Search

INTRODUCTION: Brucellosis is a chronic infectious disease with osteoarticular (OA) manifestations. It is difficult to distinguish between brucellosis and rheumatologic diseases in endemic areas. In this study, we aimed to report the clinical findings and autoantibody results of patients diagnosed with brucellosis in the rheumatology department. METHODS: In this study, 92 patients over the age of 18 with the diagnosis of "Brucellosis" were included. All patients' systemic and joint examinations were performed. In the presence of clinical signs, those with a detected value of ≥1: 160 on the standard tube agglutination test were considered to be active brucellosis. Those with arthritis, arthralgia, tenosynovitis-bursitis, spondylodiscitis and sacroiliitis were detected on examination or magnetic resonance imaging, and those with low back or hip pain were recorded. Complete blood count,C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) and RF, anti-CCP, ANA and anti-DNA results were evaluated. RESULTS: The mean age of ninety-two patients (Female: 54, 58.7%) was 39.3+-13 years. In the OA findings; arthralgia was detected with a ratio of 90.2%, arthritis with 33.7%, myalgia with 28.2%, sacroiliitis with 25% and spondylodiscitis with 6.5%. CRP and ESR means were 19 mm/h with 2.1 mg\dL. RF was positive in 12 (13%), Anti-CCP in 5 (5.4%), ANA in 7 (7.6%).There were no patients with anti-DNA positivity. The median treatment duration was 12 weeks. DISCUSSION AND CONCLUSION: The anti-CCP positivity was lower than in the literature, and RF and ANA positivity were similar. Symmetrical involvement of small joints, higher CRP and high titer autoantibody positivity were at a higher risk of developing rheumatologic disease.

The presented case report concerns a 40-years-old man who was admitted to the infectiology department for back pain and elevated C-reactive protein, leading to suspicion of spondylodiscitis. Initially, the first lumbar spine MRI yielded negative results. Nevertheless, the patient was treated with Gentamicin followed by Ceftriaxone and Levofloxacin for a sepsis to Shewanella Algae. The second lumbar spine MRI on day 8 confirmed the diagnosis.

Sporotrichosis is the most frequent subcutaneous or implantation mycosis in Latin America, and its transmission occurs as a result of traumatic inoculation into the skin by organic matter containing the thermodimorphic fungi of the genus Sporothrix. Although cutaneous forms are more common, another important site is the osteoarticular system, whose hematogenous involvement is commonly associated with disseminated forms, especially in people who have an immunosuppressive condition, such as HIV/AIDS, chronic steroid use, and alcohol abuse. We present two cases of osteoarticular sporotrichosis of the knee caused by Sporothrix brasiliensis and followed up at our institution, with different outcomes. In the cases presented here, aging, anatomical sites, comorbidities, subtherapeutic serum levels, low adherence to treatment, and late diagnosis for different reasons may explain the observed outcomes. Early diagnosis of Sporothrix infection is critical in preventing complications, including death. We also highlight the importance of multidisciplinary follow-up and adherence to treatment for a favorable outcome. [ABSTRACT FROM AUTHOR]

Copyright of Van Tip Dergisi is the property of Yuzuncu Yil University, Faculty of Medicine and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Mycobacterium Tuberculosis (MTB) primarily infects the lungs and spreads throughout the body after the initial infection. This dissemination occurs through the reactivation of a dormant focus, which is preceded by lymphohaematogenous spread. It can also spread through the bloodstream from active lung or miliary tuberculosis. Tuberculosis is the leading cause of amenorrhoea in young females in developing countries like India. Although disseminated tuberculosis with osteoarticular involvement is a rare occurrence, a 20-year-old female presented to Acharya Vinoba Bhave Rural Hospital (AVBRH) with primary complaints of amenorrhoea and swelling in the right knee joint, which were the primary symptoms of disseminated tuberculosis. The present case is exceptional because it lacks the typical pulmonary symptoms. The predominance of gynaecological symptoms over pulmonary involvement may have led to an incorrect diagnosis of malignancy instead of tuberculosis. Additionally, the suspicion of tuberculosis was delayed due to elevated ovarian tumour markers.

Background: Osteoarticular tuberculosis (OATB) is a form of extrapulmonary tuberculosis (TB) affecting bones and joints. There is a paucity of data on skeletal TB epidemiology in the annual TB reports and current literature. Many atypical presentations of the disease have also emerged. This necessitates periodic observation of the epidemiological profile of OATB. The aim of this study is to analyze the prevailing epidemiological trends of OATB in Central India. Methods: The 5-year ambispective observational study was conducted at the department of orthopedics of a tertiary care center in Central India. Records of patients diagnosed with OATB from January 2017 to December 2021 were analyzed for demographic factors, site of lesion, comorbidities (pulmonary TB, human immunodeficiency virus, and diabetes), etc., Chi-square test for linear trend was used to determine whether a linear trend exists in the number of diagnosed cases. Results: Two hundred and ten skeletal TB lesions were found in 208 patients included in the study. OATB was highly reported in young adults and females. Spinal lesions were three times more common than extraspinal OATB lesions. The lumbar spine was the most affected region. Hip was the most common extraspinal site. Unusual sites such as sternoclavicular joint and ischial tuberosity were also involved. Conclusion: The burden of OATB is increasing, especially spinal TB. The involvement of atypical sites insists on strong clinical suspicion for early diagnosis. The practice of empirical antitubercular chemotherapy needs to be reviewed considering the risk of drug resistance.

Introduction: The myriad presentation of osteoarticular brucellosis make the patient seek the help of general practitioners, orthopaedic and rheumatology specialists. Moreover, the lack of disease-specific symptomatology is the leading cause of the delay in diagnosing osteoarticular brucellosis. Given the increasing number of spinal brucellosis cases across the country, no literature is presented on the systematic management of spinal brucellosis. However, with our experience, we formulated a classification for managing spinal brucellosis. Methods: A single-centred prospective observational study was conducted with 25 confirmed cases of spinal brucellosis. Patients were analysed and graded clinically, serologically, and radiologically and were managed with antibiotics for 10–12 weeks, and if necessary, stabilisation and fusion were done based on the treatment classification devised. All patients were followed up to ensure disease clearance at serial follow-up with relevant investigations. Results: The mean age of the study participants was 52.16 ± 12.53 years. According to spondylodiscitis severity code (SSC) grading, four patients belong to grades 1, 12 to grade 2 and 9 to grade 3 at presentation. Erythrocyte sedimentation rate (p = 0.02), c-reactive protein (p

Mycobacterium Tuberculosis (MTB) primarily infects the lungs and spreads throughout the body after the initial infection. This dissemination occurs through the reactivation of a dormant focus, which is preceded by lymphohaematogenous spread. It can also spread through the bloodstream from active lung or miliary tuberculosis. Tuberculosis is the leading cause of amenorrhoea in young females in developing countries like India. Although disseminated tuberculosis with osteoarticular involvement is a rare occurrence, a 20-year-old female presented to Acharya Vinoba Bhave Rural Hospital (AVBRH) with primary complaints of amenorrhoea and swelling in the right knee joint, which were the primary symptoms of disseminated tuberculosis. The present case is exceptional because it lacks the typical pulmonary symptoms. The predominance of gynaecological symptoms over pulmonary involvement may have led to an incorrect diagnosis of malignancy instead of tuberculosis. Additionally, the suspicion of tuberculosis was delayed due to elevated ovarian tumour markers. [ABSTRACT FROM AUTHOR]

Intraocular tuberculosis should always be deemed as a differential diagnosis due to its high importance, in addition to the high morbidity of systemic infection. This condition may be associated with extraocular manifestations that are not prevalent in tuberculosis. The author reported a case of ocular tuberculosis vasculitis associated with erythema nodosum and Poncet’s disease, with resolution of the medical findings and symptoms after the standard treatment for tuberculosis. [ABSTRACT FROM AUTHOR]

Background: Osteoarticular tuberculosis (OATB) is a form of extrapulmonary tuberculosis (TB) affecting bones and joints. There is a paucity of data on skeletal TB epidemiology in the annual TB reports and current literature. Many atypical presentations of the disease have also emerged. This necessitates periodic observation of the epidemiological profile of OATB. The aim of this study is to analyze the prevailing epidemiological trends of OATB in Central India. Methods: The 5-year ambispective observational study was conducted at the department of orthopedics of a tertiary care center in Central India. Records of patients diagnosed with OATB from January 2017 to December 2021 were analyzed for demographic factors, site of lesion, comorbidities (pulmonary TB, human immunodeficiency virus, and diabetes), etc., Chi-square test for linear trend was used to determine whether a linear trend exists in the number of diagnosed cases. Results: Two hundred and ten skeletal TB lesions were found in 208 patients included in the study. OATB was highly reported in young adults and females. Spinal lesions were three times more common than extraspinal OATB lesions. The lumbar spine was the most affected region. Hip was the most common extraspinal site. Unusual sites such as sternoclavicular joint and ischial tuberosity were also involved. Conclusion: The burden of OATB is increasing, especially spinal TB. The involvement of atypical sites insists on strong clinical suspicion for early diagnosis. The practice of empirical antitubercular chemotherapy needs to be reviewed considering the risk of drug resistance. [ABSTRACT FROM AUTHOR]

Introduction: Osteoarticular infections (OAIs) constitute serious paediatric conditions that may cause severe complications. Identifying the causative organism is one of the mainstays of the care process, since its detection will confirm the diagnosis, enable adjustments to antibiotic therapy and thus optimize outcomes. Two bacteria account for the majority of OAIs before 16 years of age: Staphylococcus aureus is known for affecting the older child, whereas Kingella kingae affects infants and children younger than 4 years old. We aimed to better define clinical characteristic and biological criteria for prompt diagnosis and discrimination between these two OAI. Materials and methods: We retrospectively studied 335 children, gathering 100 K. kingae and 116 S. aureus bacteriologically proven OAIs. Age, gender, temperature at admission, involved bone or joint, and laboratory data including bacterial cultures were collected for analysis. Comparisons between patients with OAI due to K. kingae and those with OAI due to S. aureus were performed using the Mann–Whitney and Kruskal–Wallis tests. Six cut-off discrimination criteria (age, admission's T°, WBC, CRP, ESR and platelet count) were defined, and their respective ability to differentiate between OAI patients due to K. kingae versus those with S. aureus was assessed by nonparametric receiver operating characteristic (ROC) curves. Results: Univariate analysis demonstrated significant differences between the two populations for age of patients, temperature at admission, CRP, ESR, WBC, and platelet count. AUC assessed by ROC curves demonstrated an exquisite ability to discriminate between the two populations for age of the patients; whereas AUC for CRP (0.79), temperature at admission (0.76), and platelet count (0.76) indicated a fair accuracy to discriminate between the two populations. Accuracy to discriminate between the two subgroups of patients was considered as poor for WBC (AUC = 0.62), and failed for ESR (AUC = 0.58). On the basis of our results, the best model to predict K. kingae OAI included of the following cut-offs for each parameter: age < 43 months, temperature at admission < 37.9 °C, CRP < 32.5 mg/L, and platelet count > 361,500/mm3. Conclusions: OAI caused by K. kingae affects primarily infants and toddlers aged less than 4 years, whereas most of the children with OAI due to MSSA were aged 4 years and more. Considering our experience on the ground, only three variables were very suggestive of an OAI caused by K. kingae, i.e., age of less than 4 years, platelet count > 400,000, and a CRP level below 32.5 mg/L, whereas WBC and ESR were relatively of limited use in clinical practice. [ABSTRACT FROM AUTHOR]

Human brucellosis causes a variety of clinical symptoms and osteoarticular involvement is the most common involvement. We conducted a bibliometric analysis study on osteoarticular involvement in brucellosis. The study's aim was to investigate the impact of publications in this field and to discover research development and clusters. We used the Web of Science (Wos) database to obtain the data. The titles, document types, publication years, authors, organizations, keywords, abstracts of each record, H-index, and citations were analyzed. We analyzed 642 documents (research articles and review articles). 83.178% of them were published in Science Citation Index Expanded (Sci-Expanded) indexed journals. English (88.785%) was the most preferred language. Researchers from 70 countries contributed to the growth of scientific studies. Turkey was ranked first with a total of 177 publications. The United States of America (11.059%), Peoples' Republic of China (8.411%), Iran (6.698%), and Spain (6.698%) were the top five countries according to the number of publications. The publications were cited 11118 times (17.32 per item) and the mean of the H-index was 51. The publications published between 2000- 2009 received the highest number of citations and had the highest H indexes. H indexes and citation numbers of publications have decreased since 2010. This is the first report that shows the trends of osteoarticular involvement in brucellosis. In conclusion, financial support for scientific studies in regions where brucellosis is endemic may increase the number of articles to be published in the future from these regions.

Sporotrichosis is the most frequent subcutaneous or implantation mycosis in Latin America, and its transmission occurs as a result of traumatic inoculation into the skin by organic matter containing the thermodimorphic fungi of the genus Sporothrix. Although cutaneous forms are more common, another important site is the osteoarticular system, whose hematogenous involvement is commonly associated with disseminated forms, especially in people who have an immunosuppressive condition, such as HIV/AIDS, chronic steroid use, and alcohol abuse. We present two cases of osteoarticular sporotrichosis of the knee caused by Sporothrix brasiliensis and followed up at our institution, with different outcomes. In the cases presented here, aging, anatomical sites, comorbidities, subtherapeutic serum levels, low adherence to treatment, and late diagnosis for different reasons may explain the observed outcomes. Early diagnosis of Sporothrix infection is critical in preventing complications, including death. We also highlight the importance of multidisciplinary follow-up and adherence to treatment for a favorable outcome.

Background: The treatment of osteoarticular infections in pediatric patients with sickle cell disease (SCD) is a challenging task for the practitioner. The aim of this study is to evaluate cefixime for the treatment of osteoarticular infections in pediatric SCD patients by retrospective design. Methods: This study was done in the pediatric hospital of King Saud Medical City, Riyadh, Saudi Arabia. The data was obtained from medical records of patients aged 1–16 years admitted between January 2019 to December 2020, diagnosed with SCD and received cefixime for the treatment of OI. A descriptive study for pediatric patients admitted between January 2019 to December 2020 diagnosed with sickle cell disease and diagnosed with osteoarticular infection. All patients were treated with cefixime. Medians and interquartile ranges (IQRs) were used for the descriptive analysis. Results: A total of 260 patients were screened, and 51 cases [osteomyelitis (OM), n = 43, and septic arthritis (SA), n = 8] met the inclusion criteria. The median age of OM patients was 7 years, with males making up 67.4% of the cohort. The median length of IV antibiotics and hospital stays were 10 days and 11 days, respectively. The median total duration of antibiotic use was 37 and 25 days for OM and SA, respectively. The treatment success rate was 88% in OM cases and 100% in SA patients. Readmission was noted in 39.5% of the OM patients, while only 25% of the SA patients were recorded for reinfection. Conclusion: The study's findings revealed that Cefixime is a viable oral alternative for treating osteoarticular infection in pediatric SCD patients. Nonetheless, a prospective investigation is required to corroborate the findings of this study.

BackgroundOsteoarticular tuberculosis (TB) is an uncommon form of extrapulmonary TB. In this study, we analyzed the epidemiological characteristics, common sites, and drug resistance profiles of osteoarticular TB infections occurring in southwest China.MethodsA total of 3,254 cases of patients clinically diagnosed with osteoarticular TB infections between 2013 and 2021 were retrospectively analyzed. Patients' demographic and clinical characteristics were collected. Drug sensitivity testing was performed using the microporous plate ratio method. Chi-squared analysis was used to analyze the rates of and trends in mycobacterial isolates.ResultsOf the 3,254 patients, 1,968 (60.5%) were men and boys, and 1,286 (39.5%) were women and girls; patients' ages ranged from 1 to 91 years, with an average of 42 ± 19.3 years. In terms of disease, 2,261 (69.5%) had spinal TB, mainly thoracic (815, 36%) or lumbar (1,080, 48%); joint TB was found in 874 cases (26.9%), mainly occurring in the knee (263, 30%) or hip (227, 26%); and both spinal and joint TB were observed in 119 cases (3.7%). Drug susceptibility tests were performed on 241 isolated strains of MTB; 70 strains (29.0%) were resistant to at least one drug, and MDR-TB and XDR-TB were observed in 7.1 and 1.2% of strains, respectively.ConclusionsIn southwest China over this period, osteoarticular TB mainly affected middle-aged and young men with poor nutritional status. Patients from ethnic minority areas also accounted for a large proportion of cases. Spinal TB is prone to occur in the lumbar and thoracic vertebrae, and joint TB is prone to occur in the lower limb joints. Additionally, there has been an increasing trend in the number of TB cases over the past 9 years, and drug resistance has also increased.

The treatment paradigm for osteoarticular infections (OAIs) has changed drastically over the past 80 years, from the advent of penicillin to the use of broad-spectrum antibiotics. Before these drugs, surgery was the only available treatment for OAIs; today, antibiotic therapy is considered the primary response to them. As a result, surgical treatment of OAIs is thus far more rarely indicated, sometimes even considered outdated and obsolete. However, long experience has taught us that many OAI contexts can still benefit from surgical management, constituting an essential complement to medical treatment. The present article seeks to contextualize this discussion by providing a chronological review of the surgical treatments used in cases of OAI and describing the quality of evidence supporting their rehabilitation in well-established situations.

The objective of the study is to determine the accuracy of metagenomic next-generation sequencing (mNGS) in diagnosing osteoarticular tuberculosis (TB) infection and to compare it with mycobacteria growth indicator tube (MGIT) and Xpert assays. We retrospectively analyzed 162 patients admitted with suspected osteoarticular TB. Osteoarticular tissue (66.67%) and abscess specimens (33.33%) from patients were tested for MGIT, GeneXpert/RIF, and mNGS. mNGS assay detected 76 cases (46.9%) with bacterial, 63 cases (38.9%) with mycobacterial, 22 cases (13.6%) with fungal, and 1 case (0.6%) with actinomycetal organisms. These 162 pathogens were classified into 21 species. The most frequent species detected was Mycobacterium tuberculosis complex (29.0%), followed by Staphylococcus aureus (20.4%), Mycobacterium abscessus (5.6%), and Candida albicans (5.6%). Taking the "gold standard" TB diagnosis as the standard, the positive predictive values of mNGS, Xpert, and MGIT culture were both 100.00%. The negative predictive values of mNGS, Xpert, and MGIT culture and assays were 94.26%, 98.29%, and 88.46%, respectively. The sensitivity of mNGS detection (85.11%) was similar to that of Xpert (95.74%) and higher than that of MGIT culture (68.08%). The specificities of mNGS detection, Xpert, and MGIT culture were both 100.00%. The area under the curve value of the mNGS assay was 0.895 (95% CI: 0.830, 0.960), which was greater than that of the MGIT culture-based assay of 0.840 (95% CI: 0.757, 0.924), which was similar to 0.979 (95% CI: 0.945, 1.000) for Xpert assay. The pathogen detection rate of mNGS in diagnosing suspected osteoarticular TB exceeded that of conventional methods., Importance: In the detection of unknown infectious disease pathogens, the overall efficacy of traditional detection methods, such as culture, is low, and traditional PCR testing is also limited to the gene sequences of known pathogenic microorganisms. Metagenomic next-generation sequencing (mNGS) performs DNA sequencing by studying the entire microbial community genome in a given sample, without the need for isolation and culture. Previous studies have shown that mNGS performs better on pulmonary and extrapulmonary samples when compared with Xpert, traditional pathogenetic tests, and even parallel diagnostics. However, it should be emphasized that only a few studies have explored the performance of mNGS in detecting Mycobacterium tuberculosis in clinical samples associated with bone and joint infections. We conducted this retrospective study to provide additional data to support the use of mNGS in the clinical setting to identify pathogens within abscesses or tissue samples associated with bone and joint infections.

Abstract Background Wrist tuberculosis is a rare disease, which is easy to be misdiagnosed, leading to delayed treatment and poor prognosis. In this study, the clinical manifestations, diagnosis, treatment, and prognosis of 18 cases of wrist tuberculosis were analyzed retrospectively. Methods A retrospective study was conducted, investigating tuberculosis of the wrist, diagnosed in 18 patients from August 2013 to November 2018. Puncture biopsy confirmed the diagnosis. The study includes 11 males and 7 females, and 8 left and 10 right wrists. The average age was 53.5 ± 18.3 years and ranged from 15 to 81 years. The disease course was 1 to 42 months, with an average of 15.1 ± 11.3 months. Eighteen patients were underwent surgery and chemotherapy, 3 patients with severe bone defects were treated with wrist fusion, and 15 patients were underwent focus removal. The Gartland and Werley score, DASH score, the range of motion (ROM), grip strength, and imaging examinations were used to evaluate the postoperative recovery of the patients. Results Eighteen patients were followed up for 15 to 77 months, with an average follow up of 39.7 ± 15.3 months. The ESR and CRP levels were normal for all patients after chemotherapy. No recurrence of tuberculosis was observed in any of the patients. Among the 15 focus removals, the Gartland and Werley scores at admission, two weeks of chemotherapy, 1 month after surgery, and the last follow-up were 21.73 ± 4.33, 18.60 ± 3.16,11.27 ± 2.79, and 5.07 ± 2.28, respectively; and the DASH scores were 45.87 ± 5.58, 39.47 ± 4.72, 22.67 ± 6.54, and 6.73 ± 2.94, respectively. The range of motion (ROM) of the wrist and grip strength improved significantly when compared to those at admission. Among the three cases of wrist fusion, 2 were fixed with a steel plate and the fixation position of wrist joint was good. One case was fixed with Kirschner wire and resulted in a slightly deformed wrist joint. Conclusion For patients with wrist tuberculosis, early diagnosis, preoperative and postoperative chemotherapy, thorough focus removal, and appropriate fixation of the affected limb can help restore the function of the affected wrist, reduce the recurrence rate, and improve the quality of life.

Sporotrichosis is a frequent subcutaneous mycosis in Madagascar. Extracutaenous forms are exceptional and are usually seen in immunosuppressed hosts. We report a case of an aggressive clinical evolution of lymphocutaneous sporotrichosis with osteoarticular involvement in an immunocompetent patient. Therapy with oral itraconazole 200 mg twice daily for 12 months improved the lesion. Early diagnosis of Sporothrix schenkii infection is critical to prevent complications including osteoarticular involvement, disseminated forms and death.

The treatment of osteoarticular infections in pediatric patients with sickle cell disease (SCD) is a challenging task for the practitioner. The aim of this study is to evaluate cefixime for the treatment of osteoarticular infections in pediatric SCD patients by retrospective design. This study was done in the pediatric hospital of King Saud Medical City, Riyadh, Saudi Arabia. The data was obtained from medical records of patients aged 1–16 years admitted between January 2019 to December 2020, diagnosed with SCD and received cefixime for the treatment of OI. A descriptive study for pediatric patients admitted between January 2019 to December 2020 diagnosed with sickle cell disease and diagnosed with osteoarticular infection. All patients were treated with cefixime. Medians and interquartile ranges (IQRs) were used for the descriptive analysis. A total of 260 patients were screened, and 51 cases [osteomyelitis (OM), n = 43, and septic arthritis (SA), n = 8] met the inclusion criteria. The median age of OM patients was 7 years, with males making up 67.4% of the cohort. The median length of IV antibiotics and hospital stays were 10 days and 11 days, respectively. The median total duration of antibiotic use was 37 and 25 days for OM and SA, respectively. The treatment success rate was 88% in OM cases and 100% in SA patients. Readmission was noted in 39.5% of the OM patients, while only 25% of the SA patients were recorded for reinfection. The study's findings revealed that Cefixime is a viable oral alternative for treating osteoarticular infection in pediatric SCD patients. Nonetheless, a prospective investigation is required to corroborate the findings of this study. [ABSTRACT FROM AUTHOR]

Q fever osteoarticular infection in children is an underestimated disease. We report 3 cases of Q fever osteomyelitis in children and review all cases reported in the literature through March 2018. A high index of suspicion is encouraged in cases of an unusual manifestation, prolonged course, relapsing symptoms, nonresolving or slowly resolving osteomyelitis, culture-negative osteomyelitis, or bone histopathology demonstrating granulomatous changes. Urban residence or lack of direct exposure to animals does not rule out infection. Diagnosis usually requires use of newer diagnostic modalities. Optimal antimicrobial therapy has not been well established; some case-patients may improve spontaneously or during treatment with a β-lactam. The etiology of treatment failure and relapse is not well understood, and tools for follow-up are lacking. Clinicians should be aware of these infections in children to guide optimal treatment, including choice of antimicrobial drugs, duration of therapy, and methods of monitoring response to treatment..

Introduction: Osteoarticular infections (OAIs) constitute serious paediatric conditions that may cause severe complications. Identifying the causative organism is one of the mainstays of the care process, since its detection will confirm the diagnosis, enable adjustments to antibiotic therapy and thus optimize outcomes. Two bacteria account for the majority of OAIs before 16 years of age: Staphylococcus aureus is known for affecting the older child, whereas Kingella kingae affects infants and children younger than 4 years old. We aimed to better define clinical characteristic and biological criteria for prompt diagnosis and discrimination between these two OAI. Materials and methods: We retrospectively studied 335 children, gathering 100 K. kingae and 116 S. aureus bacteriologically proven OAIs. Age, gender, temperature at admission, involved bone or joint, and laboratory data including bacterial cultures were collected for analysis. Comparisons between patients with OAI due to K. kingae and those with OAI due to S. aureus were performed using the Mann–Whitney and Kruskal–Wallis tests. Six cut-off discrimination criteria (age, admission’s T°, WBC, CRP, ESR and platelet count) were defined, and their respective ability to differentiate between OAI patients due to K. kingae versus those with S. aureus was assessed by nonparametric receiver operating characteristic (ROC) curves. Results: Univariate analysis demonstrated significant differences between the two populations for age of patients, temperature at admission, CRP, ESR, WBC, and platelet count. AUC assessed by ROC curves demonstrated an exquisite ability to discriminate between the two populations for age of the patients; whereas AUC for CRP (0.79), temperature at admission (0.76), and platelet count (0.76) indicated a fair accuracy to discriminate between the two populations. Accuracy to discriminate between the two subgroups of patients was considered as poor for WBC (AUC = 0.62), and failed for ESR (AUC = 0.58). On the basis of our results, the best model to predict K. kingae OAI included of the following cut-offs for each parameter: age < 43 months, temperature at admission < 37.9 °C, CRP < 32.5 mg/L, and platelet count > 361,500/mm3. Conclusions: OAI caused by K. kingae affects primarily infants and toddlers aged less than 4 years, whereas most of the children with OAI due to MSSA were aged 4 years and more. Considering our experience on the ground, only three variables were very suggestive of an OAI caused by K. kingae, i.e., age of less than 4 years, platelet count > 400,000, and a CRP level below 32.5 mg/L, whereas WBC and ESR were relatively of limited use in clinical practice.

Copyright of Biomédica: Revista del Instituto Nacional de Salud is the property of Instituto Nacional de Salud of Colombia and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Maintaining an effective drug concentration in the nidus during the early stage is essential for the surgical treatment of osteoarticular tuberculosis (TB) and the prevention of internal infection. In this study, an implantable composite scaffold, denoted as n-HP@ICG, was synthesized by attaching isoniazid (INH) to chitosan followed by crosslinking via glutaraldehyde to porous nanohydroxyapatite/polyamide 66 (n-HA/PA66). Drug release and biocompatibility experiments showed that INH could be effectively released from the composite scaffold for approximately 15 days in vitro and 28 days in vivo with no obvious cytotoxicity or harm to liver or kidney function. The anti-TB test indicated that n-HP@ICG had satisfactory anti-TB effects, including the inhibition of Mycobacterium tuberculosis activity, proliferation and adhesion. The rabbit femoral condyle defect repair experiment showed that the composite scaffold had satisfactory osteoconduction and osseointegration. These results demonstrate that the n-HP@ICG composite scaffold can simultaneously provide relatively long-term drug release, biosafety, and anti-TB and bone regeneration activity and is thus promising for treating osteoarticular TB.

Introduction: Brucellosis is a zoonosis with a wide spectrum of clinical manifestations. However, it is still unclear whether the clinical manifestations in children are significantly different from those in adults. Methodology: Patients with brucellosis and treated at the General Hospital of Ningxia Medical University between 2009 and 2019 were divided into two groups; children (88) and adults (354). Thereafter, the records of the two groups were analyzed retrospectively. Results: The findings showed that: 1. School-age children, young and middle-aged individuals were more likely to suffer from brucellosis and most were male; 2. Fever and arthralgia were the most common manifestations in the two groups. In addition, fatigue and low back pain were rare in children although fever and lymphadenopathy were more common in this group. However, hepatomegaly and splenomegaly were common in both groups; 3. The most common complication was osteoarthritis and peripheral arthritis occurred more frequently in children. On the other hand, spondylitis was the most common in adults (this particularly involved the lumbar and sacral vertebrae); 4. An increase in the erythrocyte sedimentation rate, levels of the C-reactive protein and liver enzymes was common in both two groups; 5. There was no significant difference in the positive rate of the standard agglutination test between children (96.59%) and adults (95.20%). However, the positive rate of blood culture was higher in children (65.85%) than in adults (51.00%). Conclusions: Brucellosis causes damage to multiple systems and differences in clinical characteristics were found between children and adults. [ABSTRACT FROM AUTHOR]

Elbow is an uncommon joint to be affected by Mycobacterium tuberculosis infection. It is involved in approximately 1–5% of all cases with musculoskeletal tuberculosis (TB). Early diagnosis of TB of the elbow joint can be easily missed due to an indolent natural history, delay in presentation, and varied clinical features. Delay in diagnosis can lead to irreversible osteoarticular destruction and loss of joint function. Careful clinical assessment, adequate imaging, microbiological, and/or histopathological confirmation of Mycobacterium tuberculosis infection is essential for early diagnosis of TB of the elbow joint. Judicious and early administration of anti-tubercular therapy can lead to preservation of the joint and a satisfactory functional outcome. Surgical intervention may be needed in later stages of the disease to achieve control of the infection, correction of deformity, instability, and restoration of function. [ABSTRACT FROM AUTHOR]

Background: Wrist tuberculosis is a rare disease, which is easy to be misdiagnosed, leading to delayed treatment and poor prognosis. In this study, the clinical manifestations, diagnosis, treatment, and prognosis of 18 cases of wrist tuberculosis were analyzed retrospectively. Methods: A retrospective study was conducted, investigating tuberculosis of the wrist, diagnosed in 18 patients from August 2013 to November 2018. Puncture biopsy confirmed the diagnosis. The study includes 11 males and 7 females, and 8 left and 10 right wrists. The average age was 53.5 ± 18.3 years and ranged from 15 to 81 years. The disease course was 1 to 42 months, with an average of 15.1 ± 11.3 months. Eighteen patients were underwent surgery and chemotherapy, 3 patients with severe bone defects were treated with wrist fusion, and 15 patients were underwent focus removal. The Gartland and Werley score, DASH score, the range of motion (ROM), grip strength, and imaging examinations were used to evaluate the postoperative recovery of the patients. Results: Eighteen patients were followed up for 15 to 77 months, with an average follow up of 39.7 ± 15.3 months. The ESR and CRP levels were normal for all patients after chemotherapy. No recurrence of tuberculosis was observed in any of the patients. Among the 15 focus removals, the Gartland and Werley scores at admission, two weeks of chemotherapy, 1 month after surgery, and the last follow-up were 21.73 ± 4.33, 18.60 ± 3.16,11.27 ± 2.79, and 5.07 ± 2.28, respectively; and the DASH scores were 45.87 ± 5.58, 39.47 ± 4.72, 22.67 ± 6.54, and 6.73 ± 2.94, respectively. The range of motion (ROM) of the wrist and grip strength improved significantly when compared to those at admission. Among the three cases of wrist fusion, 2 were fixed with a steel plate and the fixation position of wrist joint was good. One case was fixed with Kirschner wire and resulted in a slightly deformed wrist joint. Conclusion: For patients with wrist tuberculosis, early diagnosis, preoperative and postoperative chemotherapy, thorough focus removal, and appropriate fixation of the affected limb can help restore the function of the affected wrist, reduce the recurrence rate, and improve the quality of life. [ABSTRACT FROM AUTHOR]

Background: We conducted this retrospective study to reveal the accuracy of metagenomic next-generation sequencing (mNGS) for diagnosing osteoarticular infections from fresh abscess specimens obtained from patients in an HIV-naive population.Methods: We retrospectively analyzed hospital records at three participating TB-specialized hospitals for patients admitted with suggestive diagnoses of osteoarticular tuberculosis between January 2018 and August 2019. Abscess specimens obtained from each patient were tested via pathogen culture, GeneXpert Mycobacterium tuberculosis (MTB)/rifampicin (RIF), and mNGS assay.Results: A total of 82 abscess samples were collected from patients with osteoarticular infections, including 53 cases with (64.6%) bacterial, 21 (25.6%) with mycobacterial, 7 (8.5%) with fungal, and 1 (1.2%) with actinomycetal organisms detected. Analysis of mNGS assay results identified potential pathogens in all cases, with M. tuberculosis complex (MTBC) most frequently isolated, followed by Staphylococcus aureus and Brucella melitensis. Conventional culture testing identified causative pathogens in only 48.4% of samples, a significantly lower rate than the mNGS pathogen identification rate (100%, p < 0.01). Culture-positive group specimens yielded significantly greater numbers of sequence reads than did culture-negative group specimens (p < 0.01). Of patients receiving surgical interventions and mNGS-guided treatment, 76 (92.7%) experienced favorable outcomes by the time of follow-up assessment at 3 months post-treatment. Notably, MTBC detection in two patients experiencing treatment failure suggests that they had mixed infections with MTBC and other pathogens.Conclusion: Results presented here demonstrate that mNGS has a greater pathogen detection rate in osteoarticular infections than conventional culture-based methods.

Background : We conducted this retrospective study to reveal the accuracy of metagenomic next-generation sequencing (mNGS) for diagnosing osteoarticular infections from fresh abscess specimens obtained from patients in an HIV-naive population. Methods : We retrospectively analyzed hospital records at three participating TB-specialized hospitals for patients admitted with suggestive diagnoses of osteoarticular tuberculosis between January 2018 and August 2019. Abscess specimens obtained from each patient were tested via pathogen culture, GeneXpert Mycobacterium tuberculosis (MTB)/rifampicin (RIF), and mNGS assay. Results : A total of 82 abscess samples were collected from patients with osteoarticular infections, including 53 cases with (64.6%) bacterial, 21 (25.6%) with mycobacterial, 7 (8.5%) with fungal, and 1 (1.2%) with actinomycetal organisms detected. Analysis of mNGS assay results identified potential pathogens in all cases, with M. tuberculosis complex (MTBC) most frequently isolated, followed by Staphylococcus aureus and Brucella melitensis. Conventional culture testing identified causative pathogens in only 48.4% of samples, a significantly lower rate than the mNGS pathogen identification rate (100%, p < 0.01). Culture-positive group specimens yielded significantly greater numbers of sequence reads than did culture-negative group specimens (p < 0.01). Of patients receiving surgical interventions and mNGS-guided treatment, 76 (92.7%) experienced favorable outcomes by the time of follow-up assessment at 3 months post-treatment. Notably, MTBC detection in two patients experiencing treatment failure suggests that they had mixed infections with MTBC and other pathogens. Conclusion : Results presented here demonstrate that mNGS has a greater pathogen detection rate in osteoarticular infections than conventional culture-based methods. [ABSTRACT FROM AUTHOR]

Q fever osteoarticular infection in children is an underestimated disease. We report 3 cases of Q fever osteomyelitis in children and review all cases reported in the literature through March 2018. A high index of suspicion is encouraged in cases of an unusual manifestation, prolonged course, relapsing symptoms, nonresolving or slowly resolving osteomyelitis, culture-negative osteomyelitis, or bone histopathology demonstrating granulomatous changes. Urban residence or lack of direct exposure to animals does not rule out infection. Diagnosis usually requires use of newer diagnostic modalities. Optimal antimicrobial therapy has not been well established; some case-patients may improve spontaneously or during treatment with a β-lactam. The etiology of treatment failure and relapse is not well understood, and tools for follow-up are lacking. Clinicians should be aware of these infections in children to guide optimal treatment, including choice of antimicrobial drugs, duration of therapy, and methods of monitoring response to treatment.. [ABSTRACT FROM AUTHOR]

Background and objectives. The aim of this study was to evaluate the clinical and laboratory characteristics of osteoarticular involvement in children with brucellosis. Methods. A total of 202 pediatric brucellosis patients were evaluated from April 2012 to August 2013. Results. Among the 202 patients, 53 (26.2%) had osteoarticular involvement. In patients with osteoarticular involvement, the mean values of estimated sedimentation rate (ESR) and C-reactive protein (C-RP) were significantly higher than in patients without osteoarticular involvement (p = 0.001, p = 0.01, respectively). The majority of patients with osteoarticular involvement (n = 48, 90.6%) had a higher standard tube agglutination (STA) test titer (= 1/640) than patients without osteoarticular involvement (n = 69, 46.3%) (p = 0.001). The most commonly found osteoarticular involvement was peripheral arthritis. The second most commonly found osteoarticular involvement was sacroiliitis (n = 5, 9.4%). Three patients (5.7%) had spondylitis. Only one patient (1.9%) had osteomyelitis. Conclusions. Osteoarticular involvement was detected in nearly one of every four childhood brucellosis patients in our study. Brucellosis should be considered as a pre-diagnosis in children with osteoarticular complaints, especially in regions where the disease is endemic. [ABSTRACT FROM AUTHOR]

Copyright of Jornal de Pediatria is the property of Sociedade Brasileira de Pediatria and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Purpose: Till date, a number of primers have been described for the diagnostic polymerase chain reaction (PCR) assays for tuberculosis (TB). However, most investigators have evaluated PCR's clinical utility using only one primer specific for Mycobacterium tuberculosis. The purpose of this study was to evaluate the efficacy of PCR tests targeting two different DNA sequences – insertion sequence 6110 (IS6110) and protein antigen b (Pab), in the same set of clinical samples from osteoarticular TB cases, and to evaluate if the sensitivity of the assay is improved. Materials and Methods: Twenty clinical samples obtained from osteoarticular TB cases were subjected to two different PCR assays - 123 base pair (bp) sequence coding for IS6110 and 419 bp sequence coding for Pab. Ten clinical samples from cases of proven septic arthritis were studied as controls. Results: The sensitivity of IS6110 PCR and Pab PCR were found to be 75% and 80%, respectively, and the specificity of both IS6110 PCR and Pab PCR was 100%. No significant difference was found between two PCR assays (P > 0.05). However, there were two cases which were negative by IS6110 PCR but were positive by Pab PCR. There was one case which was positive by IS6110 but was negative by Pab PCR. Seventeen out of 20 samples showed concordance between the results of two PCR tests, increasing the sensitivity to 85%. Conclusion: The diagnostic yield of the PCR test can be improved with the simultaneous amplification of two or more gene targets.

Sporotrichosis is a frequent subcutaneous mycosis in Madagascar. Extracutaenous forms are exceptional and are usually seen in immunosuppressed hosts. We report a case of an aggressive clinical evolution of lymphocutaneous sporotrichosis with osteoarticular involvement in an immunocompetent patient. Therapy with oral itraconazole 200 mg twice daily for 12 months improved the lesion. Early diagnosis of Sporothrix schenkii infection is critical to prevent complications including osteoarticular involvement, disseminated forms and death. [ABSTRACT FROM AUTHOR]

Case: A 47-year-old male with swelling over the patella and associated pain, subsiding with medicines but recurring after a few days. Diagnosed as prepatellar bursitis by the family physician, it eventually turns out to be osteomyelitis of the patella. Treated with curettage, biopsy, and placement of bio-composite mixed with antibiotics. Intra-operative findings and histopathology confirmed tuberculosis of the patella. On follow-up after 6 years and the completion of anti-tuberculosis treatment, the patient showed full functional and radiological recovery without recurrence., Conclusion: Early treatment with antibiotics and surgery gives excellent results. Identifying it as a tuberculous osteomyelitis is challenging when the condition is closely resembles pre-patellar bursitis., Competing Interests: None, (2024 © BY THE ARCHIVES OF BONE AND JOINT SURGERY.)

Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Canine osteoarthritis (OA), along with hip dysplasia (DSC) and elbow dysplasia (CDC) are diseases commonly found in veterinary practice in pet animals. Due to the fact that these conditions persist throughout life, it degenerates rather than improve, so it is extremely important that these dogs be treated in osteoarticular algia in dogs. OA is also one of the most common musculoskeletal disorders in humans that has become a medical and financial problem. Moreover, an even bigger problem is treating people suffering from the side effects that appear as a consequence of pain therapy in OA. As a result, recommendations have been made to use more natural agents in modifying the effects of the disease in the management of human OA pain, to the detriment of much more commonly used non-steroidal antiinflammatory drugs (NSAIDs). To this end, we are also investigating in college to find less harmful drugs and treatments to replace the long-term administration of NSAIDs or regenerative injections with corticosteroids, which today are still the best treatment options used, although they are not ideal because of the risk of side effects. This bibliographic report wishes to bring some valuable information to those interested. [ABSTRACT FROM AUTHOR]

Osteoarticular Tuberculosis (TB) of wrist joint is a rare, often misdiagnosed form of site affected by Mycobacterium Tuberculosis infection that can lead to severe disability and morbidity. This review aims to summarize the current literature on the diagnosis and management of Mycobacterium Tuberculosis infection of the wrist joint. A comprehensive search strategy using the PEO (Population, Exposure, Outcome) framework was conducted on PubMed, Google Scholar, and Web of Science databases from 1967 to 2022, excluding single case reports and correspondence articles. The keywords used for the search included ' Mycobacterium tuberculosis' 'osteoarticular' and 'wrist'. Clinical presentation, demographic details, complementary investigations undertaken, trends, and complications of different management interventions were recorded to generate this review. Osteoarticular Tuberculosis (TB) of the wrist joint accounts for fewer than 1% of all skeletal TB cases across a spectrum of age ranges. Magnetic Resonance Imaging (MRI) represents an excellent modality to reveal the extent of the disease at an early stage of the condition. Synovial fluid analysis has been recommended for microbiological diagnosis. Treatment options include anti-tubercular therapy (ATT), incision and drainage, debridement, synovectomy, and arthrodesis. Early diagnosis and treatment of wrist tuberculosis is crucial for achieving good functional outcomes in patients with this uncommon condition. Polymerase Chain Reaction (PCR) and GeneXpert technology for the detection of Mycobacterium tuberculosis (MTB) have improved diagnostic accuracy in detecting MTB DNA and rifampicin resistance. Anti-Tubercular Therapy (ATT) regime remains a foundation pillar in the overall management of these patients with focused surgical interventions leading to improved clinical outcomes. [ABSTRACT FROM AUTHOR]

Background: Langerhans cell histiocytosis (LCH), typically found in children, is a rare single or multisystem disorder with a wide range of clinical and radiological manifestations. Unusual presentations of LCH are occasionally encountered and it may be difficult to distinguish LCH from an infection or a benign or malignant tumor. Results: A 35-year-old female presented with pain in her back and left buttock, malaise, and weight loss, with a duration of several months. Her laboratory test results were within the normal ranges except for the levels of acute phase reactants, which were elevated. Magnetic resonance imaging and computed tomography revealed a unilateral destructive sacroiliac lesion, and multiple vertebral lesions with adjacent discal involvement and extensive soft tissue extensions. She was initially misdiagnosed with multifocal osteoarticular tuberculosis. An open biopsy and joint curettage was performed. Histopathological examination showed that she had LCH. Conclusion: To the best of our knowledge, this is the first case of LCH associated with a destructive unilateral sacroiliac lesion, discal involvement, and involvement of the adjacent vertebrae, in an adult patient; the LCH mimicked osteoarticular tuberculosis. Disease onset in adulthood is rare, and this can potentially delay diagnosis. Familiarity with the imaging features of unusual LCH manifestations is necessary to ensure accurate diagnosis and appropriate treatment.

This study sought to assess clinical characteristics and differences in outcomes between children with Methicillin-resistant Staphylococcus aureus (MRSA) and Methicillin-sensitive Staphylococcus aureus (MSSA) osteomyelitis or septic arthritis and whether initial antibiotic regimen affects patient outcomes. We analyzed records of children ages 15 days to 18 years admitted between 2009 and 2016 to two tertiary children’s hospitals who were diagnosed with an osteoarticular infection and had a microorganism identified. A total of 584 patients met inclusion criteria, of which 365 (62.5%) had a microbiological diagnosis. MSSA was the most common pathogen identified (45.5%), followed by MRSA (31.2%). Compared to MSSA, patients with MRSA had a higher initial C-reactive protein and longer hospitalization. Patients whose initial antibiotic regimens included vancomycin had a longer hospitalization than those initiated on clindamycin without vancomycin, even after removing sicker patients admitted to the pediatric intensive care unit. While MRSA was associated with increased severity of osteoarticular infections compared to MSSA, the incidence of MRSA has been declining at our institution. Patients with longer lengths of stay were more likely to be on vancomycin. Clindamycin should be considered in the initial antibiotic regimen for osteomyelitis and septic arthritis with ongoing surveillance of local microbiology and outcomes.

Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Anti-tuberculosis chemotherapy with a long duration and adequate dosing is the mainstay for treatment of osteoarticular tuberculosis (TB). However, it is difficult for systemic administration to reach adequate local drug concentrations and achieve effective treatment. Herein, a hydroxyapatite (HA) scaffold implant combined with a drug-releasing system was designed to achieve in situ and long-term anti-TB drug release and highly efficient therapeutic activity in vitro and in vivo . The clinical anti-TB drugs hydrophilic isoniazid (INH) and hydrophobic rifampicin (RFP) were molecularly dispersed into polyvinyl alcohol (PVA) through immersion-curing techniques and were steadily adhered onto the surfaces of HA scaffolds (HA-drug@PVA). The HA-drug@PVA scaffolds showed a long-term, sustained drug release profile and killed proliferating Mycobacterium in vitro . In vivo experimental results revealed that the HA-drug@PVA scaffolds provided over 10- and 100-fold higher concentrations in muscles and bones, respectively, as well as a much lower concentration (<0.025) in blood. Furthermore, the HA-drug@PVA scaffold implanted in an osteoarticular TB rabbit model showed obvious bone regeneration and fusion due to the inhibition of TB-associated inflammatory changes. The excellent therapeutic effects indicate that in situ implant materials combined with a long-term drug release system are promising for the treatment of osteoarticular TB and other osteoarticular infections. [ABSTRACT FROM AUTHOR]

The myriad presentation of osteoarticular brucellosis make the patient seek the help of general practitioners, orthopaedic and rheumatology specialists. Moreover, the lack of disease-specific symptomatology is the leading cause of the delay in diagnosing osteoarticular brucellosis. Given the increasing number of spinal brucellosis cases across the country, no literature is presented on the systematic management of spinal brucellosis. However, with our experience, we formulated a classification for managing spinal brucellosis. A single-centred prospective observational study was conducted with 25 confirmed cases of spinal brucellosis. Patients were analysed and graded clinically, serologically, and radiologically and were managed with antibiotics for 10–12 weeks, and if necessary, stabilisation and fusion were done based on the treatment classification devised. All patients were followed up to ensure disease clearance at serial follow-up with relevant investigations. The mean age of the study participants was 52.16 ± 12.53 years. According to spondylodiscitis severity code (SSC) grading, four patients belong to grades 1, 12 to grade 2 and 9 to grade 3 at presentation. Erythrocyte sedimentation rate (p = 0.02), c-reactive protein (p < 0.001), Brucella agglutination titers (p < 0.001), and radiological outcomes improved statistically by six months. The treatment duration was individualised according to the patient's response to the treatment, with a mean time of 11.42 ± 2.66 weeks. The mean follow-up period was 14.42 ± 8 months. High index of suspicion of patients from endemic regions, proper clinical assessment, serological evaluation, radiological assessment, appropriate decision-making (medical/surgical) in treatment, and regular follow-up were the key to successful comprehensive management of spinal brucellosis. [ABSTRACT FROM AUTHOR]

Acute osteoarticular infections are common in children and rarely complicated with deep vein thrombosis (DVT). This complication can cause significant morbidity and may even be fatal. Herein we report a ten year girl with deep vein thrombosis of left femoral vein who presented initially with septic arthritis of left knee and osteomyelitis of left femur. She required prolonged hospital admission and was managed with surgical debridement, antibiotics and anticoagulation. Journal of College of Medical Sciences-Nepal, 2013, Vol-9, No-1, 52-55 DOI: http://dx.doi.org/10.3126/jcmsn.v9i1.9675