A 65 Year Old Diabetic Man Has a Ulcer With A Draining Sinus Tract On His Leg

A 65 year old man with known case of diabetes and peripheral vascular disease complains of pain in his leg where he has an old ulcer with a draining sinus tract. Along with other investigations an X ray was done which is shown below:

Central part showing an ill defined osteolytic area and major part consists of reactive sclerosis.

The patient was diagnosed to have Osteomyelitis.

Case Discussion.

Osteomyelitis in adults almost always presents in patients with underlying diabetes, peripheral vascular disease or both with an ulcer or a soft tissue infection.

Clinical features: May include:

• Fever
• Irritability in case of children
• Pain, swelling and warmth in the area of infection.

Causes: Most cases of osteomyelitis are cause by the bacterial Staphylococcus aureus. It can spread to involve the bone via the blood stream, through a nearby infection of the skin or by direct contamination

Complications: include:

• Impaired blood circulation due to infection in the bone may lead to bone death and necrosis.
• Septic arthritis when the infection spreads from the bone to the nearby joints.
• Impaired growth most commonly seen in children
• If the sinus tract remains open with draining ous there are high chances for skin cancer in the affected area.

Diagnostic testing:

1. X ray is always the best initial test. The earliest finding of osteomyelitis on the X ray is the elevation of the periosteum. 

2. If X ray is normal MRI is the next recommended imaging test.

3. Blood test may reveal elevated white cell counts indicating an underlying infection. 

4. Bone biopsy is the gold standard for diagnosing osteomyelitis, and it also helps in identifying the organisms involved in the infection.  

Treatment:

Since Staphylococcus is the most common organism involved treatment is targeted against this bacteria. Oxacillin or naficillin intravenously for 4 - 6 weeks is given if the organism is sensitive to theses antibiotics. 

MRSA is treated with vancomycin or linezolid.

Oral treatment is not effective and the antibiotics are given by intravenous route.