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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 4  |  Issue : 2  |  Page : 132-134

Acute hematogenous E. coli osteomyelitis of bilateral tibia in chronic immune thrombocytopenic purpura


1 Senior Registrar, Institute of Orthopaedics, Bala Gangadhara Swamy Global Hospital, Kengeri, Bangalore, Karnataka, India
2 Consultant, Institute of Orthopaedics, Bala Gangadhara Swamy Global Hospital, Kengeri, Bangalore, Karnataka, India
3 Haemato Oncologist, Institute of Orthopaedics, Bala Gangadhara Swamy Global Hospital, Kengeri, Bangalore, Karnataka, India

Date of Web Publication16-Jun-2015

Correspondence Address:
Sandeep Dixit
No-67, Institute of Orthopaedics, BGS Global Hospital, Kengeri, Bangalore - 560 060, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-0521.157896

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  Abstract 

Immune Thrombocytopenic Purpura (ITP) is an autoimmune disorder which is characterized by low circulating platelets with an increased susceptibility to recurrent infections. Treatment with immunosuppressive drugs may increase the risk of infections in ITP. Delayed diagnosis because of blunted host immune response and lack of outward signs and symptoms places the treating physician at a disadvantage in the management of this type of disease. Osteoarticular infection is very rare in ITP. We present a case of acute haematogenous E. coli osteomyelitis of bilateral tibia in a patient of chronic ITP on immunosuppressive drugs. With high index of suspicion and use of Magnetic Resonance Imaging (MRI) early diagnosis was made and treated successfully.

Keywords: Immune thrombocytopenic purpura, Osteomyelitis, Osteonecrosis


How to cite this article:
Dixit S, Jagadeesan MK, Jadhav S, Chikkarangappa R. Acute hematogenous E. coli osteomyelitis of bilateral tibia in chronic immune thrombocytopenic purpura. Saudi J Health Sci 2015;4:132-4

How to cite this URL:
Dixit S, Jagadeesan MK, Jadhav S, Chikkarangappa R. Acute hematogenous E. coli osteomyelitis of bilateral tibia in chronic immune thrombocytopenic purpura. Saudi J Health Sci [serial online] 2015 [cited 2019 Oct 22];4:132-4. Available from: http://www.saudijhealthsci.org/text.asp?2015/4/2/132/157896


  Introduction Top


Immune Thrombocytopenic Purpura (ITP) is an autoimmune disorder which is characterized by low circulating platelets and an increased susceptibility to recurrent infections. Osteoarticular involvement is rare even though respiratory and gastrointestinal (GI) infections are seen in almost all patients. ITP occurs in 1.0-12.5 per 100,000 per year. [1] The clinical manifestations of thrombocytopenia include purpura, petechiae and bruising. Treatment options for ITP include corticosteroids as first line, followed by intravenous immunoglobulin, anti-D, anti-CD20 (Rituximab) and splenectomy as a last resort. [1],[2] Treatment with immunosuppressive drugs may increase the risk of infections. [3] The adjusted 1-year relative risk (RR) of infection was 4.5 for patients with chronic ITP compared with the general population cohort. [4] We present a case of acute haematogenous E. coli osteomyelitis of bilateral tibia in a patient of chronic ITP on immunosuppressive drugs.


  Case report Top


A female aged 35 years was diagnosed to have ITP one year ago. She was on treatment with corticosteroid, dapsone and azathioprine. She presented to us with pain in left knee and upper leg associated with spikes of temperature since 2 days. Clinically, except for tenderness over proximal tibial condyles she did not have classical signs of infection. Her X-ray of left knee and leg did not show any radiological abnormality. Her total white blood cell (WBC) counts were 9300/cumm, erythrocyte sedimentation rate (ESR) was 6 mm at the end of one hour, C-reactive protien was negative, and platelet count was <5,000/cumm. Magnetic Resonance Imaging (MRI) scan of left knee and leg showed features suggestive of avascular necrosis of distal femoral condyles and proximal half of tibia along with medullary abscess in upper tibia [Figure 1]. In view of severe thrombocytopenia (Platelet <5,000/cumm), computed tomography (CT) guided aspiration and decompression was done on the same day [Figure 2]. Gram stain showed numerous pus cells and gram negative bacilli. She was put on broad spectrum antibiotics and limb was splinted. Culture grew E. coli sensitive to meropenem. In spite of intravenous antibiotics for 48 hours, she continued to have fever and repeat CT showed recollection of abscess in left upper tibia for which repeat CT-guided aspiration and pigtail catheter insertion was done. Her platelet count increased the next day and she was taken up for left upper tibial cortical window and drainage on third day of hospitalisation. She improved clinically over the next 2 days.
Figure 1: MRI showing Medullary abscess in the left proximal tibia

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Figure 2: CT guided aspiration of the abscess

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She complained of pain in right tibia associated with spikes of fever on fifth day. MRI of right leg and screening of femur showed features suggestive of acute osteomyelitis with medullary abscess in upper end of right tibia [Figure 3]. Under platelet transfusion cover she underwent right upper tibial cortical window and drainage. She responded well to 6 weeks of intravenous antibiotics. Repeat radiograph showed no signs of chronic osteomyelitis [Figure 4].
Figure 3: MRI both leg showing features of osteomyelitis in both proximal tibiae

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Figure 4: 12 weeks post operative radiographs showing cortical windows

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She continued to have spontaneous haemorrhages in the form of epistaxis and haematuria. As the last resort she underwent splenectomy to improve her platelet counts.


  Discussion Top


Many immunocompromised patients are developing infections. Blunted host immune response delays the diagnosis of placing the treating physician at a disadvantage in the treatment of this type of disease. Immunocompromised patients are infected by a different group of pathogens than their healthier cohorts (e. g., Pseudomonas, gram-negative bacteria and fungal infections) because their host defenses are diminished. [5] Our patient had a diagnostic dilemma in view of lack of clinical signs and serological markers of infection. A high index of suspicion in this case led us to early diagnosis and prompt treatment.

When compared to general population the risk of inpatient and outpatient hospital contacts for infections increased 4.5-fold in the first year of diagnosis of ITP. From the second to fifth year of follow-up patients with ITP continued to have an 80% higher risk of this outcome. There was no osteomyelitis in 62 patients (out of 407 ITP patients) who had infection in the first year of diagnosis. [4] Our patient had acute E. coli osteomyelitis of both upper tibiae.

ITP patients on steroid treatment either short term or long term develop osteonecrosis. [5],[6] Direct radiography is not diagnostic for osteonecrosis until a relatively late stage of disease. MRI is the diagnostic study of choice with respect to both sensitivity and specificity because it can define early radiographically negative AVN in asymptomatic individuals. [7],[8]

There are few reports in the medical literature describing osteomyelitis in conjunction with osteonecrosis. Cooper et al., described a case of Candida albicans in the femoral head of a patient with steroid-induced AVN. Kahn and Bade reported S. aureus osteomyelitis in the lunate of a patient with Kienböck's disease. Epps et al., reported that tissue infarction predisposes patients with sickle cell disease to osteomyelitis. Osteomyelitis and bone infarction can be seen in the same patient population. Medullary infarcts may function as sequestra, predisposing patients to osteomyelitis and soft-tissue infection. [9] In our case, osteomyelitis was superimposed on osteonecrosis of proximal tibia which was diagnosed by MRI. Relying on plain radiographs would have caused delay in diagnosis and progression to chronic osteomyelitis.


  Conclusion Top


High index of suspicion and use of MR Imaging will help in early diagnosis. Preexisting osteonecrosis can be a nidus for infection. Prompt surgical treatment weighed against the risk of bleeding, in such immunocompromised thrombocytopenic patient, can prevent progression to chronic osteomyelitis.

 
  References Top

1.
Michel M, Chanet V, Galicier L, Ruivard M, Levy Y, Hermine O, et al. Autoimmune thrombocytopenic purpura and common variable immunodeficiency: Analysis of 21 cases and review of the literature. Medicine (Baltimore) 2004;83:254-63.  Back to cited text no. 1
    
2.
Mahevas M, Le Page L, Salle V, Cevallos R, Smail A, Duhaut P, et al. Efficiency of rituximab in the treatment of autoimmune thrombocytopenic purpura associated with common variable immunodeficiency. Am J Hematol 2006;81:645-6.  Back to cited text no. 2
    
3.
Cines DB, McMillan R. Management of adult idiopathic thrombocytopenic purpura. Annu Rev Med 2005;56:425-42.  Back to cited text no. 3
    
4.
Norgaard M, Jensen AO, Engebjerg MC, Farkas DK, Thomsen RW, Cha S, et al. Long-term clinical outcomes of patients with primary chronic immune thrombocytopenia: A Danish population-based cohort study. Blood 2011;117:3514-20.  Back to cited text no. 4
    
5.
Nagasawa K, Tada Y, Koarada S, Horiuchi T, Tsukamoto H, Murai K, et al. Very early development of steroid-associated osteonecrosis of femoral head in systemic lupus erythematosus: Prospective study by MRI. Lupus 2005;14:385-90.  Back to cited text no. 5
    
6.
Hong N, Du XK. Avascular necrosis of bone in severe acute respiratory syndrome. Clin Radiol 2004;59:602-8.  Back to cited text no. 6
    
7.
Griffith JF, Antonio GE, Kumta SM, Hui DS, Wong JK, Joynt GM, et al. Osteonecrosis of hip and knee in patients with severe acute respiratory syndrome treated with steroids. Radiology 2005;235:168-75.  Back to cited text no. 7
    
8.
Stevens K, Tao C, Lee SU, Salem N, Vandevenne J, Cheng C, et al. Subchondral fractures in osteonecrosis of the femoral head: Comparison of radiography, CT, and MR imaging. AJR Am J Roentgenol 2003;180:363-8.  Back to cited text no. 8
    
9.
Blacksin MF, Finzel KC, Benevenia J. Osteomyelitis originating in and around bone infarcts: Giant sequestrum phenomena. AJR Am J Roentgenol 2001;176:387-91.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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