1- Unidade de Infecciologia, Área de Pediatria Médica, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Lisboa
2- Unidade de Ortopedia, Área de Pediatria Cirúrgica, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Lisboa
- 20º Congresso Nacional de Pediatria
- 11th Excellence in Pediatrics Conference
Introduction: Diagnosis of multifocal osteomyelitis can be difficult in children with sickle cell disease (SCD), but distinctive features as symmetrical bone involvement are useful. Treatment is also a challenge and should take in account the different pathogenic organisms commonly found in asplenic children and the possibility for multiresistant bacterias. Prolonged courses of parenteral therapy and aggressive surgical interventions are therefore frequently necessary.
Case description: A 9-year-old female with SCD presented from Angola with persistent fever and osteomyelitis. There was a three week-history of pneumoniae treated with cefazolin and ciprofloxacin, latter switched for chloramphenicol and clindamycin. She was admitted at our hospital with the diagnosis of multifocal osteomyelitis and cefotaxime and gentamicin were initiated. MRI confirmed multifocal osteomyelitis of the humerus and radius and suggested abscesses which where drained twice. It also presented bilateral arthritis of the elbows with left effusion and shoulder synovitis/arthritis. Bone and synovial fluid biopsies were positive for multirresistant Serratia marcescens. She was medicated with meropenem and amikacin for 12 weeks and hyperbaric oxygen therapy (HOT) with clinical improvement. On day 33, due to neutropenia with relapsing fever we admitted nosocomial infection and she was medicated with vancomycin and amphotericin B, latter discontinued due to severe hypokalaemia. No agent was identified. She lost 6 kilograms and coming from a country where tuberculosis is endemic IGRA determination was accessed and became positive. Thorax CT excluded pulmonary tuberculosis, but spinal MRI showed inflammatory/infectious spondylodiscitis of L4-S2 and therefore bone tuberculosis was assumed and isoniazid, rifampicin, pyrazinamide and ethambutol were initiated. A month later toxic hepatitis was diagnosed and after a discontinuation, isoniazid was replaced by levofloxacin, with no further complications. She was discharged after completing the antibiotic therapy and on the following observations she maintained some limitations on the extension of both arms and abduction of the left shoulder.
Conclusions: Chronic osteomyelitis is a challenge to every physician. Besides bone infection, sequestra and impaired local vascularity with compromised tissue envelope can occur and sequelae are frequent. In this case, the absence of clinical resolution besides appropriate antibiotics and surgical debridement and the epidemiological context raised the suspicion of bone tuberculosis. Appropriate treatment and latter adjuvant therapy with HOT were the key.
Palavras Chave: Bone tuberculosis; Multifocal chronic osteomyelitis; Serratia marcescens; Sickel cell disease