Always stick to the basics: History and physical
Click Here to Manage Email Alerts
A 10-year old male complained to his mother about right shoulder pain. When she looked at the shoulder, she noticed what she described as some “areas of blistering,” with a few that appeared to have opened, leaving some redundant skin. She took him to an urgent care clinic, where he was diagnosed with a skin infection (presumably Staphylococcus aureus) and prescribed trimethoprim/sulfamethoxazole (TMP/SMX). The lesions seemed to quickly improve, but when asked, he still complained about some pain, so she took him to his primary care clinic. The mother relayed to the triage person that the child had an episode of severe Salmonella osteomyelitis in his right shoulder when he was an infant, almost 10 years earlier. With that information, the child was sent directly to radiology for plain radiographs of the right shoulder (Figure 1), which were preliminarily read as a fracture at the old infection site. With that report, the patient was urgently sent to the local orthopedic clinic without being examined.
Upon seeing the images and the radiology report — and again, without seeing the patient — the orthopedic surgeon immediately referred the child to the tertiary care center 90 miles away, to the pediatric orthopedic clinic where he had been treated 10 years earlier.
Upon arrival the next day, the patient was jointly seen and examined by myself (since I was involved in his care for the previous Salmonella osteomyelitis), and the orthopedic surgeon who was also involved with the infection 10 years earlier, as well as the on-call pediatric orthopedic surgeon. The right arm and shoulder exam was completely normal, except for the remnants of a blistering cutaneous infection, with some redundant skin around the periphery, and what appeared to be some healing scratch marks (Figure 2). At that time, when pressed for subjective evidence of pain, the patient admitted that it did not hurt anymore.
Summary:
- 10-year-old male with history of severe Salmonella osteomyelitis of the right proximal humerus 10 years ago;
- recent pain about the right shoulder;
- coincident blistering sores, apparently responding to TMP/SMX with resolution of the pain; and
- unusual plain radiographs.
What’s your diagnosis?
A. Chronic osteomyelitis with a draining fistula
B. Brodie abscess
C. Bullous impetigo on the shoulder
D. Recurrent Salmonella osteomyelitis
Case Discussion
The answer is C, bullous impetigo on the shoulder. This simple problem was complicated by the omission of basic history and physical exam principles, brought on by overbooked clinics and stressed providers — both growing problems in almost all clinical settings. The patient was taken to three different providers before he was referred to the tertiary facility.
Note in Figure 3 the appearance of bullous impetigo in a different patient, which demonstrates the small areas of redundant skin around the edges of a blister that has opened.
The history of a severe Salmonella infection of the right proximal humerus 10 years earlier was complicated by the virtual disappearance of the humeral head (Figures 4 and 5). Once this history was passed along by the family, it was assumed to be somehow related to his current complaint. However, examination of the arm would have demonstrated a normal shoulder, with a superficial scratch injury to the overlying skin that became secondarily infected. This diagnosis was confirmed in the pediatric orthopedic clinic, where the radiographs were interpreted by the surgeon and radiologist as being a normal variant, reflecting the healing of a distant injury. The local radiologist did not have that history to factor into the interpretation.
Obviously, the lesson is to never deviate from the time-honored practice of obtaining a history and physical, even if it is a brief, complaint-focused history and physical. Once the mother mentioned the patient’s osteomyelitis history, the subsequent clinical approach was understandably affected. However, this case shows the folly of skipping the exam.
Chronic osteomyelitis may develop over a period of years, but it would be extremely unusual if it were associated with an infection 10 years earlier. When chronic osteomyelitis is seen, a draining fistula may develop, usually at the site of a surgical scar or traumatic injury (Figure 6). However, it should not appear as a superficial blistering lesion. Subacute or chronic infections can also result in a walled-off lesion within the bone called a Brodie abscess (Figure 7), for which surgical debridement (Figure 8) and prolonged antibiotics are used. Figures 9 and 10 show yet another patient with chronic osteomyelitis of the mid-femur, manifested as a draining fistula, which subsequently required debridement.
Gorham-Stout (vanishing or disappearing bone) disease is a very uncommon, multifactorial phenomenon, with various underlying causes, including infection. In my career, I have been involved in the joint management of two patients with disappearing bones during or following severe osteomyelitis. For a more in-depth review of my experience with this condition, please see my column in the August 2011 issue.
- For more information:
- James H. Brien, DO, is with the department of infectious diseases at McLane Children’s Hospital, Baylor Scott & White Health, and an adjunct professor of pediatrics at Texas A&M College of Medicine in Temple, Texas. He also is a member of the Infectious Diseases in Children Editorial Board. Brien can be reached at jhbrien@aol.com.
Disclosure: Brien reports no relevant financial disclosures.
Collapse
Click Here to Manage Email Alerts