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SCD child with limb pain

SCD child with limb pain. History: a 10 year old child brought to A&E complaining of fatigue, increasing right leg pain and persistent fever for 3 days. OE: the child was in extreme discomfort, having high grade fever, his leg was swollen, tender, immobile and worm. Defferential diagnosis:.

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SCD child with limb pain

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  1. SCD child with limb pain

  2. History:a 10 year old child brought to A&E complaining of fatigue, increasing right leg pain and persistent fever for 3 days.O\E: the child was in extreme discomfort, having high grade fever, his leg was swollen, tender, immobile and worm.

  3. Defferential diagnosis: • Osteomyelitits • Acute bone pain crisis • Avascular necrosis • Cellulitis • Bone tumor

  4. Investigations : • CBC: - Hb 8 g\dl • WBC, ESR & acute phase reactants were elevated • blood film showed deeply staining sickle cells & target cells. • Blood culture : - Salmonellae species

  5. Radilological investigation: • Radiograph: -Was normal in the first days -10th day showed periosteal elevation with medullary lucencies

  6. Bone scan:

  7. osteomyelitits • an acute or chronic inflammatory process of the bone and its structures secondary to infection with pyogenic organisms . • In SCD patient the most common organisms are S aureus and Salmonellae species. • The differentiation of bone infarction from acute osteomyelitis in patients with sickle-cell disease is challenging, as the clinical presentations of the two conditions are similar and imaging and laboratory studies are of limited value.

  8. What are the radiological investigations that should be done to distinguish osteomyelitis from other causes of limb pain in a SC child ???

  9. Radiography: • Radiographic evidence of acute osteomyelitis is first suggested by overlying soft-tissue edema at 3-5 days after infection. • Bony changes are not evident for 14-21 days and initially manifest as periosteal elevation followed by cortical or medullary lucencies . • demonstrates areas of infarction for painful bones. • shows features of different bone tumours.

  10. 54-year-old woman with Staphylococcus aureus osteomyelitis. Frontal radiograph of left knee shows cortical thickening (open arrows), lytic lesion (arrowheads), and bone infarct (solid arrows). Infarction of the long bones in sickle cell disease . fibula with advanced, coarse, thick periosteal reaction spreading over the full length of the shaft, which resembles an involucrum Osteoid Osteoma

  11. Stress fructure osteolytic osteosarcom in the distal femur osteosclerotic osteosarcoma in the distal femur

  12. Ultrasound • This simple and inexpensive technique has shown promise, particularly in children with acute osteomyelitis. • Ultrasonography may demonstrate changes as early as 1-2 days after onset of symptoms. • Abnormalities include soft tissue abscess or fluid collection and periosteal elevation. • Ultrasonography allows for ultrasound-guided aspiration

  13. Radionuclide bone scanning • A 3-phase bone scan with technetium 99m is probably the initial imaging modality of choice. • When scintigraphy is normal but symptoms persist, the study should be repeated after 2 to 3 days. • bone scans usually shows moderate or intense radioisotope uptake for bone tumor such as osteoid osteoma.

  14. MRI • The MRI is effective in the early detection and surgical localization of osteomyelitis . • Sensitivity ranges from 90-100%. • demonstrates areas of avascular necrosis and may distinguish between osteomyelitis and bony infarction for painful bones

  15. Bilateral bone infarction in the femora on MRI. Coronal T1-weighted image of the knees shows well-demarcated, inhomogeneous low-signal foci in the distal femora consistent with bone infarcts. The foci of low signal within the lesions correspond to areas of calcification within infarcts

  16. MR imaging changes of acute osteomyelitis SCD Axial T1-weighted and (E) T2-weighted images of the distal tibia. Observe abnormal marrow signals (low on T1-weighted and high on T2-weighted images):compare with normal signal pattern of the adjacent fibula. Also note edema (high signal on T2-weighted images) of the soft tissues surrounding the distal tibia. Coronal T1-weighted images of (A) tibia and (B) ankle show edema (low signal) replacing the usual bright signal of fatty marrow

  17. CT • CT scans can depict abnormal calcification, ossification, and intracortical abnormalities. • It probably is most useful in the evaluation of spinal vertebral lesions. It may also be superior in areas with complex anatomy: pelvis, sternum, and calcaneus.

  18. 54-year-old woman with Staphylococcus aureus osteomyelitis. CT scan of distal femoral shafts shows cortical thickening (arrows) and sclerotic borders (arrowheads) of bilateral bone infarcts

  19. 43-year-old man with Staphylococcus aureus infection. IV contrast-enhanced CT scan of left distal femur shows rim-enhancing abscesses (small arrowheads) in soft tissues and enhancement of synovium (large arrowheads) lining the surapatellar bursa. Increased attenuation (open arrow) is also noted in medullary cavity consistent with site of infection. Medullary cavity on right side is normal

  20. The End

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