Eur J Orthop Surg Traumatol (2010) 20:329–331

DOI 10.1007/s00590-009-0564-1

CASE REPORT

An unusual etiology of osteomyelitis

Hichem Mnif · Makram Zrig · Karim Amara · Sabeur Hammami · Mustapha Koubaa · Mohamed Neji Gueddiche · Abderrazek Abid

Received: 22 August 2009 / Accepted: 22 September 2009 / Published online: 22 October 2009© Springer-Verlag 2009

Abstract While skin and soft-tissue complication ofvaricella are well known, osteomyelitis secondary to vari-cella is rarely reported in the literature. We describe acase of 3-year-child with varicella associated with pandia-physal osteomyelitis caused by streptococcus type A �hemolytic.

Keywords Varicella · Osteomyelitis · Complication

Introduction

Varicella is a common childhood viral disease. Multiplecomplications of varicella have been reported. The majorityof these consist on skin and soft-tissue complication. Twobacteria are implicated: Staphylocossus aureus and groupA-� hemolytic streptococcus. Skeletal complication includesarthritis and rarely osteomyelitis. We describe a case ofpandiaphysal femoral osteomyelitis of a child as a compli-cation of varicella.

Case report

A previously healthy 3-year-old boy presented a fever andtypical rash of varicella. He was admitted in the pediatricdepartment due to surinfection of skin lesion. Intravenousoxacillin treatment was started. Three days later he com-plains of pain in his right limb. The child would not walkand any swelling or bone pains were noted. The whiteblood cell (WBC) was elevated (18,500 E/mm3), erythro-cyte sedimentation rate (ESR) in the Wrst hour was acceler-ated (120 mm/H), and C-reactive protein was high(250 mg/l). The X-ray of the pelvis and the right knee werenormal. Pediatricians conclude to a transient synovitis ofthe hip. A week later the patient continued to be febrile(40°C), and developed a tenderness of his distal rightfemur. He was referred to an orthopedic surgeon. Physicalexamination showed tenderness and swelling at the rightlimb (Fig. 1) and localized pain in supracondylar femoralwith normal passive motion of the right hip and knee. Atthat time the blood culture was positive to group A beta-hemolytic Streptococcus. Radiographs of the right femurrevealed deep soft-tissue swelling. The ultrasonographyprecisely deWned the extent of a subperiosteal collectionfrom the distal femoral metaphyse (Fig. 2). Immediately,pus was drained through an external approach (Fig. 3) andantibiotherapy was changed to Cefotaxime–fosfomycine.Post operatively the limb was immobilized in a spica cast.Three week after surgery, a stable apyrexia was obtained,the WBC was within normal limits, CRP fall to 8 mg/l andESR was 41 mm the Wrst hour. At this stage the boy wasdischarged from hospital, and oral antibiotherapy was pre-scribed. One month later the cast was removed and the boywas allowed to move freely. Twelve month post opera-tively, the ESR was normal, the radiographs showed heal-ing process (Fig. 4). Neither pain nor fever was noted.

H. Mnif (&) · M. Zrig · K. Amara · M. Koubaa · A. AbidDepartment of Orthopaedic Surgery, Monastir Fattouma-Bourguiba Teaching Hospital, Monastir, Tunisiae-mail: mnif_hich@yahoo.fr

S. Hammami · M. N. GueddicheDepartment of Pediatrics, Monastir Fattouma-Bourguiba Teaching Hospital, Monastir, Tunisia

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Discussion

Varicella is a common, highly contagious disease. It isusually benign but has potentially serious complications.The most common complications were skin/soft-tissueinfections. Other complications were pneumonia, meningo-encephalitis, acute disseminated encephalomyelitis, hema-tological and osteoarticular especially synovitis and asepticarthritis. Although the association of invasive osteomyelitisand varicella has been recognized, only sporadic cases ofosteomyelitis associated with varicella have been reported.

In 1989, Kain et al. [9] reported one case and reviewed theliterature. We found 20 cases in all the literature [1–7, 10,11]. Osteomyelitis represents only 0.2–2% of varicellasevere complications [13].

As suggest by Liebergall and Porat [10], the port of entryis probably the varicella pocks. The spread infection to thebone may be directly or hematogenically. In fact bacterimiaoccurred in 0.5% of patients with varicella.

In contrasts with typical osteomyelitis, infection withgroup A-�-hemolytic streptococcus is more common inpatients with osteomyelitis after varicella than in patientswith typical bacterial osteomyelitis [8]. This may be due to

Fig. 1 Clinical aspect of the right limb

Fig. 2 Radiography demonstrates no bony involvement but soft-tis-sue swelling

Fig. 3 Peri operative view of the subperiosteal abscess

Fig. 4 Healing process at the right femur

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an increase in the prevalence of group A-� hemolytic strep-tococcus infection during varicella which is isolated in 60–85% of skin and deep seats infection [1, 11].

The signs and symptoms seem to be indistinguishablefrom those caused by other microorganisms. Common fea-tures of osteomyelitis were pain, tenderness, diVuse swell-ing, and pseudoparalytic limb. The most consistentlaboratory Wnding in osteomyelitis remains C-reactive pro-tein and ESR. Although ESR continues to be the major lab-oratory index used to monitor treatment response inpatients with osteoarticular infections [12].

Soft-tissue swelling and bone destruction shown on con-ventional radiographs in children with osteomyelitis aftervaricella are similar to those seen in other types of bacterialosteomyelitis [7]. The ultrasonography is useful to detectsubperiosteal Xuid and for daily survey. In fact this examhas revealed subperiosteal Xuid collection of our case. Scin-tigraphy is valuable for localizing the site of bone involve-ment; increased uptake is typically seen in all three phasesof the examination. Magnetic resonance images (MRI)showed the full extent of the bone destruction, periostealelevation, subperiosteal Xuid collections, and surroundingsoft-tissue changes. MR images are valuable for detectingsubperiosteal Xuid collections and in planning percutaneousor surgical approaches.

Group A-�-hemolytic streptococcus remains extremelysensible to penicillin which is considered as the treatmentof choice. However until streptococci are isolated, initialantibiotherapy must include an antistaphylococcal such asthird generation cephalosporin. Prompt response is dealingwith early recognition and intravenous treatment. If subpe-riosteal Xuid is detected rapid evacuation is recommendedby all authors.

In conclusion post varicella osteomyelitis is rare. Osteo-myelitis should be suspected in any child who has pain in alimb or joint with or without fever after an episode of

varicella. Group A-�-hemolytic streptococcus should alsobe highly considered in cases of osteomyelitis associatedwith varicella infection.

ConXict of interest statement No funds were received in support ofthis study.

References

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