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Hematogenous Osteomyelitis - Causes, Symptoms, Diagnosis, and Management

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Hematogenous osteomyelitis refers to bone infection and destruction caused by a systemic bacterial infection that spreads through blood.

Medically reviewed by

Dr. Pradeep Arun Kumar. L

Published At March 14, 2023
Reviewed AtDecember 1, 2023

Introduction

Hematogenous osteomyelitis continues to be difficult to diagnose, with complex problems in management, serious morbidity, and mortality, despite the availability of potent antimicrobial medicines, improved diagnostic approaches, and surgical procedures. Hematogenous osteomyelitis can be successfully treated. Most people need surgical removal of areas of the bone that are infected and destroyed. After surgery, powerful antibiotics, usually intravenous, are needed. Read this article to learn more about hematogenous osteomyelitis.

What Is Hematogenous Osteomyelitis?

Hematogenous osteomyelitis is a bone infection caused by microorganisms traveling through the bloodstream or spreading from adjacent tissues. This bacterial infection of the bone leads to inflammation and bone destruction. The most commonly involved site is the long bones of the legs. Boys are twice as likely to get affected than girls, and more than 50 % of cases comprise children younger than five years. Early diagnosis and treatment of hematogenous osteomyelitis are crucial to avoid serious life-threatening conditions and permanent disability.

What Are the Causes of Osteomyelitis?

Bacteria may reach the bone by one of these three mechanisms:

1) Direct spread of bacteria secondary to trauma or surgery.

2) Bacteria spread from an adjoining soft-tissue infection.

3) Hematogenous spread from a remote focus of infection.

What Are the Possible Causes of Hematogenous Osteomyelitis?

Hematogenous circulation of bacteria can be from various infectious conditions, such as recent events of the below conditions;

  • Urinary tract infection.

  • Cellulitis (bacterial infection of the skin).

  • Catheter infection.

  • Abscess.

  • Dental surgical procedures.

  • Meningitis (infection in the brain or spinal cord).

  • Endocarditis (infection in the inner lining of the heart).

  • Open trauma.

  • The bone recently injured, especially if there is a break in the outer layer of bone (cortex) and results in a hematoma (swelling with pooling of blood), can serve as an excellent thriving medium for bacteria to seed.

What Are the Types Of Hematogenous Osteomyelitis?

  1. Acute: Symptoms last for less than two weeks.

  2. Subacute: Symptoms last from two weeks to three months.

  3. Chronic: Infection is long-standing that develops over months to years.

What Are the Symptoms of Hematogenous Osteomyelitis?

Single-site infection is the most frequent, but multifocal hematogenous osteomyelitis can occur, especially in young infants and neonates. The onset of symptoms in hematogenous osteomyelitis is often gradual and constant. The affected person may present with the following symptoms;

  • Localized pain.

  • Localized swelling.

  • Erythema around a long bone.

  • Limited range of motion.

  • Limping or refusal to bear weight.

  • Refusal to use an extremity (pseudoparalysis).

  • Fever of unknown origin.

  • Back pain in case of vertebral osteomyelitis.

  • Tachycardia (increased heart rate).

  • The classic signs of inflammation, such as redness, warmth, and swelling, do not occur unless the infection has progressed to certain points.

When to Get Help for Hematogenous Osteomyelitis?

Consulting the doctor is advisable in case of experiencing worsening bone pain along with a fever of unknown origin. If a risk factor is associated with an infection because of a medical disease or recent surgery or injury, consult the doctor immediately when signs and symptoms of infection occur.

How Is Hematogenous Osteomyelitis Diagnosed?

The clinician obtains a complete history and performs a thorough examination with appropriate diagnostic investigations.

1. Detailed History:The clinician carefully takes history regarding any potential instigating event, such as trauma to the affected area, recent urinary, skin, ear, dental, or pulmonary infections, and the outcome of related infections. The clinician may question the social history or get a drug screen if intravenous drug use is suspected. Specifically, the clinician will take information about recent investigations and antibiotic medication usage. Getting the drug, strength, and duration of therapy may help in antibiotic selection, as most of the cases of hematogenous osteomyelitis are caused by the same bacteria as the source of infection.

2. Laboratory Investigations: Blood investigation values may be normal or elevated, and blood cultures are found positive in only around one-half of hematogenous osteomyelitis cases. In general, the following findings may be present in laboratory investigations;

  • Elevated WBC (white blood cell count).

  • ESR (erythrocyte sedimentation rate) elevated.

  • CRP (creatinine reactive protein) elevated.

  • Positive blood cultures.

  • Positive bone cultures.

3. X-Rays and Ultrasound Imaging: Plain radiography and ultrasound can exclude other causes. An X-ray can exclude a fracture and malignancy, while an ultrasound is very sharp in detecting joint effusions. It is useful for the initial diagnosis of suspicion to back up with MRI (magnetic resonance imaging) or nuclear imaging. X-rays often delay visual signs of osteomyelitis compared to symptoms. Early changes are subtle and may only be obvious five to seven days after bacterial infection in children and 10 to 14 days in the case of adults once up to 50 % bone content has been destroyed. X-rays are used for the early findings and to start a protected weight bearing to prevent pathological fracture of the affected bone until advanced imaging can be performed to form the standard treatment plan.

4. Biopsy: Bone biopsy is preferred over X-rays for diagnosing this bacterial infection in the bone tissues.

5. MRI: It is a useful modality because of its ability to detect bone marrow edema, an important feature seen in osteomyelitis as early as three to five days post-inoculation.

Despite the numerous diagnostic tests, studies suggest that the gold standard for osteomyelitis diagnosis is a bone biopsy, microbiology, and pathology examination.

How Is Hematogenous Osteomyelitis Treated?

If suspicion is high for hematogenous osteomyelitis, the doctor may see the affected individual more often for follow-up and monitoring. As stated earlier, the doctor may develop and change the course of treatment depending on the clinical response to ongoing therapies and laboratory examination.

However, definitive treatment for hematogenous osteomyelitis is widely debated. The treatment often consists of antibiotic medications and surgical debridement of the affected bone area. While children often undergo three to four weeks of antibiotic therapy, either oral or intravenous, depending on the severity of the infection, in adults, surgery is often required along with culture-driven antibiotic medications.

Complications of Hematogenous Osteomyelitis

Delayed or incomplete treatment can result in a continuation of symptoms, an increase in the spread of infection in the bone, and pathological fracture. It can arrest the growth of affected bones in children where bones are in their growth phase. In addition, the absence of any treatment may lead to death in severe and widespread infection cases.

Conclusion

Hematogenous osteomyelitis in case of children is a serious infection worldwide. It requires an individualized, multidisciplinary approach. Despite proper surgical debridement (cleaning and removing of the infective tissues surgically) and treatment with potent antibiotics, chronic hematogenous osteomyelitis in adults has a 30 % recurrence annually. Thus, the antibiotic treatment is continued to achieve optimal outcomes until the creatine reactive protein concentration in the blood is normal or significantly decreased.

Source Article IclonSourcesSource Article Arrow
Dr. Pradeep Arun Kumar. L
Dr. Pradeep Arun Kumar. L

Orthopedician and Traumatology

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