7D-11, Joint fluid: Bacillus spp. Blood culture w/o growthD-10, Increased swelling. I&DD-9, Joint fluid: Enterococcus fecalisD-8, sent home on IV pip/tazo + tobraCrawls at home x 6 daysD-2, increased pain.D-1, increased warmth. No swelling, redness.Knee XR: no osteomyelitisD-0, Increased ESR. Transferred.
8Exam at CHW Afebrile, VSS Right lower extremity surgical incision wound is appropriately healed. There is effusion noted. Range of motion of the knee is painful, able to achieve range from degrees.
9Laboratories at CHW WBC 6,600 5,500 49S 32L 17M ESR 70 >100 CRP 6.8 Joint fluid: “many PMNs. No organisms.”Blood culture: no growth
10Knee XR:There is a mild amount of soft tissue swelling with an effusion and irregularity involving the right tibial epiphysis that is most likely developmental in nature.MRI of R leg:Large joint fluid accumulation within the knee with thickening of the suprapatellar bursa. After intravenous administration of gadolinium, there is intense enhancement of the synovium diffusely.In the medial condyle of the femur, there is a defect going through the cartilaginous component to the bony ossification center. This extends over approximately 1.5 cm length ... and likely reflects fluid tracking along this area. The posterior cartilage component shows mild increased signal on T2's and does enhance slightly. The bone enhances to a slight degree as well.
16MRI: Today's examination shows interval placement of a Penrose drain within the suprapatellar bursa. Diffuse extensive synovial enhancement is redemonstrated. There is a new approximately 4 x 2 x 4 cm fluid collection superior to the suprapatellar bursa and superomedial to the knee which is suspicious for a soft tissue abscess. Although the drain is just adjacent to the inferior border of this fluid collection, there may be septations which prevent appropriate drainage.There is continued abnormal signal and enhancement in the medial femoral condyle consistent with osteomyelitis. There is no evidence of bone abscess.
17D10, I&D #5Initially the previous incision site was opened on the medial aspect of the right knee, this was extended up approximately 8-10 cm into the area of the vastus medialis. There was a lot of necrotic tissue in this area extending up just anterior to the distal femur and beneath the quadriceps muscle.There was a large defect in the medial femoral condyle, the edges were débrided and it was evident that the infection carried down into the femoral epiphysis in the area of the medial femoral condyle. This was débrided back to stable bony tissue; all of the necrotic bone in the area was removed using a curet. The articular cartilage of the femoral medial condyle had a full thickness transverse split at the mid aspect of the condyle and this had no bony backing following the bony debridement. The condylar cartilage was left in place in an effort to spare further cartilage loss.
18Hospital course D10, new rash following surgery Stop cefepime and cipro. Keep clinda.Start meropenemD11, fungus reported from epiphyseal culture(s)
26Long term plan Terbinafine x 3 months Safer, cheaper alternative after that:griseofulvin, fluconazole, itraconazole, voriconazoleDuration for septic arthritis + osteomyelitis?Concern? relapse >5%, abnormal growth, loss of function, malignancy, amyloidosis> 3 weeks, alwayssubacute/chronic presentation: longer
27Medicine as science Need for competing hypothesis (p=0.05) Joint is sterile, but patient is worseUse the bioassay in front of youLaboratory tests confirm or rebut your hypothesisKnow your assaysLag in CRPRange of CRPPractice due diligenceCow paddy microbiology
28Cow paddy microbiology 1: Chatterjee A, Chakrabarti A, Chatto-Padhyay D, Sen Gupta DN.Isolation of dermatophytes from dung.Vet Rec Oct 25;107(17):399. No abstract available.2: Bernstein CN, Blanchard JF, Rawsthorne P, Collins MT.Population-based case control study of seroprevalence of Mycobacteriumparatuberculosis in patients with Crohn's disease and ulcerative colitis.J Clin Microbiol Mar;42(3):3: Collins MT, Sockett DC, Goodger WJ, Conrad TA, Thomas CB, Carr DJ.Herd prevalence and geographic distribution of, and risk factors for, bovineparatuberculosis in Wisconsin.J Am Vet Med Assoc Feb 15;204(4):4: Ellingson JL, Cheville JC, Brees D, Miller JM, Cheville NF.Absence of Mycobacterium avium subspecies paratuberculosis components fromCrohn's disease intestinal biopsy tissues.Clin Med Res Jul;1(3):
29Cow paddy microbiology 5: Ellingson JL, Anderson JL, Koziczkowski JJ, Radcliff RP, Sloan SJ, Allen SE,Sullivan NM.Detection of viable Mycobacterium avium subsp. paratuberculosis in retailpasteurized whole milk by two culture methods and PCR.J Food Prot May;68(5):6: Verweij PE, Cox NJ, Meis JF.Oral terbinafine for treatment of pulmonary Pseudallescheria boydii infectionrefractory to itraconazole therapy.Eur J Clin Microbiol Infect Dis Jan;16(1):26-8. No abstract available.7: Franz E, van Diepeningen AD, de Vos OJ, van Bruggen AH.Effects of cattle feeding regimen and soil management type on the fate ofEscherichia coli O157:H7 and salmonella enterica serovar typhimurium in manure,manure-amended soil, and lettuce.Appl Environ Microbiol Oct;71(10):
30Cow paddy microbiology 8: Lebuhn M, Effenberger M, Garces G, Gronauer A, Wilderer PA.Hygienization by anaerobic digestion: comparison between evaluation bycultivation and quantitative real-time PCR.Water Sci Technol. 2005;52(1-2):93-9.9: Miyatake F, Iwabuchi K.Effect of high compost temperature on enzymatic activity and species diversityof culturable bacteria in cattle manure compost.Bioresour Technol Nov;96(16):10: Jiang X, Islam M, Morgan J, Doyle MP.Fate of Listeria monocytogenes in bovine manure-amended soil.J Food Prot Aug;67(8):
31Cow paddy microbiology 11: Dorner SM, Huck PM, Slawson RM.Estimating potential environmental loadings of Cryptosporidium spp. andCampylobacter spp. from livestock in the Grand River Watershed, Ontario, Canada.Environ Sci Technol Jun 15;38(12):12: Bradford SA, Schijven J.Release of Cryptosporidium and Giardia from dairy calf manure: impact ofsolution salinity.Environ Sci Technol Sep 15;36(18):13: Bell RG.Comparative virulence and immunodiffusion analysis of Petriellidium boydii(Shear) Malloch strains isolated from feedlot manure and a human mycetoma.Can J Microbiol Jul;24(7):14: Miller RW, Pickens LG, Gordon CH.Effect of Bacillus thuringiensis in cattle manure on house fly larvae.J Econ Entomol Aug;64(4): No abstract available.
32CRP in bone & joint infections (1) Hammer HB, Kvien TK, Glennas A, Melby K. A longitudinal study of calprotectin as an inflammatory marker in patients with reactive arthritis. Clin Exp Rheumatol 1995; 13(1):59-64.(2) Kallio MJT, Unkila-Kallio L, Aalto K, Peltola H. Serum C-reactive protein, erythrocyte sedimentation rate and white blood cell count in septic arthritis in children. Pediatr Infect Dis J 1997; 16(4):(3) Khachatourians AG, Patzakis MJ, Roidis N, Holtom PD. Laboratory monitoring in pediatric acute osteomyelitis and septic arthritis. Clin Orthop Relat Res 2003;(409):(4) Kocher MS, Mandiga R, Murphy JM, Goldmann D, Harper M, Sundel R et al. A clinical practice guideline for treatment of septic arthritis in children: efficacy in improving process of care and effect on outcome of septic arthritis of the hip. J Bone Joint Surg Am 2003; 85-A(6):(5) Levine MJ, McGuire KJ, McGowan KL, Flynn JM. Assessment of the test characteristics of C-reactive protein for septic arthritis in children. J Pediatr Orthop 2003; 23(3):(6) Martinot M, Sordet C, Soubrier M, Puechal X, Saraux A, Liote F et al. Diagnostic value of serum and synovial procalcitonin in acute arthritis: a prospective study of 42 patients. Clin Exp Rheumatol 2005; 23(3):(7) Peltola H, Unkila-Kallio L, Kallio MJ. Simplified treatment of acute staphylococcal osteomyelitis of childhood. The Finnish Study Group. Pediatrics 1997; 99(6):
33CRP in bone & joint infections (8) (8) Roine I, Faingezicht I, Arguedas A, Herrera JF, Rodriguez F. Serial serum C-reactive protein to monitor recovery from acute hematogenous osteomyelitis in children. Pediatr Infect Dis J 1995; 14(1):40-44.(9) Roine I, Arguedas A, Faingezicht I, Rodriguez F. Early detection of sequela-prone osteomyelitis in children with use of simple clinical and laboratory criteria. Clin Infect Dis 1997; 24:(10) Unkila-Kallio L, Kallio MJ, Eskola J, Peltola H. Serum C-reactive protein, erythrocyte sedimentation rate, and white blood cell count in acute hematogenous osteomyelitis of children. Pediatrics 1994; 93(1):59-62.(11) Unkila-Kallio L, Kallio MJ, Peltola H. The usefulness of C-reactive protein levels in the identification of concurrent septic arthritis in children who have acute hematogenous osteomyelitis. A comparison with the usefulness of the erythrocyte sedimentation rate and the white blood-cell count. J Bone Joint Surg Am 1994; 76(6):