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CASE REPORT
Year : 2022  |  Volume : 15  |  Issue : 3  |  Page : 415-417  

Primary sternal osteomyelitis and sickle cell anemia


1 Department of Surgery, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria

Date of Submission30-Jun-2020
Date of Decision13-Oct-2020
Date of Acceptance22-Jul-2021
Date of Web Publication26-Feb-2022

Correspondence Address:
Ismail Inuwa Mohammed
Department of Surgery, Aminu Kano Teaching Hospital, Kano
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_336_20

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  Abstract 


Osteomyelitis of the sternal bone is very rare and is usually secondary to trauma or surgery. Primary sternal osteomyelitis and secondary sternal osteomyelitis commonly are caused by Staphylococcus spp, and in drug addicts by Pseudomonas aerugenosa, while in sickle cell anemic children, Salmonella spp are mostly implicated. We, therefore, present an unusual causative organism, Streptococcal spp in a sickle cell anemic child.

Keywords: Primary sternal osteomyelitis, sickle cell anemia, streptococcal infection


How to cite this article:
Mohammed II, Ahmad J, Oyebanji T, Abdurrhman MA, Adamu KM, Abubakar KM, Aliyu I. Primary sternal osteomyelitis and sickle cell anemia. Med J DY Patil Vidyapeeth 2022;15:415-7

How to cite this URL:
Mohammed II, Ahmad J, Oyebanji T, Abdurrhman MA, Adamu KM, Abubakar KM, Aliyu I. Primary sternal osteomyelitis and sickle cell anemia. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2022 Jul 4];15:415-7. Available from: https://www.mjdrdypv.org/text.asp?2022/15/3/415/338624




  Introduction Top


Primary sternal osteomyelitis (PSO) is very uncommon, only a few cases have been reported. Majority of cases of sternal osteomyelitis are secondary to trauma or surgery, especially following open-heart surgery. The causative agent is mostly staphylococcal infection, pseudomonas, and  Salmonella More Details spp.[1],[2] There are few cases reported to be caused by streptococcal infection in literature.[1],[2] The common predisposing factors in PSO are drug addiction, sickle cell anemia, diabetes mellitus, and immunosuppression.[3]

About 20 cases of primary osteomyelitis had been reported in the past, of which 15 of them had identifiable pathogen; Staphylococcus aureus was the most common followed by Salmonella, especially among sickle cell anemic children;[3] most of these patients presented acutely with obvious signs and symptoms of acute inflammation.[3] However, uncommon organisms have equally been implicated in sternal osteomyelitis such as Actinomyces israelii[4] and Peptostreptococcus anaerobius.[5]

We, therefore, present a 3-year-old sickle cell anemic child with PSO caused by Streptococcal pneumoniae which is also uncommon in sickle cell anemia patients.


  Case Report Top


A 3-year-old known sickle cell anemic child (SS genotype) presented to our pediatric emergency unit with a 5-day history of continuous fever, anterior chest wall pain, and swelling. He was treated with regular antibiotics with poor response. There were no cough, difficulty in breathing or urinary symptoms, and no history of trauma or surgery.

Clinical examination revealed acutely ill-looking child with anterior mid-sternal circular tender swelling measuring 3 cm × 2 cm which was fluctuant and warm to touch; the white blood cell count was 20 × 109/L (leukocytosis) and the packed cell volume was 29%, while the erythrocyte sedimentation rate was 15 mm/h. The lateral chest X-ray showed displace second sternal nucleus with soft tissue swelling [Figure 1], and the blood culture isolated Streptococcal pneumoniae with sensitivity to vancomycin and amikacin.
Figure 1: The lateral chest X-ray showed displace second sternal nucleus with soft tissue swelling

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He had incision and drainage under local anesthesia initially, but the wound persistently discharged purulent effluent and 6 days later, he had surgical debridement under local anesthesia [Figure 2]. Daily wound dressing was continued. He was placed on intravenous antibiotics for 2 weeks then oral for 4 weeks based on sensitivity. He did well and was discharged home in good health 1 week after commencement of oral antibiotics, and the wound had healed completely by the 4th week of discharge [Figure 3].
Figure 2: Discharging purulent effluent

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Figure 3: Healed wound

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  Discussion Top


Sternal osteomyelitis in both children and adults typically occurs as a result of trauma or surgery through sternotomy for cardiothoracic surgical procedure, this form of osteomyelitis is called secondary.[6] PSO trauma or surgery has to be excluded and is commonly seen in patients with immunosuppression, drug addiction, sickle cell disease (as seen in this index patients), diabetes mellitus, obesity, sepsis, and background immunosuppressive diseases.[7] Sternal osteomyelitis accounts for 0.1%–0.3% of all osteomyelitis.[8] The most common causative organisms in both primary and secondary sternal osteomyelitis are S. aureus, Pseudomonas aerugenosa in drug addicts, and Salmonella in sickle cell anemia;[8] very few cases reported in the literature to be caused by Streptococcus pneumoniae. The clinical presentations (other than the associated differences in their risk factors for PSO), their line of management, and outcome – except in cases been compounded by comorbidity - are often the same irrespective of the etiologic agent. Therefore, an early culture report which will streamline the choice of antibiotics is essential to successful treatment.

The diagnosis of sternal osteomyelitis may require bone biopsy, radiological investigations such as chest X-rays, computer tomography scan, and magnetic resonance imaging of the chest. Furthermore, technetium Tc 99 m pyrophosphate bone scan, gallium citrate Ga 67, and Indium 111 are best suited for follow-up because of lacks specificity. However, we were only able to do chest X-ray due to financial constraint.[9]

PSO usually presents with anterior chest wall swelling, sternal pain, and fever as presented in our index patient. Other differential diagnosis includes cellulitis, soft tissue abscess, soft tissue sarcoma, osteosarcoma, and benign soft tissue tumors such as lipoma and hemangioma. Treatment of PSO is quite difficult and challenging. It requires a high index of clinical suspicion. Blood and aspirate culture is required to make a definitive etiological diagnosis. Prolonged treatment with intravenous and oral antibiotics is the mainstay of treatment coupled with debridement.[10]

Since the development of open-heart surgery in mid-fifties, secondary sternal osteomyelitis has become a well-known complication of open-heart surgery following sternotomy. Treatment of secondary sternal osteomyelitis requires more aggressive debridement than PSO.[10] This may require total sternectomy and removal of associated cartilages with reconstruction using pectoralis muscles myocutaneous flaps.[10]


  Conclusion Top


Management of PSO in children with sickle cell diseases caused by streptococcal infection is challenging, early diagnosis based on clinical presentation and blood and aspirate cultures are essential. Surgical debridement with at least 2 weeks of intravenous antibiotics followed with oral antibiotics is the key to successful treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jang YN, Sohn HS, Cho SY, Choi SM. Primary sternal osteomyelitis caused by Staphylococcus aureus in an immunocompetent adult. Infect Chemother 2017;49:223-6.  Back to cited text no. 1
    
2.
Araiza-Garaygordobil D, Soto-Nieto GI, Aguilar-Rojas LA, Catrip J. Primary sternal osteomyelitis caused by Salmonella enteritidis. Enferm Infecc Microbiol Clin 2017;35:60-2.  Back to cited text no. 2
    
3.
Matta RF, El Hajje MJ, Safadieh L, Salem G, Hmaimess G, Korkomaz R, et al. Primary sternal osteomyelitis: A report of two cases with literature review. Pediatr Infect Dis J 2010;29:976-8.  Back to cited text no. 3
    
4.
Lee JH, Jeon SC, Jang HJ, Kim H, Kim YH, Chung WS. Primary sternal osteomyelitis caused by Actinomyces israelii. Korean J Thorac Cardiovasc Surg 2015;48:86-9.  Back to cited text no. 4
    
5.
Chen YL, Tsai SH, Hsu KC, Chen CS, Hsu CW. Primary sternal osteomyelitis due to Peptostreptococcus anaerobius. Infection 2012;40:195-7.  Back to cited text no. 5
    
6.
Platt MA, Ziegler K. Primary sternal osteomyelitis with bacteremia and distal seeding. J Emerg Med 2012;43:e93-5.  Back to cited text no. 6
    
7.
Song E, Jaishankar GB, Saleh H, Jithpratuck W, Sahni R, Krishnaswamy G. Chronic granulomatous disease: A review of the infectious and inflammatory complications. Clin Mol Allergy 2011;9:10.  Back to cited text no. 7
    
8.
Vacek TP, Rehman S, Yu S, Moza A, Assaly R. Another cause of chest pain: Staphylococcus aureus sternal osteomyelitis in an otherwise healthy adult. Int Med Case Rep J 2014;7:133-7.  Back to cited text no. 8
    
9.
Pineda C, Vargas A, Rodríguez AV. Imaging of osteomyelitis: Current concepts. Infect Dis Clin North Am 2006;20:789-825.  Back to cited text no. 9
    
10.
Kara A, Tezer H, Devrim I, Caglar M, Cengiz AB, Gür D, et al. Primary sternal osteomyelitis in a healthy child due to community-acquired methicillin-resistant Staphylococcus aureus and literature review. Scand J Infect Dis 2007;39:469-72.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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