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Case Report
Chronic Osteomyelitis ina Newborn Paediatrics Section BaPPaditya daS, PranaB Kumar dey, SatyaBrata roy chowdhury, KalPana datta showed features of chronic osteomyelitis. A diagnosis A term, 14-day-old male baby was presented with high of chronic osteomyeltis with septicaemia was made grade fever, decreased feeding, lethargy, progressively and treated conservatively with intravenous antibiotics increasing swel ing and restricted movement of right fol owed by oral. He showed good improvement. The elbow since 7th day of life. He was born by normal vaginal case is reported here for it's rarity as it was presented in delivery in a hospital with uneventful antenatal, natal and first week of life.
immediate postnatal period. X-ray of the right elbow Keywords: Chronic osteomyelitis, Septicaemia, Neonate normal limit. Digital X-RAY [Table/Fig-1] of right elbow Osteomyelitis is defined as an inflamation of the bone (AP and Lateral view) showed metaphysical irregularity caused by an infecting organism. It may also involve associated with permeative destruction at the lower end marrow, cortex, periosteum and the surrounding soft of humeral diaphysis, continuous periosteal reaction,bony tissues. It can be useful y sub-classified on the basis of the fragmentation at the distomedial aspect of humeral causative organism (pyogenic bacteria or mycobacteria), diaphysis. All the features were suggestive of chronic the route, duration and anatomic location of the infection osteomyelitis. Blood culture showed no growth. Based [1]. Osteoarticular infections, although uncommon, on the clinical, radiological and other investigations final represent a severe condition in neonates. To the best diagnosis was made as chronic osteomyelitis. Baby of our knowledge very few cases has been reported till was managed with intravenous cefuroxime. Sling was date. Osteoarticular, Infections in newborns are largely maintained. After 3 weeks of intravenous therapy CRP of an acute in nature [2]. Lower extremity joints are was decreased, circumference came down to 12 cm commonly affected [3]. Herein we report a rare case of and range of movement was increased gradually. Repeat chronic osteomyelitis of humerous since 7th day of life.
X-RAY [Table/Fig-2] showed resolution to a great extent. Baby was dischared on oral cefuroxime for three weeks CASe RepoRT
and regular physiotherapy. After completion of antibiotic A 14-days-old male baby was brought to us with fever, course circumference came down to 11cm and the baby decreased feeding, lethargy, progressively increasing attained full range of movement of right elbow.
swelling and restricted movement of right elbow since 7th day of life. Fever was of high grade, continuous in character. Baby was born to a booked primigravida by normal vaginal delivery at term in the same institution. Antenatal and immediate post-natal periods were uneventful. Birth weight of the baby was 2.5 kg. On examination, right elbow was swollen, reddish, tender, warm to touch with circumference of 15 cm where as the left measured only 11 cm. The skin of the overlying lesion was normal.
Investigation revealed haemoglobin of 15 gm%, WBC of 34600/cmm with polymorph 75% and Platelet of [Table/Fig-1]: X-ray of right elbow(AP & Lat view) obtained
292000/cmm. Peripheral smear showed toxic granules on the seventh day of life at the time of admission showing and band cell 5% of neutrophil.CRP was 9.8mg/dl and metaphysial irregularity associated with permeative ESR 50mm (1st hour). HIV I, II and VDRL test of the destruction at the lower end of humeral diaphysis,continuous periosteal reaction,bony fragmentation at the mother were negative. Coagulation profile was within distomedial aspect of humeral diaphysis Indian Journal of Neonatal Medicine and Research. 2013 Oct, Vol-1(2): 22-24

Bappaditya Das et al., Chronic Osteomyelitis in Newborn cultures are positive in 30% to 50% of patients [8]. Bone aspiration under CT or ultrasound guidance may reveal an aetiologic agent when the blood cultures are negative [8]. Plain radiography is extremely helpful in diagnosis of chronic osteomyelitis which may yield areas of sequestration with dead bone lying in a pocket of cellular debris outlined by the sclerotic border, periosteal proliferative activity, modeling of the entire cortex and endosteum, and areas of bone lysis. Plain films do help in demonstrating fractures or bone malignancies, which are included in the differential diagnosis of osteomyelitis.
[9]. Technetium-labeled methylene diphosphate bone scan, CT, MRI are also useful in selective situations.
Antibiotics are recommended for at least 4–6 weeks [Table/Fig-2]: X-ray of right elbow (AP view) showing
duration or till normalization of CRP or ESR [9]. Surgical resolution to a great extent after 3 weeks debridement is more critical for optimal treatment of chronic osteomyelitis [7]. Hyperbaric oxygen may be a useful adjunctive treatment measure in the management of chronic osteomyelitis that is refractory to standard Chronic osteomyelitis is rare in newborn. The diagnosis approaches. So to conclude, a possible diagnosis of is difficult and often delayed as the clinical features osteomyelitis, though rare, should be kept in the back differ significantly from older children, adolescent and of mind in case of a newborn in first few weeks of life adults [4]. In literature few cases were reported but when there are features of inflammation and difficulty in rarely found within first week of life. A case was reported limb movement and a plain radiograph may be enough where a 33 days old baby was hospitalized for pre- to diagnose this condition in most cases.
maturity, septicemia, respiratory distress syndrome and gastrointestinal bleeding. Her chest X-ray showed bilateral humeral osteomyelitis and bilateral glenohumeral [1] Krogstad P. Osteomyelitis and septic arthritis. In:Feigin RD, Cherry JD, Demmler GJ, et al, editors. Textbook of joint arthritis [5]. Another case was reported where a five pediatric infectious diseases. 5th edition. Philadelphia:WB weeks old term appropriate for gestational age baby saunders; 2004. P. 713-3 born by vacuum assisted vaginal delivery presented with [2] Gupta V, Kumari C, Bhatia B. Chronic osteomyelitis in a difficulty in moving his right upper limb since 3 weeks of neonate: unusal presentation. Journal of Neonatology. life. X ray was suggestive of osteomyelitis [3]. In a study, 2011, apr-june; 25(2):73 which included thirty-four neonates with osteomyelitis [3] Quadir M, Ali SR, Lakhani M, Hashmi P, Amirali A. Klebsiel a osteomyelitis of the right humerous involbing the right showed that the hip (19 cases) was the most common shoulder joint in an infant. J Pak Med Assoc. 2010, sept; site involved. Swelling and pseudoparalysis were the most significant local signs. Radiographic abnormalities, [4] Knudsen CJM, Hoffman EF. Neonatal osteomyelitis.The such as metaphyseal rarefaction and/or joint subluxation Journal of bone and joint surgery.1990 sept, 72-B(5), 846- around hip were found on the initial radiographs in 18 of the 19 cases [4]. In another study it was found [5] Ghorashi Z, Nezami N, Hoseinpour-Feizi H, et al. Osteomyelitis, septicaemia and meningitis caused by that 41% cases were secondary to complication of Klebsiella in a low birth weight newborn: a case report. J pregnancy and 47% were secondary to complications of Med. Case Reports 2011; 5: 241.) deliveries. Majority of the babies had antecedent illness [6] Weissberg Ed, Smith AL, Smith DH. Clinical features of or were subjected to potentially infective procedures in neonatal osteomyelitis, Pediatrics. 1974; 53: 505-10 ) perinatal period [6]. However, in our case mother had an [7] Dubey L, Krasinski K, Hernanz-Schulman M. Osteomyelitis secondary to trauma or infected contiguous soft tissue. uneventful pregnancy and institutional delivery but baby Paediatr Infect Dis J. 1988; 7:26–34.
presented with clinical features and laboratory findings [8] Karwowska A, Davies HD, Jadavji T. Epidemiology of of sepsis.
and outcome of osteomyelitis in the era of sequential Chronic osteomyelitis is most commonly caused by intravenous-oral therapy. Paediatr Infect Dis J. S. aureus and gram-negative enterics. Polymicrobial [9] Kaplan SL. Osteomyelitis in Children. Infect Dis Clin N Am. aetiologies are found in a high proportion of children 19 (2005) 787–97.
with osteomyelitis secondary to trauma or contiguous spread [7]. Haematogenous spread is most common. Metaphysis of long bones, such as the femur, tibia, and humerus are usually involved [1].
The diagnosis of chronic osteomyelitis is based on clinical, laboratory and imaging studies. Standard laboratory indicators of inflammation, such as the WBC, ESR, and CRP, are all generally elevated. Blood Indian Journal of Neonatal Medicine and Research. 2013 Oct, Vol-1(2): 22-24 Bappaditya Das et al., Chronic Osteomyelitis in Newborn name, addreSS, e-mail id oF the 1. Dr Bappaditya Das correSPondinG author: 2. Dr Pranab Kumar Dey Dr Pranab Kumar Dey, 3. Dr Satyabrata Roy chowdhury Govt. Housing Estate,Block-B, Flat-6, 82 Belgachia 4. Dr Kalpana Datta Road,Kolkata-700037,West Bengal, India.
Phone: 918902365478 ParticularS oF contriButorS: 1. Junior Resident (MD), Department of Paediatrics, Medical College, Kolkata, India. Financial or other comPetinG intereStS: 2. Clinical Tutor, Department of Paediatrics, Medical College, Kolkata, India.
3. Junior Resident (MD), Department of Paediatrics, Medical College, Kolkata, India.
4. Professor, Department of Paediatrics, Medical College, Kolkata, India.
Date of Publishing: oct 31, 2013 Indian Journal of Neonatal Medicine and Research. 2013 Oct, Vol-1(2): 22-24

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