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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 18  |  Issue : 1  |  Page : 47-50

An unusual presentation of acute osteomyelitis of tibia with superficial venous thrombosis in a child


1 RVM Institute of Medical Science and Research Centre, Siddipet, Telangana, India
2 Department of Paediatrics, RVM Institute of Medical Science and Research Centre, Siddipet, Telangana, India
3 MBBS Student, Rangaraya Medical College, Kakinada, Andhra Pradesh, India

Date of Submission12-Nov-2020
Date of Decision20-Dec-2020
Date of Acceptance21-Jan-2021
Date of Web Publication02-Mar-2021

Correspondence Address:
Tarun Kumar Suvvari
Rangaraya Medical College, Kakinada, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_124_20

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  Abstract 


Acute hematogenous osteomyelitis is the most common cause of osteomyelitis in children. It requires early diagnosis and treatment to minimize the risk of sequela of growth disturbances and deformity. We present a case of an unusual presentation of osteomyelitis of the tibia with Superficial venous thrombosis in a 2½ year male child, which was 1st ever reported association. A high degree of clinical suspicion of venous thrombosis, especially in pediatrics osteomyelitis, is required, with high C-reactive protein and erythrocyte sedimentation rate levels, as the child presents insidiously.

Keywords: Osteomyelitis, superficial venous thrombosis, tibia


How to cite this article:
Veldanda NS, Kondle VK, Paka RR, Suvvari TK. An unusual presentation of acute osteomyelitis of tibia with superficial venous thrombosis in a child. Apollo Med 2021;18:47-50

How to cite this URL:
Veldanda NS, Kondle VK, Paka RR, Suvvari TK. An unusual presentation of acute osteomyelitis of tibia with superficial venous thrombosis in a child. Apollo Med [serial online] 2021 [cited 2021 Apr 11];18:47-50. Available from: https://www.apollomedicine.org/text.asp?2021/18/1/47/311299


  Introduction Top


It is not uncommon to encounter complicated osteomyelitis in pediatric practice. Acute hematogenous osteomyelitis is the most common source of infection in children, typically affecting the long bones such as the femur (27%) and tibia (26%). Acute osteomyelitis (13/10,000) associated with venous thrombosis is a rare presentation with an estimated incidence of 0.07/10,000.[1]

Our case developed an unusual association of superficial venous thrombosis (SVT) and prolonged hospital course; its the first-ever reported association. SVT further led to an eccentric course in this case.


  Case Report Top


A 2½-year-old male child was presented with fever, limp and pain full left limb swelling for 10 days. Fever was intermittent, high grade with chills. The swelling was Sudden in onset and seen from ankle to knee. The pain was dull and continuous, which started with a pain score of 3/10 and increased to 5/10, aggravated by walking and standing, slightly relieved by rest. Restricted knee and ankle movements were seen in the patient. He has a history of upper respiratory tract infection-10 days before the onset of swelling. The patient’s treatment history revealed antibiotic and adhesive bandage usage from a quack [Figure 1].
Figure 1: Child admitted with an adhesive bandage from a quack

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During the physical examination, the patient was pale, lethargic, irritable, and a squint of the right eye was found. During the general examination, the pulse rate was 144/min; the temperature was 103°F; blood pressure was 80/56 mm of Hg; the respiratory rate was 36/min, dorsalis pedis and posterior tibial arterial pulses were felt. Local examination of leg revealed swelling in the medial aspect of left leg, extending from ankle to knee, diffuse with ill-defined borders; overlying skin was erythematous, warm, tender to touch with no discharging sinus and soft in consistency (not attached to the skin, nonmobile). The knee and ankle have only a limited range of motion from 0° to 30°, and further movements were painful. For hip, all movements are normal, and no pain is felt. All systemic examinations were found to be normal. Differential diagnoses include osteomyelitis, septic arthritis, deep-vein thrombosis, Juvenile idiopathic arthritis, and cellulitis.

The child was admitted to the pediatric intensive care unit with suspicion of sepsis, started on ceftriaxone, and linezolid with intensive and supportive care. Laboratory findings revealed an elevated erythrocyte sedimentation rate, elevated C-reactive protein (CRP), microcytic hypochromic anemia, neutrophilic leukocytosis. Widal, HIV, surface antigen of the hepatitis B virus (HBsAg) tests showed negative. Blood and pus cultures were sterile, immune profile, and hemoglobin electrophoresis was normal. X-ray of the left leg showing mid-calf swelling extending up to mid-thigh with no bony pathology [Figure 2]. As the radiological findings of acute osteomyelitis are absent/subtle in the initial days, one cannot rule it out; one has to go for advanced investigations. Ultrasonography revealed a moderate amount of fluid seen surrounding the Left tibia. Nonsteroidal anti-inflammatory drugs, warm compresses, magnesium sulfate, dressings were provided to the patient. The child remained febrile, and painful swelling of the leg persisted despite intensive care. Vascular insufficiency was suspected, and work up was enhanced in that direction.
Figure 2: X-ray of the left leg showing mid-calf swelling extending up to mid-thigh with no bony pathology

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Colour Doppler test revealed a thrombus measuring 12 cm length, 3.5 mm width in a great saphenous vein in the upper 1/3rd of the left leg. Magnetic resonance imaging scan revealed fluid intensity noted surrounding the left tibia (1.5 cm thick and 11 cm length), Patchy marrow edema, extensive hyperintense signals throughout the length of the tibia [Figure 3] and [Figure 4]. For the osteomyelitis of the tibia with an abscess – Enoxaparin was initiated according to the American college of chest physicians protocol and continued till thrombus resolution. The abscess was drained by making a drill hole in the bone after packed red blood cells transfusion. The child was monitored meticulously for distress and pulmonary embolism. The child gradually responded to the treatment and was discharged on oral faropenam and linezolid with weekly follow-up and wound dressing.
Figure 3: Patchy marrow edema, extensive hyperintense signals throughout the length of tibia

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Figure 4: Magnetic resonance imaging scan revealed fluid intensity noted surrounding the left tibia

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  Discussion Top


Acute osteomyelitis (13/10,000) associated with venous thrombosis is a rare presentation with an estimated incidence of 0.07/10,000.[1] Hematogenous spread of osteomyelitis is the most common source of infection in children, typically affecting the long bones. The femur (27) % and tibia (26) % are most commonly affected.[2]

The possible contributing factors for the prolonged hospital stay were anemia, delayed presentation, the possibility of methicillin-resistant Staphylococcus aureus (MRSA), cellulitis, and septic arthritis involving both the knee and ankle joints.[3] Superficial venous thrombus further led to an eccentric course in my case [Figure 5].
Figure 5: Possible contributing factors for such an unusual presentation of osteomyelitis with superficial venous thrombosis

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Subtle or absent radiological features in the first 2 weeks mandate a high degree of clinical suspicion.[4] Delayed diagnosis can lead to long-term sequelae/permanent disabilities.[5] Clinical suspicion of venous thrombosis should be high, especially in pediatric osteomyelitis with high CRP, through routine screening is not needed.[6] Early recognition and prompt treatment comprising antibiotics and anticoagulant therapy should be initiated as soon as thrombus is suspected; any delay in diagnosis may contribute to serious complications and even fatal consequences.

Our case developed an unusual association of SVT and prolonged hospital course; its first-ever reported association. The possible contributing factors for the prolonged hospital stay were delayed presentation, possibilities of MRSA, extensive osteomyelitis, and a subperiosteal abscess that might lead to septic thrombophlebitis, mismanagement by a quack might have contributed to the development of SVT. SVT further led to an eccentric course in this case.

Such cases are usually a diagnostic dilemma due to overlapping clinical presentation of SVT and osteomyelitis. Unless acute osteomyelitis in children is diagnosed early and treated appropriately, it leads to prolonged hospital safety and antibiotic administration, and it can be a devastating or even fatal disease. Awareness and a high index of suspicion of this association are necessary for an early diagnosis and prompt correct treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jain V, Singh V, Mishra A. Acute osteomyelitis associated with deep vein thrombosis in a patient of acute abdomen: A diagnostic dilemma. J Clin Orthop Trauma 2012;3:112-4.  Back to cited text no. 1
    
2.
Yeo A, Ramachandran M. Acute haematogenous osteomyelitis in children. BMJ 2014;348:g66.  Back to cited text no. 2
    
3.
Mantadakis E, Plessa E, Vouloumanou EK, Michailidis L, Chatzimichael A, Falagas ME. Deep venous thrombosis in children with musculoskeletal infections: The clinical evidence. Int J Infect Dis 2012;16:e236-43.  Back to cited text no. 3
    
4.
Hollmig ST, Copley LA, Browne RH, Grande LM, Wilson PL. Deep venous thrombosis associated with osteomyelitis in children. J Bone Joint Surg Am 2007;89:1517-23.  Back to cited text no. 4
    
5.
Nourse C, Starr M, Munckhof W. Community-acquired methicillin-resistant Staphylococcus aureus causes severe disseminated infection and deep venous thrombosis in children: Literature review and recommendations for management. J Paediatr Child Health 2007;43:656-61.  Back to cited text no. 5
    
6.
Bouchoucha S, Benghachame F, Trifa M, Saied W, Douira W, Nessib MN, et al. Deep venous thrombosis associated with acute hematogenous osteomyelitis in children. Orthop Traumatol Surg Res 2010;96:890-3.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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