A 13 Year Old Male With Knee Pain - Page #4

Working Diagnosis:
Sub-acute Abscess vs. Chondroblastoma vs. Eosinophilic Granuloma

A curettage was performed and a graft with calcium phosphate antibiotic matrix was placed on the site of the lesion. Culture of the abscess grew Methicillin-Sensitive Staphylococcus Aureus. He was also referred to dermatology for treatment of his severe eczema, which was the presumptive etiology of the infection. He was treated with four weeks of Keflex.

Follow up MRI was done and showed resolution of the abscess

Author's Comments:
Three months later, patient was seen at our office. Incision site was well healed and ambulation was normal. His pain had resolved and his eczema was well under control.

Editor's Comments:
Brodie’s abscess is a form of subacute osteomyelitis. Presentation is usually insidious with mild symptoms and no systemic reaction. The most common age at presentation is 2-15 years old. Staph aureus is the cause of half the cases in of osteomyelitis in infants and children. Group A streptococcus is the second most common cause in older children and adolescents. 28% occur in the tibia and fibula, while 25% occur in the femur. The metaphysis is the most commonly affected area, because the cortex is the thinnest. Radiographs usually show an area of lucency with sclerotic margin. It may be confused with a bone tumor.
Work-up can include CBC, ESR, and CRP (often normal). Blood cultures are usually negative. Radiographs are the initial imaging test of choice, but often a MRI or CT is needed for further characterization. Open drainage and culture tend to have a better diagnostic rate than fine needle aspiration. Biopsy can help to differentiate from bone tumor.
Treatment usually requires surgical debridement and antibiotics for 4-6 weeks. Most reoccurrences are within 6 months. Clinical healing usually precedes radiographic healing which can take 3-12 months.

Cyclosporine adverse reactions: Neuromuscular & skeletal- Arthralgia, bone fracture, joint dislocation, joint pain, leg cramps/muscle contractions, muscle pain, myalgia, neuropathy, paresthesia, stiffness, synovial cyst, tendon disorder, tingling, tremor, weakness.
Miscellaneous-Abscess, allergic reactions, bacterial infection, carcinoma, diaphoresis increased, Flu-like syndrome, fungal infection, herpes simplex, herpes zoster, hiccups, infection, lymphadenopathy, lymphoma, moniliasis, night sweats, tonsillitis, viral infection

Krogstad, Paul. Epidemiology, pathogenesis, and microbiology of hematogenous osteomyelitis in children. UptoDate online. Accessed 7/5/2013.

Khoshaa, Khalid. Subacute Osteomyelitis (Brodie Abscess) Medscape. http://emedicine.medscape.com/article/1248682-overview. Accessed 7/5/2013

Cyclsporine drug information from Lexicomp. Accessed 7/5/2013

1. Quantitative Analysis of the Plain Radiographic Appearance of Brodie's Abscess
LOPES, THELMA D. MD; REINUS, WILLIAM R. MD; WILSON, ANTHONY J. MB, CHB, Investigative Radiology: January 1997 - Volume 32 - Issue 1 - pp 51-58

P.R. Kornaat1, M. Camerlinck2, 3, F.M. Vanhoenacker2, 3, G. De Praeter3, H.M. Kroon
JBR-BTR, 2010, 93: 81-86.

3. Radiographic Imaging in Osteomyelitis: The Role of Plain Radiography, Computed Tomography, Ultrasonography, Magnetic Resonance Imaging, and Scintigraphy
Carlos Pineda, M.D., Rolando Espinosa, M.D., and Angelica Pena, M.D.
Semin Plast Surg. 2009 May; 23(2): 80-89.

Anis Ben Lassoued, Mhamed Bahri, Wajdi Bouallègue, Ramzi Boufar's and Vladimir Gavrilov
J Bone Joint Surg Br 2011 vol. 93-B no. SUPP IV 535

Acknowledgment to Dr. Jose Flores and Dr. Everett Schlam.

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