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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 18  |  Issue : 1  |  Page : 49-51

Chronic pyogenic osteomyelitis of the Rib: A case report in a sickle cell disease patient


1 Department of Surgery, Orthopaedics Unit, Aminu Kano Teaching Hospital, Bayero University Kano, Kano, Nigeria
2 Department of Surgery, Cardiothoracic Unit, Aminu Kano Teaching Hospital, Bayero University Kano, Kano, Nigeria

Date of Submission25-Jun-2020
Date of Decision07-Jul-2020
Date of Acceptance09-Dec-2020
Date of Web Publication4-May-2021

Correspondence Address:
Dr. Ismail Muhammad Inuwa
Department of Surgery, Cardiothoracic Unit, Aminu Kano Teaching Hospital, Bayero University Kano, Kano
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njbcs.njbcs_20_20

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  Abstract 


Rib osteomyelitis is extremely rare and accounts for <1% of haematogenous osteomyelitis. We report a rare case of chronic pyogenic osteomyelitis involving the rib in a 29-year-old female sickle cell disease (SCD) patient who presented with recurrent discharging sinus over the right chest wall for 20 years. The patient had partial excision of the 5th rib/sequestrectomy with chest tube insertion. She did very well and was discharged after chest tube removal to the orthopaedic outpatient department for follow-up. Being of various aetiology with non-specific clinical manifestation, its diagnosis is challenging. Clinicians should be aware of the possibility of rib osteomyelities in a SCD patient. Early recognition and prompt treatment allow high cure rate.

Keywords: Chronic osteomyelitis, rib, sickle cell disease


How to cite this article:
Adamu KM, Inuwa IM. Chronic pyogenic osteomyelitis of the Rib: A case report in a sickle cell disease patient. Niger J Basic Clin Sci 2021;18:49-51

How to cite this URL:
Adamu KM, Inuwa IM. Chronic pyogenic osteomyelitis of the Rib: A case report in a sickle cell disease patient. Niger J Basic Clin Sci [serial online] 2021 [cited 2021 May 13];18:49-51. Available from: https://www.njbcs.net/text.asp?2021/18/1/49/315407




  Introduction Top


Sickle cell disease (SCD) is the most common single-gene disorder in African–Americans, affecting approximately 1 of 375 persons of African ancestry, with infection as one of the major complications of the disease in childhood.[1] Bone involvement is the most common clinical manifestation of SCD,[2] and osteomyelitis is one of the most common invasive bacterial infections in SCD patients and in children in general, leading to hospitalisation and prolonged antibiotic administration.[3] Most cases arise in the metaphysis of long bones such as Femur, Tibia and Humerus, and involvements of short and flat bones such as ribs are rare.[3] Tibia is the commonest site of osteomyelitis, even in SCD.[4] Rib osteomyelitis is extremely rare and account for <1% of haematogenous osteomyelitis.[5],[6] It is considerably more common in low-income countries.[7] We report a rare case of chronic pyogenic osteomyelitis involving the rib in a 29-year-old female SCD patient.


  Case Report Top


A 29-year-old female SCD patient presented to the orthopaedic outpatient department with a history of a recurrent discharging sinus over the right chest wall of 20 years. This was associated with pain and occasional low-grade fever. There was no significant history of trauma. She sustained multiple fractures at various sites with multiple surgeries, the details of which were not available. She had been having, on average, four episodes of Vaso-occlusive crisis per month. She also has a history of recurrent convulsions during childhood with multiple blood transfusions. She was jointly managed by the orthopaedic, cardiothoracic surgery, nephrologist and infectious diseases doctors. There was poor follow-up due to financial constraints.

She is short for age with multiple scars all over her body (both clavicles, all limbs, chest wall). There was a discharging sinus over the right lateral chest wall in the region of the 5th rib [Figure 1]. There was also shortening of the right lower limb (Limb length discrepancy (LLD) of 5 cm).
Figure 1: Clinical photograph of the patient with a discharging sinus over the right lateral chest wall

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Routine blood investigation revealed haemoglobin of 6 g/dl, a total leucocyte count of 10 × 109/L with 78% neutrophils. Erythrocyte sedimentation rate was 30 mm/h. The chest X-ray revealed sclerosis of adjacent cortices of the posterior 3–5th ribs likely from healed infection/fractures, a sequestrum on the 5th rib and cardiomegaly. Abdominal ultrasonography showed features of bilateral pyelonephritis. E/U/Cr was within the normal limit, and grouping and cross-matching of 2 units/pints of blood were also done.

The patient had partial excision/sequestrectomy [Figure 2] of the 5th rib with chest tube insertion after obtaining informed consent and anaesthetic clearance. About 3 ml of pus was obtained during the surgery, which was sent to the microbiology department for culture and sensitivity. The culture revealed Staphylococcus aureus. The excised rib and the sequestrum were sent for histopathological evaluation and the diagnosis of chronic pyogenic osteomyelitis was confirmed by histopathologist.
Figure 2: Partially excised rib and the sequestrum

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Intra-operative findings were a sinus tract with purulent discharge in the region of the 5th rib right lateral chest wall and adhesions between the pleura/Lung and the lateral chest wall.

The post-operative period was uneventful, and the patient was kept on parenteral antibiotics, analgesics, intravenous fluid and monitoring of vital signs. She did very well and was discharged after chest tube removal for follow-up in the orthopaedic outpatient department.


  Discussion Top


Patients with SCD have a high incidence of bacterial infection, with osteomyelitis being the second-most common infection.[8] Infection is a significant contributor to morbidity and mortality in SCD, particularly in children. It remains the leading cause of death, particularly in less developed nations.[9] Rib osteomyelitis is a rare entity and generally results from penetrating trauma, a contagious infection like empyema or pneumonia or via haematogenous seeding from a distant focus of infection.[5],[6],[9] In our case, it was most likely due to a haematogenous seeding from a distant focus of infection. Osteomyelitis, due to haematogenous spread, occurs in areas with the largest blood supply where the bone is more metabolically active. Most likely sites for dissemination are anterior, near the costochondral junction (76%), and posteriorly near the costovertebral angle.[10],[11] Osteomyelitis of the rib is generally unifocal, but multifocal lesions have been reported in severely ill newborns.[12] Even though our patient presented with a unifocal lesion, she could have had multifocal lesions before the presentation, evidence by multiple scars over the chest wall and chest X-ray features of the previous infection on 3–5th ribs.

The earliest signs and symptoms of rib osteomyelitis are generally nonspecific, which result in delayed diagnosis and inappropriate management. In most cases, the patients generally present with fever, pain and an abscess or sinus that fails to heal.[3],[12] Our patient also presented with a history of discharging sinus associated with pain and low-grade fever.

The most common infecting pathogen is S. aureus.[7],[12],[13] The culture of the pus obtained from our patient revealed S. aureus. Atypical organisms, such as mycobacterium tuberculosis[9],[13] and fungal infections,[14] especially in immunocompromised individuals, can cause rib osteomyeliltis. Salmonella typhi is also an important causative organism in SCD patients.[4],[14]

The diagnosis of rib osteomyelitis requires a strong index of suspicion. Imaging modalities like chest X-ray, computed tomography (CT) scan and magnetic resonance imaging (MRI) are useful. Sometimes chest X-rays may fail to detect early skeletal changes and the diagnosis may be delayed until there is bone destruction with overlying soft-tissue changes.[15] The definitive diagnosis requires culture of the aspirated pus or blood culture.[3],[5],[15] Our patient could not do CT scan and MRI because of financial constraints.

Empiric treatment with a broad-spectrum regimen of parenteral therapy is warranted, always including an agent directed to S. aureus before pus culture result is out. Surgical debridement is more critical for optimal treatment of cases of chronic osteomyelitis[3],[12],[15] as was done on our patient.


  Conclusion Top


Rib osteomyelitis is rare. It can be easily misdiagnosed because of its rarity and non-specific clinical manifestations. Clinicians should be aware of the possibility of rib osteomyelitis in children with SCD. High index of suspicion in addition to imaging modalities and pus culture, will give a definitive diagnosis. Early recognition and prompt treatment allow high cure rate.

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.
Eizabeth B, Natasha S, Lisa W, Jeremy N. Sickle cell disease in children: Differentiating osteomyelitis from vaso-occlusive crisis. Arch Pediatr Adolesc Med 2009;163:251-5.  Back to cited text no. 1
    
2.
Antonio A, Irene R. Bone involvement in sickle cell disease. Br J Heamatol 2005;129:482-90.  Back to cited text no. 2
    
3.
Kaplan LS. Osteomyelitis in children. Infect Dis Clin North Am 2005;19:787-97.  Back to cited text no. 3
    
4.
Sadat-Ali M. The status of acute osteomyelitis in sickle cell disease. A 15-year review. Int Surg 1998;83:84-7.  Back to cited text no. 4
    
5.
Vijay V, Srivastava N, Yadav YK, Srivasta S, Shukla S. Chronic pyogenic osteomyelitis of the rib: A case report in a pediatric patient. Scholar J Appl Med Sci 2015;3:1307-8.  Back to cited text no. 5
    
6.
Idrissa S, Tazi M, Cherrabi H, Souley A, Mahmoudi A, Elmadi A, et al. Multifocal rib osteomyelitis in children: A case report and literature review. J Surg Case Rep 2017;2017:rjx142.  Back to cited text no. 6
    
7.
Peltola H, Paakkonen M. Acute osteomyelitis in children. N Engl J Med 2014;370:352-360.  Back to cited text no. 7
    
8.
Wong AL, Sakamoto KM, Johnson EE. Differentiating osteomyelitis from bone infarction in sickle cell disease. Pediatr Emerg Care 2001;17:60-3.  Back to cited text no. 8
    
9.
Catherine B, Baba I, Stephen KO. Infection in sickle cell disease. A review. Int J Infect Dis 2010;14:e2-12.  Back to cited text no. 9
    
10.
Nascimento M, Oliveira E, Soares S, Almeida R, Espada F. Rib osteomyelitis in a pediatric patient case report and literature review. Pediatr Infect Dis J 2012;31:1190-4.  Back to cited text no. 10
    
11.
Raffaeli G, Borzani I, Pinzani R, Giannitto C, Principi N, Esposito S. Abdominal mass hiding rib osteomyelitis. Ital J Pediatr 2016;42:37.  Back to cited text no. 11
    
12.
Basa NR, Si M, Ndiforchu F. Staphylococcal rib osteomyelitis in a pediatric patient. J Pediatr Surg 2004;39:1576-7.  Back to cited text no. 12
    
13.
Bishara J, Gartman-Israel D, Weinberger M, Maimon S, Tamir G, Pitlik S. Osteomyelitis of the ribs in the antibiotic era. Scand J Infect Dis 2000;32:223-7.  Back to cited text no. 13
    
14.
Gamaletsou MN, Kontoyiannis DP, Sipsas NV, Moriyama B, Alexander E, Roilides E, et al. Candida osteomyelitis: Analysis of 207 pediatric and adult cases (1970-2011). Clin Infect Dis 2015;55:1338-51.  Back to cited text no. 14
    
15.
Mohanty D, Agrawal V, Jain BK, Gupta R, Rathi V, Gupta A. Osteomyelitis of the ribs: A strategy for prompt diagnosis and effective management. Trop Doct 2008;38:239-41.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2]



 

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