ChristensenCase presentation sternal osteomyelitis.pptx

5/24/16
ChiefComplaint
!  A15yearoldhighschoolwrestlerpresentswithachiefcomplaintof
sharpsternalchestpain
JKendallChristensen,DO
EdwinKornoelje,DO
BrianHinkley,DO
http://www.methalab.net/health/cancer-patient-receives-3d-printed-sternum-ribs-in-first-of-its-kind-surgery/
http://medicalpicturesinfo.com/sternum/
History
History
!  Days1–2
!  Day1
!  Days3–4
!  Overthenext2dayspaincontinuedtoworsenandwaswakinghimfrom
sleep.
! 
! 
Patientwasatwrestlingpracticewhenhenoticedgraduallyworseningsternalchest
painafter5-6take-downdrills.
Sternalchestpaincontinuedthroughoutpracticeandgraduallyworsenedovernight.
!  Day2
! 
!  Hedevelopedfever
Hisparentstookhimtoseetheirchiropractorwhichresultedinsignificant
worseningofhispain.
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2viewchest
History
!  Day4
!  Hewastakentoorthopedicurgentcareclinicandevaluatedwithplainfilms
andanMRI
! 
Bothwerereadasnormal
!  HewassenttohisPCPtobeworkedupforpneumonia
! 
! 
!  EmergencyDepartment
! 
!  Noacutecardiopulmonaryprocess
identified.
examnotconsistentwithpneumonia
Hislabswerenormalatthattime
History
!  Day5
! 
!  FINDINGS:
!  Visualizedsternumappearsgrossly
intact.
Labs–Normal
!  TroponinT–<0.011
CTChestwithContrast
!  FINDINGS:
!  Regardingtheosseousstructures,thereareallgrossly
intactandage-appropriate.Specificallythesternum
showsnodisplacedfractureorcorticaldisruption.
Developingossificationcentersofthesternumall
appearintactandage-appropriate.
EKG–Normal
! 
! 
NSR,HR82,RVRinV1(normalinathlete)
NootheracuteST/Twavechangesnoted,orevidenceof
ischemia.
! 
CXRrepeated–normal
! 
CT–readasnormal
!  IMPRESSION:
!  Normalfindings.
!  Specificallythereisnoevidenceofdisplacedor
deformingsternal,riborvertebralbodyfracture.
!  Noacutecardiopulmonaryprocess.
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History
History
! Days6–8
!  Day7
!  BloodculturesorderedbyPCP
!  Painandfevercontinued
! 
Feversreaching104.5F
! 
!  Developed
!  Myalgias
!  Dizziness
!  anorexia
!  Intermittentnauseaandvomiting
! 
Grampositivecocciinclusters
!  Day8
!  Senttotheemergencydepartmentatalocalchildren’shospital
!  Admittedtohospitalwithpediatricinfectiousdiseaseconsult
PossiblysecondarytoTylenol#3
ByZorin09-Ownwork,CCBY-SA3.0,https://commons.wikimedia.org/w/index.php?curid=22027665
PhysicalExam
!  Vitals:
!  Temperature PhysicalExam
!  Cardiovascular:Normalrate,regularrhythmandnormalheartsounds.
-38ºC
!  Bloodpressure
-114/54
!  Pulse
-78
!  SpO2
-96%
!  Respiratoryrate
!  Pulmonary:pooreffortsecondarytopain.Hehasnowheezes,
rhonchi,orrales.
!  Chestwall:Heexhibitstendernessofthesternumandsurrounding
tissues.Nomass,laceration,crepitus,edema,deformity,swelling,or
retractionsnoted.
-20
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DifferenBalDiagnosis
TestsandResults
!  Sternalosteomyelitis
!  Labs:
!  WBC–5.79
!  Bands–17%
!  Sedrate–20
!  CRP–188.4
!  Endocarditis
!  Infectedretrosternalhematoma
!  Pericarditis/myocarditis
!  Infectedpericardialeffusion
!  Malignancy
!  ECHO:Structurallynormalwithnoevidenceofvegetation
sternum.(n.d.)Mosby'sMedicalDictionary,8thedition.(2009).RetrievedMay62016from
http://medical-dictionary.thefreedictionary.com/sternum
TestsandResults
Final/WorkingDiagnosis
!  MRIwithandwithoutcontrast
!  Primarysternalosteomyelitiscomplicatedbystaphylococcusaureus
!  Findings:MinimalT2andpostgadoliniumhyperintensityinthefirstandsecondsternalsegmentswith
bacteremia.
surroundingedema,includingtheretrosternalspaceandpectoralisinsertions;noosteonecrosisor
periostealabscess.MinimalfocalT2andpostgadoliniumhyperintensitysuperiorlyinthemidlineofthe
manubriumbutnoadjacentsofttissueabnormality.Normalappearanceofthecostalcartilageandcostosternal
junctions.Nopericardialeffusion.Smallrightpleuraleffusion.Streakylowerlobediseasemayrepresent
pneumoniaoratelectasis.Theupperabdomenasvisualizedisnormal.
! IMPRESSION:Probablesternalosteomyelitis.
http://www.gettyimages.com/detail/photo/staphylococcus-aureus-high-resstock-photography/128578136
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Treatment
Outcome&Follow-up
!  IVVancomycinuntilsensitivitieswereavailable
!  Follow-updonebypediatricinfectiousdiseaseafter4weeksoforal
!  IVAncef(cefazolin)for2weeksfollowedbyoralKeflex(cephalexin)for4
weeks.
!  Surgicalinterventionwasnotfoundtobenecessary.
Keflex.
!  Hewasfeelingmuchbetteranddeniedanypainordifficultybreathing
!  Appetitehadimprovedandinflammatorymarkershadreturnedtonormal
!  Hewasdischargedfromthepediatricinfectiousdiseasepractice
ReturntoacBvity
PRIMARYSTERNALOSTEOMYELITIS
!  Hehadgraduallyreturnedtosportsundersupervisionoforthopedics
!  Rarecondition
afterremovalofPICCline
!  Whenheexerciseshefeelsoutofshapebuthasnomarkedfatigue
!  IntheUSitisusuallycausedbyStaphaureus
!  Secondmostcommonpathogenispseudomonasaeruginosa
!  Intravenousheroinusers
!  Mayormaynotfollowblunttraumatothechest
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PRIMARYSTERNALOSTEOMYELITIS
!  Rarecauses
!  Aspergillus
!  Nocardia
!  ActinomycesIsraelii
PRIMARYSTERNALOSTEOMYELITIS
TREATMENT
!  Incisionanddrainagewithsurgicaldebridement
!  Effortstakentokeepposteriorperiosteumintact
!  Mildcasescanbetreatedwithappropriateantibiotictherapyalone
!  Lessaggressivethansecondaryosteomyelitis
!  SternalosteomyelitissecondarytoTuberculosisisacauseinendemic
areas.
!  Hyperbaricoxygentherapy
!  Mayspeedrecoveryanddecreaseneedforreconstructivetherapy.
SecondarySternalOsteomyeliBs
SecondarySternalOsteomyeliBs
!  Causes:
!  Causes:
!  Complicationofopenheartsurgery
!  Complicationofopenheartsurgery
!  Penetratingtrauma
!  Penetratingtrauma
!  Whateverthisis!
!  Whateverthisis!
http://skullappreciationsociety.com/sternum-skull-implant/
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https://3dprint.com/95371/3d-printed-ribs-and-sternum/
References
!  KellyCA,ChettyMN.Primarysternalosteomyelitis.Thorax.1985;
40.11:872-873.
!  MeldrumWH,HasanZ.PrimarySternalOsteomyelitis:ACaseReport
andReviewoftheLiterature.Journalofcardio-thoracicmedicine.2016;
winter,vol.4iss.1:418-421.
!  MittapalliMR.PrimaryOsteomyelitisoftheSternum.Thorax.1979;
34:680-681.
!  WilenskyAO,SamuelsSS.Osteomyelitisofthesternum.AnnSurg.1926;
83:206-16.
ThankYou!
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