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CASE REPORT
Year : 2017  |  Volume : 6  |  Issue : 3  |  Page : 184-186

A case report on chronic osteomyelitis of the right tibia in a pediatric male patient and its management


1 Department of Pharmacy Practice, JSS College of Pharmacy, Ooty, The Nilgiris, Tamil Nadu, India
2 Department of Orthopaedics, Government District Headquarters Hospital, Ooty, The Nilgiris, Tamil Nadu, India

Date of Web Publication9-Aug-2017

Correspondence Address:
Ponnusankar Sivasankaran
Department of Pharmacy Practice, JSS College of Pharmacy, Rocklands, Post Box No. 20, Ooty - 643 001, The Nilgiris, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_157_16

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  Abstract 


The present case explains the treatment strategies followed for a chronic osteomyelitis case of a pediatric patient in a secondary care public hospital, Ooty, Tamil Nadu, India. He was presented with the complaints of pain and swelling on the right leg, which was treated with nonsteroidal anti-inflammatory drugs such as diclofenac and ibuprofen. Similarly, the tissue abscess observed was managed with parenteral antibiotics such as cefotaxime and amikacin. Surgery was done to remove the devascularized tissue and postoperative care was given with chymoral forte and vitamin supplements (Vitamin B complex, calcium and Vitamin C). In this patient, the reason for the occurrence of chronic osteomyelitis may be a complication of the previous surgery due to the accidental fall. Therefore, proper care should be given in the management of traumatic injuries in children and early diagnosis of osteomyelitis is essential to prevent the complications.

Keywords: Chronic osteomyelitis, management, pediatrics, secondary care hospital


How to cite this article:
Keerthana C, Indu T H, Ganeshamoorthy J, Sivasankaran P. A case report on chronic osteomyelitis of the right tibia in a pediatric male patient and its management. Int J Health Allied Sci 2017;6:184-6

How to cite this URL:
Keerthana C, Indu T H, Ganeshamoorthy J, Sivasankaran P. A case report on chronic osteomyelitis of the right tibia in a pediatric male patient and its management. Int J Health Allied Sci [serial online] 2017 [cited 2020 Jan 20];6:184-6. Available from: http://www.ijhas.in/text.asp?2017/6/3/184/212587




  Introduction Top


Osteomyelitis is a bacterial infection (commonly caused by Staphylococci and Streptococci) with the progressive inflammatory destruction of bone and bone marrow.[1],[2] Infection in the bone leads to exudate formation and expands laterally resulting in soft tissue abscess. This causes impairment of blood flow, producing a dead piece of bone, which later separates from the healthy bone.[3] The tenderness, pain, swelling, fever, and decreased motion are associated with osteomyelitis and may lead to complications such as squamous cell carcinoma and septicemia in the later stages.[3],[4] The global incidence rate of osteomyelitis is 13/100,000.[5],[6] The present case describes the treatment strategies followed in a secondary care public hospital, Ooty, Tamil Nadu, India.


  Case Report Top


A 12-year-old male child was presented to the pediatric unit of the secondary care public hospital, Ooty on March 7, 2016, with the complaints of pain and swelling on the right leg with pus discharge for the past 4 months [Figure 1]. He had undergone a surgery in the right leg 5 months back in a private hospital due to an accidental fall. Consent was obtained in written form from the patient's caretaker and the data were collected. The boy was found to be underweight (body mass index - 16) and the vitals were as follows: pulse rate - 86 b/min; respiratory rate – 20 b/min; and temperature - 98.4°F. He had osteomyelitic lesions on the right tibia [Figure 1]. The laboratory investigation details are given in [Table 1].
Figure 1: Diffuse skin lesions with abscess in the right leg. Preoperative X-ray (lateral view). Postoperative X-ray (lateral view)

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Table 1: Laboratory investigation details

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The patient was given with Vitamin B complex tablet - 30.5 mg od, calcium tablet - 300 mg od, cefotaxime injection - 1 g bd, amikacin injection - 300 mg od, ibuprofen tablet - 200 mg tds, and ranitidine tablet - 150 mg bd. On day 3, right leg pain was sustained. Computed tomography scan report showed permeative osteolytic lesion on the proximal right tibia. The magnetic resonance imaging report came on the 5th day which showed chronic osteomyelitis involving upper tibia with sequestrum and pathological fractures on sinus tracts and then he was recommended for surgery. The same drugs were continued. Wound swab and debridement were done and Vitamin C tablet was added to the prescription. Intravenous (IV) fluid 500 ml ringer lactate was infused over 24 h during the nil per oral period. Tetanus toxoid injection (0–5cc IV stat) was given to prevent infection. Xylocaine injection 20 mg and ceftriaxone injection 1 g IV were administered half an hour before the surgery. The surgery was done to remove the sequestrum on the 8th day. Diclofenac injection IV (sos) and chymoral forte (trypsin + chymotrypsin) tablet tds was added to the prescription and amikacin injection was stopped. On the 1st postoperative day, 350 ml of blood was transfused as the patient was anemic. Limb elevation and physiotherapy was advised from the next day onward. Ferrous sulfate tablet - 20 mg od, linezolid syrup - 100 mg/5 ml bd, Flora-BC (folic acid, Lactobacillus, Vitamin B3, B5) syrup - 5 ml bd was added to the therapy from the 2nd postoperative day and was continued for the next 2 days. The child felt better and was discharged with calcium tablet 300 mg od for 30 days and linezolid oral suspension 500 mg/5 ml bd for 10 days.


  Discussion Top


Osteomyelitis is a common disease among children of poor in the rural population, especially in India.[7] It generally occurs secondary to a contagious infection after a trauma or surgery.[8],[9] The present patient reported that he had undergone a surgery previously and any infection developed on that occasion, which left untreated could be the reason for chronic osteomyelitis. The age of the patient (12 years) could be one of the predisposing factors as the incidence of osteomyelitis is found to be higher in younger children of age 10–16 years.[5],[6] Among them, boys are affected about twice than girls.[7]

The National Organization of Rare Disorders and Nottingham University Hospital guidelines for the management of chronic osteomyelitis include antibiotics, surgery, and symptomatic care. Antibiotics should be started only after doing the culture test and clindamycin - 40 mg/kg/day or vancomycin - 15 mg/kg q 12 h are the best choice of drugs [7] and can be given for 6 weeks duration. Along with this, surgical debridement is also necessary to remove the devascularized tissues.[9] The topical administration of 2% fusidic acid cream or synthetic calcium tablets with standard antibiotic mixture of 500 mg powdered vancomycin and 240 mg of gentamycin can be more effective as these can cover both Gram-positive and Gram-negative bacteria.[10] The bone culture test can guide in the proper antibiotic selection, which could not be performed due to the limited facilities available in the secondary care public hospital.[11]

The patient was given with parenteral antibiotic amikacin, due to the unavailability of clindamycin which is the first choice of drug for the treatment of chronic osteomyelitis as per the Tamil Nadu State Government treatment guidelines. Linezolid syrup was also given to prevent further bacterial infections. Surgery was done in this patient to eradicate infected or devascularized tissue as the antibiotics cannot penetrate devascularized tissue.[9] The doses prescribed for the parenteral antibiotics were according to the pediatric doses. However, the administration of parenteral antibiotics such as amikacin and cefotaxime for 7 days increases the risk of resistance and nephrotoxicity in the case of chronic osteomyelitis.[4] It is necessary to monitor the renal function tests after 5 days which was not done. Similarly, C-reactive protein level was not checked in this patient which is a diagnostic test for osteomyelitis.[4]

Anemia (decreased hemoglobin levels) and malnourishment (underweight) observed can be the complications of chronic osteomyelitis. Similarly, the elevated erythrocyte sedimentation rate also signals the same.[9] Therefore, calcium, ferrous sulfate, Vitamin C and B complex tablets were prescribed to maintain the nutritional status of the patient. The patient was counseled to take iron rich and nutritious foods to prevent these issues.


  Conclusion Top


It is essential to identify and resolve the predisposing factors which can lead to osteomyelitis. In this patient, the reason for the occurrence of chronic osteomyelitis may be the complications of the previous surgery due to the accidental fall (untreated infection followed by the surgery can lead to the formation of devascularized tissue). Therefore, proper care should be given in management of traumatic injuries that affects the bone and it should not be left untreated especially, in children. Early diagnosis of osteomyelitis is essential to prevent the complications.

Acknowledgment

The authors would like to acknowledged the support provided by the Government Headquarters Hospital, Ooty, Tamil Nadu, India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Arias F, Mata-Essayag S, Landaeta ME, Capriles CH, Pérez C, Núñez MJ, et al. Candida albicans osteomyelitis: Case report and literature review. Int J Infect Dis 2004;8:307-14.  Back to cited text no. 1
    
2.
Walter G, Kemmerer M, Kappler C, Hoffmann R. Treatment algorithms for chronic osteomyelitis. Dtsch Arztebl Int 2012;109:257-64.  Back to cited text no. 2
    
3.
Kirsner RS, Spencer J, Falanga V, Garland LE, Kerdel FA. Squamous cell carcinoma arising in osteomyelitis and chronic wounds. Treatment with Mohs micrographic surgery vs. amputation. Dermatol Surg 1996;22:1015-8.  Back to cited text no. 3
    
4.
Dipiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey ML. Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York: McGraw Hill Inc.; 2008.  Back to cited text no. 4
    
5.
Riise ØR, Kirkhus E, Handeland KS, Flatø B, Reiseter T, Cvancarova M, et al. Childhood osteomyelitis-incidence and differentiation from other acute onset musculoskeletal features in a population-based study. BMC Pediatr 2008;8:45.  Back to cited text no. 5
    
6.
Narasanagi SS. Osteomyelitis in rural India. Prog Pediatr Surg 1982;15:203-8.  Back to cited text no. 6
    
7.
MD Guidelines. Available from: http://www.mdguidelines.com/osteomyelitis. [Last accessed on 2016 Aug 04].  Back to cited text no. 7
    
8.
Gomes D, Pereira M, Bettencourt AF. Osteomyelitis: An overview of antimicrobial therapy. Braz J Pharm Sci 2013;49:13-26.  Back to cited text no. 8
    
9.
Kumar GR, Syed BA, Prasad N, Praveen S. Chronic suppurative osteomyelitis of subcondylar region: A case report. Int J Clin Pediatr Dent 2013;6:119-23.  Back to cited text no. 9
    
10.
Gauland C. Managing lower-extremity osteomyelitis locally with surgical debridement and synthetic calcium sulfate antibiotic tablets. Adv Skin Wound Care 2011;24:515-23.  Back to cited text no. 10
    
11.
Fraimow HS. Systemic antimicrobial therapy in osteomyelitis. Semin Plast Surg 2009;23:90-9.  Back to cited text no. 11
    


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