OVIVA trial is a parallel group, randomised (1:1), un-blinded, non-inferiority trial conducted in thirty hospitals across the UK. Eligible participants are adults (>18 years) with a clinical syndrome consistent with a bone, joint or metalware-associated infection who have received ≤7 days of intravenous antibiotic therapy from the date of definitive surgery (or the start of planned curative therapy in patients treated without surgical intervention). Participants are randomised to receive either oral or intravenous antibiotics, selected by a specialist infection physician, for the first 6 weeks of therapy. The primary outcome measure is definite treatment failure within one year of randomisation, as assessed by a blinded endpoint committee, according to pre-defined microbiological, histological and clinical criteria. Enrolling 1,050 subjects will provide 90 % power to demonstrate non-inferiority, defined as less than 7.5 % absolute increase in treatment failure rate in patients randomised to oral therapy as compared to intravenous therapy (one-sided alpha of 0.05)., Discussion: If our results demonstrate non-inferiority of orally administered antibiotic therapy, this trial is likely to facilitate a dramatically improved patient experience and alleviate a substantial financial burden on healthcare services., Trial Registration: ISRCTN91566927 - 14/02/2013.

Background: The aim of this study was to investigate changes in oropharyngeal K. kingae carriage during the first 4 y of life, including seasonal variation and comparison of asymptomatic carriage with cases of invasive osteoarticular infections (OAI)., Methods: Oropharyngeal bacterial K. kingae carriage was screened in 744 healthy children aged 7-48 mo between January 2009 and December 2012. Oropharyngeal swabs were analyzed by rt-PCR targeting the DNA of K. kingae RTX toxin, epidemiological characteristics of asymptomatic carriers and OAI case patients were recorded., Results: The carriage prevalence showed no significant difference between age groups or seasons. Compared with asymptomatic carriers, OAI cases were more likely to be aged from 7 to 12 mo (OR = 2.5; 95% CI (1.2-5.0)) and 13-24 mo (OR = 2.2; 95% CI (1.2-3.9)), and less likely over 36 mo (OR = 0.2; 95% CI (0.1-0.7)). Fewer OAI cases were identified in spring compared to asymptomatic carriers (OR = 0.3; 95% CI (0.1-0.7)), while more were detected in autumn (OR = 2.5; 95% CI (1.4-4.4))., Conclusion: Although oropharyngeal K. kingae colonization is a prerequisite for further invasive infection, this epidemiological study emphasizes that the carriage rate variations do not correlate with the variations of OAI incidence by gender, season, or age group.

Hydatid disease is an extremely uncommon differential diagnosis in the cystic/lytic lesions of bone. We present a rare case of echinococcal infection of femur which presented as pathological fracture in a middle-aged female and diagnosis was confirmed by histopathology. Hydatid disease of bone is often asymptomatic, and its diagnosis is usually made when lesions have become extensive.

We report a case of nosocomial mediastinitis and sternal osteitis due to M. hominis after open-heart surgery in an immuno-competent patient. This infection has been diagnosed by incubating the culture media for an extended period of time, and sequencing 16S rDNA directly from the clinical samples., (Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives: Matrix metalloproteinases (MMPs) has been implicated in the pathogenesis of infective, cancer and autoimmune diseases. In this study, we investigated the serum level of MMPs and its clinical importance in human brucellosis., Patients and Methods: This study included 60 brucellosis patients treated at the Clinic for Infectious Diseases, Clinical Centre, University of Sarajevo. Matrix metalloproteinases serum levels were quantified by ELISA., Results: The investigation involved three groups: 30 patients with complications, 30 patients without complications of brucellosis and 30 healthy control examinees. The complications of human brucellosis varied but osteoarticular involvement dominated (n=21/30; 70%). Matrix metalloproteinases serum levels in the patients with complications were highest. The serum level of MMP-1 in patients with complications was the highest at 9.45; in patients without complications it was 3.78 and in the control examinees it was lowest at 3.62 (p=0.001). The serum level of MMP-9 in patients with complications was the highest at 105.66; in patients without complications 64.67, and in the control examinees it was lowest at 37.32 (p=0.001). The serum level of MMP-13 in patients with complications was highest at 138.86; in patients without complications at 64.85; and in the control examinees it was the lowest at 29.55 (p=0.001). Pearson's coefficient showed a statistically significant positive correlation between levels of tested matrix metalloproteinases and development complications in human brucellosis (p=0.001)., Conclusion: This study showed the diagnostic value and importance of detection of matrix metalloproteinases in human brucellosis. MMPs are a useful serum biomarker for assessment of disease activity., (Copyright © 2015 by Academy of Sciences and Arts of Bosnia and Herzegovina.)

The yeasts Candida and Cryptococcus spp. are important human opportunistic pathogens. Candida spp. rely on skin or mucosal breach to cause bloodstream infection, whereas Cryptococcus spp. exploit depressed cell-mediated immunity characteristic of advanced HIV infection. The treatment for both organisms relies on the administration of rapidly fungicidal agents. In candidaemia, source control is important, with removal of prosthetic material and drainage of collections, as well as hunting for and tailoring therapy to disseminated sites of infection, particularly the eyes and heart. For cryptococcal meningitis, restoration of immune function through antiretroviral therapy (ART) is key, together with careful management of the complications of raised intracranial pressure and relapsed infection, both pre- and post-ART., (Copyright © 2015 Cold Spring Harbor Laboratory Press; all rights reserved.)

Granulomatous infections are commonly associated with mycobacteria, brucellosis, actinomycosis, nocardiosis, spirochetes, and fungi. Rarely, granuloma formation is a host response to other bacterial infection. Osteomyelitis and osteitis that reactivate many years after the primary episode is a known phenomenon. A reactivation that presents as a granulomatous disease is rare. We present a case of reactivated osteitis due to Moraxella osloensis with consecutive granuloma formation.

Background: The treatment of knee arthritis with coexistent bone or joint sepsis is challenging. Despite the condition causing considerable morbidity, there is no generally agreed-upon approach to its treatment., Description of Technique: We used aggressive débridement of the knee and implantation of intraoperatively molded articulating antibiotic cement spacers with 4 g vancomycin and 2 g streptomycin per bag of cement for patients with unknown organisms as a first stage. When the infecting organism was known, organism-specific antibiotics were used. For fungal infections, 400 mg amphotericin B was added per bag of cement. This was followed by TKA as a second stage once soft tissues had healed 2 to 29 months later, (mean, 6 months) and return of laboratory parameters to within a normal range. One patient underwent two débridement and spacer procedures for suspected persistent infection., Methods: To determine whether this approach resulted in adequate control of infection and satisfactory scores for pain and function, we retrospectively reviewed 15 patients who presented with infected arthritic knees between 2001 and 2009; all patients with infected arthritic knees were treated with this same technique during this period. We assessed knee ROM, Knee Society scores, WOMAC scores, and VAS scores preoperatively and during followup. Followup was at a mean of 4 years (range, 2-7 years); No patient was lost to followup before 2 years., Results: Two of the 15 patients were comfortable with the spacers and declined a more definitive reconstruction, and no patient had a recurrent infection after TKA. Before spacer placement, the mean ROM was 103.° (range, 60°-150°), with the spacers in place it decreased to a mean 87° (range, 60°-135°), and after TKA it improved to a mean of 115° (range, 75°-150°). The mean Knee Society Knee and Function scores progressed from 41 and 43 preoperatively to 85 and 83 at latest followup, respectively. The WOMAC scores improved from 51 initially to 18 after TKA. The mean VAS scores improved from 66 preoperatively to 18 after the TKA., Conclusions: In this small proof-of-concept series, we found that joint débridement and use of intraoperatively molded articulating antibiotic cement spacers as part of a staged approach to treat the infected arthritic knee before TKA resulted in infection control in all patients at a minimum of 2 years' followup, reduction of knee pain, and restoration of knee function. We suggest that larger, comparative series be performed to further validate these results.

A case of a patient suffering from tuberculosis of the pubic symphysis and pubic bone is presented. There were no symptoms other than pain in the right groin area for 12 months. An X-ray of the pelvis showed an osteodestructive lesion of the pubic bone, and an MRI revealed an abscess formation of the pubic symphysis. Tissue samples were collected via CT-guided needle biopsy. Histological evaluation of tissue and analysis by PCR prompted the diagnosis of musculoskeletal tuberculosis. Despite antituberculous chemotherapy according to the current guidelines, the osteodestructive lesion progressed. This case highlights the difficulty of treating bone infections in general. Moreover, Mycobacterium tuberculosis as a rare causative agent of bone infections is discussed.

Background: This is a therapeutic study to evaluate the results of the management of forearm infected nonunion using bone transport with external fixators after debridement., Methods: We have retrospectively reviewed a consecutive series of 21 patients from October 1994 to June 2010 in our institution who were treated for the forearm infected nonunion by bone transport with external fixator after debridement. There were 12 males and 9 females. The mean age of the patients was 27.1 years. Of the initial fractures, nonunion of the radius alone invovled in 7 patients, nonunion of the ulna alone invovled in 12, and nonunion of the radius and ulna invovled in 2. Nineteen limbs (85.7%) were in active infected state with sinus and drainage. The mean amount of bone defect was 3.1 cm (range 1.8-4.6 cm) as measured on plain radiographs., Results: The mean follow-up was 77.5 months. All patients achieved bony union and were satisfied with the functional and cosmetic outcome. All the infection had been controlled. The mean external fixation index was 42.5 day/cm. The average time for wound healing was 42 days. The mean length gained was 3.5 cm (2.1-5.3 cm)., Conclusions: The technique of bone transport after debridement is a safe, effective, and minimally invasive treatment for forearm infected nonunion.

The clinical course of Staphylococcus aureus bacteremia varies extensively. We sought to determine the relationship between genetic characteristics of the infecting pathogen and clinical outcomes in an exploratory study. In two study centers, 317 blood culture isolates were analyzed by DNA microarray and spa genotyping. By uni- and multivariate regression analyses associations of genotype data with 30-day all-cause mortality, severe sepsis/septic shock, disseminated disease, endocarditis, and osteoarticular infection were investigated. Univariate analysis showed significant association between S. aureus genes/gene-clusters or clonal complexes and clinical endpoints. For example CC15 was associated with 30-day mortality and CC22 with osteoarticular infection. In multivariate analysis methicillin resistance (mecA, OR 4.8 [1.43-16.06]) and the beta-lactamase-gene (bla, OR 3.12 [1.17-8.30]) remained independently associated with 30-day mortality. The presence of genes for enterotoxins (sed/sej/ser) was associated with endocarditis (OR 5.11 [1.14-18.62]). Host factors such as McCabe classification (OR 4.52 [2.09-9.79] for mortality), age (OR 1.06 [1.03-1.10] per year), and community-acquisition (OR 3.40 [1.31-8.81]) had a major influence on disease severity, dissemination and mortality. Individual genotypes and clonal complexes of S. aureus can only partially explain clinical features and outcomes of S. aureus bacteremia. Genotype-phenotype association studies need to include adjustments for host factors like age, comorbidity and community-acquisition.

Infections of the bone and soft tissue of the limbs need to be diagnosed and treated urgently regardless of the patient's age. Clinical features are often non-specific. MRI and, in some cases, sonography investigations lead to early diagnosis and appropriate management. Computed tomography has limited value. Needle aspiration and biopsy need not be routine. In children, anatomical particularities explain the different morphological manifestations, which vary with age. It is important to both know when to propose the diagnosis of infection, so that appropriate imaging investigations are carried out, and to be aware of the symptomatology of limb infections in children and adults and understand the differential diagnoses for each age group. Clinicians should also be aware of the specific characteristics in children., (Copyright © 2012. Published by Elsevier Masson SAS.)

Spinal infections represent a difficult challenge to treating clinicians. Infections in the presence of implants are even more so. In this review the literature appears to reflect a change of practice in which the aim is to retain implants if possible. The newer spinal procedures such as disc replacements pose different problems largely due to the more difficult access. The situation in the spine is more difficult than in general orthopaedics when dealing with infection due to the requirement for stability and to protect neurological function. The main thrust of management, therefore, is early diagnosis and a high index of suspicion followed by adequate if not radical management in a multidisciplinary setting. In the event prevention is better than cure and therefore consideration of the various mechanisms to avoid infection must be taken. There are some 'novel' considerations for the avoidance of infection alongside the tried and tested techniques. There are also new procedures for wound closure and the elimination of dead space.

This paper describes a cat with severe localised infections with Cryptococcus neoformans/gattii species complex and Mycobacterium avium affecting the subcutis and underlying fascia and bone of the right pelvic limb. The simultaneous isolation of both pathogens in this patient was unexpected and posed unique issues concerning both diagnosis and clinical management. The aetiopathogenesis of this infection is discussed in relation to aspects of diagnosis and therapy., (Copyright © 2011 ISFM and AAFP. Published by Elsevier Ltd. All rights reserved.)

Primary musculoskeletal hydatidosis is less frequent than hydatidosis of the parenchymal organs. This localization has been little studied and so there is little information in the literature on the subsequent disease evolution. We present a case of primary hydatidosis of the abductor muscle that came to medical attention very late. After complete surgical removal of the huge mass, a secondary bone localization developed, causing a femoral pertrochanteric pathological fracture. The case described is exceptional in view of both the localization and the great size of the primary multi-lobed muscle hydatid cyst. We underline the difficulties of diagnosis and treatment of both the primary muscle localization and the secondary bone recurrence., (Copyright © 2009 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Hydatidosis is a parasitic disease caused by Echinococcus granulosus or, less frequently Echinococcus multilocularis. The liver and lungs are most often affected; hydatid disease of radius without involvement of other sites is extremely rare. Osseous hydatid disease should be included in the differential diagnosis for cystic lesions of bone. The diagnosis of bone hydatidosis is primarily based on radiological and histopathological findings. Here we present a case of hydatid cyst in the lower third of radius in a 34-year old woman. The cysts were removed with wide excision and post-operative albendazole was given. No recurrence was observed on two years follow-up.

Hydatid disease is caused by the tapeworm of genus ;Echinococcus. Genus Echinococcus has different species including Echinococcus vogeli, Echinococcus granulosus and Echinococcus multilucularis. Echinococcus granulosus is the most common cause of hydatid disease in humans. This disease can take place either directly through ingestion of parasite eggs from contact with infected dogs or indirectly from the ingestion of contaminated water or food. Infestation of hydatid disease in humans most commonly occurs in the liver (55-70%), followed by the lungs (18-35%). Bone hydatidosis however is very rare,whenever it occurs; it is usually secondary to visceral involvement. We present herein a case of primary hydatid cyst involving superior pubic ramus in a 43 years male patient, which is not a common site for the occurrence of this disease. Diagnosis is usually delayed if high index of suspicion is not there. MRI is a good tool for reaching diagnoses.

Rhinosporidiosis is a chronic granulomatous fungal disease caused by Rhinosporidiosis seeberi. It usually affects the mucocutaneous tissue of the nose; bone involvement is rare. We report the clinical features, diagnosis, and management of rhinosporidiosis involving the face, forehead, and right foot. As antimicrobial therapy was ineffective, a below-knee amputation was performed.

During the past several years, it has become quite evident that positron emission tomography (PET) with 18F-fluorodeoxyglucose (FDG) imaging can play a major role in the management of patients with suspected infection. Particularly, several groups have demonstrated that this powerful imaging methodology is very effective in the evaluation of osteomyelitis, infected prostheses, fever of unknown origin, and AIDS. In view of its extraordinary sensitivity in detecting disease activity and the ability to quantitate the degree of FDG uptake, PET might prove to be an appropriate modality for monitoring disease activity and evaluating response to therapy. FDG-PET has many advantages over existing imaging techniques for the diagnosis of infectious diseases. These include feasibility of securing diagnostic results within 1.5 to 2 h, excellent spatial resolution, and accurate anatomical localization of sites of abnormality. The availability of PET/computed tomography as a practical tool has further enhanced the role of metabolic imaging in many settings. In the future, this modality is very likely to be employed on a routine basis for detecting, characterizing, and monitoring patients with suspected and proven infection.

Background and Objectives: Delayed presentation of haematogenous bone and joint sepsis is common in our childhood population and leads to a large burden of avoidable morbidity extending into adult life. We set out to determine causative factors in these delays., Design: A prospective study was undertaken over a 1-year period., Setting: Ngwelezane Hospital, a regional hospital in Kwa-Zulu-Natal serving 9 rural district hospitals., Subjects: Children under 15 years with their first presentation of bone and joint sepsis, comprising 80 consecutive cases. Tuberculosis cases were excluded., Outcome Measures: Children were categorised at follow-up into two groups. The first group had uncomplicated recoveries, with complete return of function and no clinical or radiological signs of unresorbed sequestra. The second group had complications, with evidence of one or more of the following: chronicity of infection, pathological fracture, deformity, growth plate disturbance, avascular necrosis or joint stiffness., Results: Delay in obtaining definitive treatment correlated strongly with initial misdiagnosis. Only 4/25 septic hips were correctly diagnosed and referred expediently; 19/50 osteomyelitis cases were initially misdiagnosed and treated as cellulitis, and a further 19/50 were misdiagnosed as trauma. Predictably, delayed treatment correlated strongly with a complicated outcome. No significant associations were found between delays and distance to nearest primary health care facility, relative levels of socio-economic deprivation within the study group, maternal educational attainment, or traditional healer consultation., Conclusion: Health care professionals at all levels should be alerted to the continued high incidence of this disease. We propose some 'red flags' to assist primary health care workers in the diagnosis of this condition.

Unlabelled: White blood cell scanning with (99m)Tc-hexamethylpropylene amine oxime (HMPAO) has proven highly sensitive and specific in the diagnosis and follow-up of patients with suspected osteomyelitis. The aim of this prospective study was to evaluate the usefulness of SPECT and transmission CT performed simultaneously using a hybrid imaging device for the functional anatomic mapping of bone and joint infections., Methods: (99m)Tc-HMPAO scintigraphy was performed on 28 consecutive patients: 15 with suspected bone infection (group 1) and 13 with suspected orthopedic implant infection (group 2). Planar scans were acquired 30 min, 4 h, and 24 h after injection. SPECT/CT was obtained 6 h after tracer injection, using a dual-head gamma-camera coupled with a low-power x-ray tube. In all patients, scintigraphic results were matched with the results of surgery or cultures and of clinical follow-up., Results: (99m)Tc-HMPAO scintigraphy was true-positive for infection in 18 of 28 patients (for a total of 21 sites of uptake) and true-negative in 10 of 28 subjects. SPECT/CT provided an accurate anatomic localization of all positive foci. With regard to the final diagnosis, SPECT/CT added a significant clinical contribution in 10 of 28 patients (35.7%). In fact, SPECT/CT differentiated soft-tissue from bone involvement both in patients with osteomyelitis and in patients with orthopedic implants, allowed correct diagnosis of osteomyelitis in patients with structural alterations after trauma, and identified synovial infection without prosthesis involvement in patients with a knee implant., Conclusion: Our results indicate that SPECT/CT performed using a hybrid device can improve imaging with (99m)Tc-HMPAO-labeled leukocytes in patients with suspected osteomyelitis by providing accurate anatomic localization and precise definition of the extent of infection.

Case Description: A 4-year-old English Pointer was examined because of chronic, progressive signs of pulmonary disease and failure to respond to medical treatment., Clinical Findings: At examination, radiography of the thorax revealed increased pulmonary opacity and air bronchograms in the right caudal lung lobe, and radiography of the forelimbs revealed periosteal bone production typical of hypertrophic osteopathy. Attempts to isolate a causative organism included bacterial culture of bronchoalveolar lavage fluid and a lung tissue specimen obtained via fine-needle aspiration. Despite a cytologic diagnosis of septic suppurative inflammation in the lavage fluid, those specimens did not yield bacterial growth. However, a biopsy specimen obtained during a lung lobectomy procedure yielded growth of Eikenella corrodens., Treatment and Outcome: Despite successful surgical removal of the consolidated lung lobe and initiation of antimicrobial treatment, the dog died 6 days after surgery., Clinical Relevance: The authors are not aware of reports of pulmonary infection with E. corrodens in animals. Infection with the organism is rare, but it is possible that infections are underreported given that the organism is difficult to culture and biopsy may be necessary to obtain enough tissue to yield a diagnosis.

The 16S rRNA gene PCR in the diagnosis of bone and joint infections has not been systematically tested. Five hundred twenty-five bone and joint samples collected from 525 patients were cultured and submitted to 16S rRNA gene PCR detection of bacteria in parallel. The amplicons with mixed sequences were also cloned. When discordant results were observed, culture and PCR were performed once again. Bacteria were detected in 139 of 525 samples. Culture and 16S rRNA gene PCR yielded identical documentation in 475 samples. Discrepancies were linked to 13 false-positive culture results, 5 false-positive PCR results, 9 false-negative PCR results, 16 false-negative culture results, and 7 mixed infections. Cloning and sequencing of 16S rRNA gene amplicons in 6 of 8 patients with mixed infections identified 2 to 8 bacteria per sample. Rarely described human pathogens such as Alcaligenes faecalis, Comamonas terrigena, and 21 anaerobes were characterized. We also detected, by 16S rRNA gene PCR, four previously identified bacteria never reported in human infection, Alkanindiges illinoisensis, dehydroabietic acid-degrading bacterium DhA-73, unidentified Hailaer soda lake bacterium, and uncultured bacterium clone HuCa4. Seven organisms representing new potential species were also detected. PCR followed by cloning and sequencing may help to identify new pathogens involved in mixed bone infection.

The case of a 55-year-old female patient with discogenic sclerosis of a thoracic vertebra is illuminated by a radiologic vignette. The clinical and radiologic features, including those of conventional radiography, computed tomography scanning and magnetic resonance imaging are hallmarked in this portrait. The importance of differentiating the condition particularly from infectious spondylodiscitis and metastatic disease to the spine is underpinned.

Aim: To describe the frequency, types, clinical characteristics, diagnostic tools, and outcome of osteoarticular brucellosis., Methods: The study was carried out at the Hospital for Infectious Diseases in Skopje between January 1998 and December 2002. Three hundred and thirty one consecutive patients with brucellosis were enrolled and prospectively assessed according to a previously designed protocol. Brucellosis was diagnosed on the basis of clinical signs, and confirmed by the detection of specific antibodies at significant titers., Results: One hundred and ninety six (59.2%) patients had osteoarticular involvement. Peripheral arthritis was found in 119 (60.7%) patients, followed by sacroiliitis in 60 (30.6%) and spondylitis in 56 (28.6%) of them. In 86 (43.9%) patients, osteoarticular changes were localized in two or more sites. The patients with osteoarticular brucellosis showed more prolonged illness prior to diagnosis and higher erythrocyte sedimentation rate, compared to those without osteoarticular localization. There were no other significant demographic, epidemiological, clinical, and laboratory differences between the two groups. Relapses occurred in 28 (17.5%) and therapeutic failure in 25 (12.8%) patients, 24 of them with spondylitis., Conclusions: Osteoarticular brucellosis was a common form of focal brucellosis and the most unfavorable outcome was seen in patients with spondylitis.

Background: Over the past years we have had a relatively large number of patients in our hospital with endocarditis. There has been a variety of clinical presentations, as illustrated by the following case presentations., Material and Methods: We have conducted a search in our data-based archives of the period from 1.1.1994 to 31.12.2001 and found 25 patients discharged with a diagnosis of endocarditis. We have chosen five case histories that we discuss in the context of published literature., Results and Interpretation: The signs and symptoms presented include a stroke, severe back pain, a swollen knee, pneumonia and cardiac failure. We especially discuss intravenous drug users and endocarditis of the heart's right side.

A 49-year-old farmer had a history of recurrent knee effusion for 20 years. He did not report undergoing any diagnostic or therapeutic procedures apart from repeated aspirations of the joint fluid. After the isolation of Brucella melitensis from the joint fluid, computed tomography-guided bone biopsy was performed and histopathologic examination of the biopsy sample confirmed the diagnosis of chronic Brucella osteomyelitis. Arthroscopic synovectomy combined with antimicrobial therapy with doxycyclin, rifampicin, and ciprofloxacin for six months resulted in clinical recovery. This case indicates that brucellosis should be suspected in patients with non-specific and chronic osteoarticular symptoms, especially in endemic regions.

Hydatid disease of bone is rare; success in management is difficult as recurrence is common. We report the successful use of orthopaedic oncological techniques and technology in treating a patient with hydatid disease affecting his humerus.