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51 y.o. Man with Bilateral Osteomyelitis of the Hands

51 y.o. Man with Bilateral Osteomyelitis of the Hands. David Feldstein, MD PCC 5/10/06. Patient. 51 y.o. man with hx of pulmonary sarcoidosis Osteomyelitis of bilateral 5 th fingers 8 weeks (PTA) Pain, erythema, swelling right 5 th PIP joint No trauma, injury, fevers chills

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51 y.o. Man with Bilateral Osteomyelitis of the Hands

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  1. 51 y.o. Man with Bilateral Osteomyelitis of the Hands David Feldstein, MD PCC 5/10/06

  2. Patient • 51 y.o. man with hx of pulmonary sarcoidosis • Osteomyelitis of bilateral 5th fingers • 8 weeks (PTA) • Pain, erythema, swelling right 5th PIP joint • No trauma, injury, fevers chills • Urgent care – clinical dx fracture and splinted

  3. Patient • 7 weeks (PTA) • Return UC increased swelling and pain • Xray with bony destruction head of 5th proximal phalynx • Ceftri x 1 and started on cephalexin • 4 weeks (PTA) • Admitted to outside hospital • Progression of sx right 5th finger • Left 5th finger now with swelling and erythema

  4. Patient • Outside Hospital • Xray • Almost complete destruction right 5th middle phalynx • Lucency left 5th proximal phalynx • Bone scan • Increased signal bilateral 5th fingers and right wrist

  5. Patient • Outside Hospital Management • Incision and drainage right 5th finger • Pin placed for stabilization • Gram stain and cx of fluid negative • Vancomycin /Rifampin and discharged • No clinical improvement and worsening xrays 3 weeks later • Sent to UW (FINALLY!!)

  6. Why? • Why did he fail treatment?

  7. At UW • No constitutional sx or other skin findings • PMH – Sarcoidosis • SH – Machinist, lives on a farm • PE • VSS, NAD • Lungs clear • Skin – see photos

  8. Objectives • Recognize improper treatment of osteomyelitis • Describe symptoms of blastomycosis infection • Describe treatment of blastomycosis

  9. Blastomyces Dermatitidis • Dimorphic fungus • Mycelial phase in nature • Converts to yeast at body temperature • Warm moist soil in wooded areas rich in organic debris • Endemic – See figure

  10. Incidence of Blastomycosis in North America Rippon JW. Medical Mycology: The Pathogenic Fungi and Pathogenic Actinomycetes. 3rd ed. Philadelphia: WB Saunders; 1988:474.

  11. Clinical Manifestations • Very variable • Infection caused by inhalation in almost all cases • Most cases include symptomatic pulmonary infection

  12. Wisconsin • 2 retrospective studies • Centers for Disease Control and Prevention (CDC). Blastomycosis--Wisconsin, 1986-1995. (1996) • Baumgardner DJ. Halsmer SE. Egan G. Symptoms of pulmonary blastomycosis: northern Wisconsin, United States. (2004)

  13. CDC • All reported cases in WI 1986-1995 • 670 cases • 29 fatal • Primary pulmonary disease without extrapulmonary manifestations • 76% • Extrapulmonary disease only • 18% • Pulmonary and Extrapulmonary • 6%

  14. Baumgardner • Retrospective investigation of 170 reported cases in Vilas County • 1979-2001 • 91% pulmonary symptoms • Pulmonary cases contacted and interviewed (118 of 154)

  15. Patients with Pulmonary Blasto Baumgardner, etal.

  16. Common Extrapulmonary Sx • Skin • Verrucous or ulcerative • Bone • Any bone • Xrays not specific • GU • Prostatitis and epididymoorchitis • CNS • Epidural or cranial abscesses

  17. Diagnosis • Diagnosis • Histology • Culture • Easy to culture • Serology • Not sensitive or specific • 95% cross reactivity with Histo • Also cross-reactive with paracoccidiodomycosis

  18. Treatment • No good RCTs • Guidelines based on small open label studies, case series and expert opinion • Ampho for life threatening • Itraconazole for mild to moderate • At least 6 months

  19. IDSA Guidelines Pulmonary • Life threatening – Amphotericin B • Mild/Mod – Itraconazole Disseminated • CNS – Ampho B • Non-CNS • Life threatening – Ampho B • Mild/Mod - Itraconazole

  20. Clinical Follow-up

  21. Conclusions • Treatment of osteomyelitis • Bone Culture • Reassess when not responding • Manifestations of Blasto • Pulmonary most common • Can affect almost any organ • Treatment • Ampho or Itraconazole • No good trials of efficacy

  22. References • Centers for Disease Control and Prevention (CDC). Blastomycosis--Wisconsin, 1986-1995. MMWR - Morbidity & Mortality Weekly Report. 45(28):601-3, 1996 Jul 19. • Baumgardner DJ. Halsmer SE. Egan G. Symptoms of pulmonary blastomycosis: northern Wisconsin, United States. Wilderness & Environmental Medicine. 15(4):250-6, 2004. • Chapman SW. Bradsher RW Jr. Campbell GD Jr. Pappas PG. Kauffman CA. Practice guidelines for the management of patients with blastomycosis. Infectious Diseases Society of America. Clinical Infectious Diseases. 30(4):679-83, 2000 Apr.

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