Grand Round presentation –Wednesday 25th August

2004
New born Unit

CHRONIC OSTEOMYELITIS IN EARLY

INFANCY

Presenter: Dr Maina
Discussant: Dr Mogire (Orthopedic Surgeon)
 Name:Baby K. O.
Age: 6/12

D.O.B: 16/2/04
D.O.A: 19/2/04
R.F.A:- Mother attempted to strangle the child
in post-natal ward.
Antenatal Hx
Mother attended ANC once at 7/12 gestation.
Rx for malaria, given T.T injection.
ANP – Not done
Pregnancy non-eventful.
 Obstetric Hx
Primigravida, L.M.P – 15/5/03
E.D.D – 21/2/04
G.B.D – 39/40+
Menarche – 14 yrs – Cycle – 4/28,
Regular, No F.P use.
Perinatal Hx
 Presented at KNH in active labour.
 Rapid test done for HIV – Positive, Mother given
Nevirapine stat dose.
 Had SVD - Term female infant. BWT – 2300 gm
 A/S – 9/1, 10/5
 Baby given Oral Niverapine stat dose , Put on
formula feeds.
Post natal Hx
 Baby did well
 Mother developed ? puerperal psychosis 2 days
post delivery, deteriorated 2/7 later and
succumbed with ? HIV encephalitis
 FSHx
Only child
Mother 25yrs old – Housewife.
Father 30 yrs old - casual labourer
Mother Rx for PTB in 2002, No known
Chronic Illnesses in the family.
Drugs0 / Smoke0 / Alcohol0
 Examination
O/E
 Term female infant SGA, in good General
Condition, Pink, Not Jaundiced, afebrile, No
dysmorphism
Vital Signs
 R.R – 42/min
 Temp- 36.4°c
 H.R – 140 / Min

R/S
 Not in distress,
 Chest clear
 Examination cont….
CVS
 Pulses – felt N, S1 S2 heard N - no murmur
CNS
 Active baby, good response to handling, Neonatal
reflexes – All present N
 N tone
 Head Circumference – 33 cms, A.F – 1.5cms X
1.5cms flat
P.A
 Not distended,Cord N, well ligated, No organomegally
GUS – N female ext. Genitalia.
Impression
 Stable HIV exposed,SGA term baby
Plan
 Admitted. Put on Nan, Kept warm while
awaiting collection by the relatives, who failed
to turn up.
 Baby was doing well on
 Formula feeds / KCC milk
 Iron Supplements
 Septrin Prophylaxis (Started on Wk 6/52)
 Immunization – updated
 WT at 1/12 – 3050gms – gain of 25gms / day
At age of 45/7
Noted to have swollen lt upper arm, had fever
(Temp - 38°c)
 No Hx of trauma
 Previously well.
O/E fair general condition, febrile. Not pale, Not
Jaundiced, No lymphadenopathy.
L.E – swollen lt mid-humeral area, warm, tender,
no skin changes, pulses - felt
 No spontaneous movement of the arm observed
 Shoulder / elbow joints – N
 Other limbs – N
Systems – NAD
Impression
 Cellulitis
 DDx

 Osteomyelitis

 Pyomyositis

  Started on I.V floxapen, I.V gentamicin, Sy.

Paracetamol / Limb – elevation.
Investigation
 Septic screen full H’gram / ESR, Blood
cultures, X-ray, Lt arm.
 D2 of Rx – Temperature normalised, arm
still swollen.
 Results
H’gram.
 WBC – 13.1 x 109 / L N-45, L-55
 RBC – 3.12 x 1012 / L

 H.B – 9.3g/dl PBF – Normocytic

Normochromic
 MCV – 86ft

 PLTS – 608 X 109 / L

 ESR – Sample Insufficient

X-Ray – N.
Blood cultures – Negative
D5 of Rx
 Baby noted to have a pointing fluctuant area
over the swelling.
 I & D done under L.A
 Pus swab taken for M/C/S
 Meanwhile Rx continued.

Results
 Pus swab G/Stain – G+ve cocci seen
 Culture – Staph , aureus.
 Sensitive to – Amoxycillin, Augmentin,
Oxacillin, Erythromycin, Ciprofloxacin,
Gentamicin.
 Rx changed to Augmentin, gentamicin
continued.
Swelling reduced wound formed a sinus.
Repeat X-rays ≈ 2/52 of I.V Rx
Showed reduced bone density minimal
periosteal rxns

Orthopedics review.
 Advised to continue I.V Rx for 10/52 / daily
cleaning and dressing of wound.
 Follow up reviews
Week 4 of Rx
Swelling noted less, but still no
spontaneous movement.
Shoulder joint – noted hyperflexible &
tender ? joint involvement

Invs
Pus swab / blood cultures – Negative
X-ray (done at 5/52 of Rx) – Showed
features of chronic osteomyelitis
(sequestrum + involucrum), shoulder joint
involvement.
Orthopaedic Review
Advised to continue treatment ( for 3/12)
immobilise arm, continue cleaning /
dressing of wound.
Wk. 8/52 of Rx
Arm noted held in adduction / Internally
rotated.Humerus angulated at mid shaft
area
? Pathological #
sinus oozing minimal pus
Repeat X-ray # mid-shaft humerus
(pseudoarthrosis – Resorption of
sequestrum , involucrum in early phase of
uniting). Shoulder joint space reduced.
INVS
H’gram
 WBC – 10.2 x 109/L N 20, L 76, M3, E1
 RBC – 4.5 X 1012 / L . RBCS – Normocytic
Normochromic
 HB – 10.0gm/dl

 HCT – 30%

 MCV – 72 ft

 PLTS – 450 X 109 / L

 ESR – 20mm/hr

 Blood culture / pus swab – negative

Orthopaedic review
Advised to splint the arm with u-slab
To continue IV treatment
Wk 11/52 of Rx
Baby showed marked improvement, sinus
resolved
LE
 Arm held in normal posture
 Normal power

 Baby started on Physiotheraphy

Latest X-ray – healing of fracture with

minimal angulation
H’gram
 WBC – 9.6 X 109/L N35 L60 M4 E1
 RBC – 5.24 x 1012/L RBCs – Anisocytosis
Normochromic
 H.B – 12.2g/dl

 HCT – 38.5%

 MCV – 73fl

 MCHC – 31.8

 Plts – 364 x 109/L

 ESR – 16mm/hr.
 Growth assessment
Bwt – 2300g
Cwt – 5600g @ 6/12 age
H/C
 33 cms at birth
 Current 41cms
Current Length – 61cms
Milestones – Sitting with support
Currently baby is able to use the arm and is
discharged through Orthopaedic clinic on –
Septrin, Iron Supplements, Oral Augmentin.
 SUMMARY OF INVS
H’gram. H’gram H’gram
WBC – 13.1 x 109 / L - WBC – 10.2 x 109/L N WBC – 9.6 X 109/L N35
20, L 76, M3, E1 L60 M4 E1
N-45, L-55
- RBC – 4.5 X 1012 / L RBC – 5.24 x 1012/L
RBC – 3.12 x 1012 / L RBCS – Normocytic RBCs – Anisocytosis
H.B – 9.3g/dl PBF – Normochromic Normochromic
Normocytic HB – 10.0gm/dl - H.B – 12.2g/dl
Normochromic HCT – 30% - HCT – 38.5%
MCV – 86ft MCV – 72 ft - MCV – 73fl
PLTS – 608 X 109 / L PLTS – 450 X 109 / L - MCHC – 31.8
ESR – Sample ESR – 20mm/hr - Plts – 364 x 109/L
Insufficient - ESR – 16mm/hr.
- Latest ESR – 14mm/hr

Blood Culture –ve Blood culture/pus swab -ve Blood cultures -ve
Pus swab G/Stain
 G+ve cocci seen
 Culture – Staph , aureus.
 Sensitive to – Amoxycillin,
 Augmentin, Oxacillin,
 Erythromycin, Ciprofloxacin,
 Gentamicin.
U/ES
 Na – 136mmo/L
 K+ - 3.5 mmol/L
 BUN – 2.5 mmol/L
 Cr – 25 ųmol/L
ELISA for HIV antibodies – Positive
OTHER INVS
 C – reactive protein
 CD4 Count

 Viral Load

 Radio nucleotide studies (Technetium radio

nucleotide scan)
 CT Scan / MRI

 ? Bone / Sinus tract Biopsy

Thank you