Acute osteomyelitis in children: The pathogenesis revisited?
Acute osteomyelitis in children: The pathogenesis revisited?
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DOI：
10.1016/j.otsr.2009.12.012
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发表时间：
2010-05-01
影响因子：
2.3
通讯作者：
Lacassin, F.
中科院分区：
文献类型：
--
作者：
Labbe, J. -L.;Peres, O.;Lacassin, F.
研究目的：本研究回顾了我们在新喀里多尼亚努梅阿领土医院从1985年至2004年20年间450名儿童急性血源性骨髓炎的经验。我们的目的是制定一个新的理论的发病机制，这种影响，并报告我们的研究之间的差距，在病理学的温带国家和我们自己的热带太平洋area.Patient和方法：只有儿童与最初正常的X射线和表现出症状不到一个星期被列入研究。亚急性骨髓炎、婴儿骨关节炎、脊柱和骶髂关节感染均被排除。所有儿童均根据预先制定的方案进行治疗，包括：临床检查;血液检查;超声检查，以确定骨膜隆起的存在和大小，并排除软组织脓肿和频繁的化脓性肌炎。超声用于决定单独使用抗生素或手术治疗。CT用于深部结构评估和药物治疗指导，手术仅限于骨膜下脓肿的开放引流。定期随访的门诊病人继续进行，直到正常的血液检查和X线结果achieved.Results和讨论：四百五十名儿童诊断为急性血源性骨髓炎，平均发病率为22例，每年（范围，12-35）。这一发病率是欧洲的2至5倍。我们53%的病例需要手术引流（欧洲为20%）。从种族上看，60%的儿童是美拉尼西亚人，20%是波利尼西亚人（两者占当地人口的不到50%）。我们的邻居新西兰也报告了波利尼西亚人的类似发病率，大约是欧洲血统人口的四倍。在90%的病例中，四肢受到影响，特别是下肢70%。43名儿童（9.5%）记录了多发性骨病变和全身感染。血液培养和手术样本在80%的病例中呈阳性，其他病例呈阴性。所有患儿均成功治疗，无慢性进展或后遗症需要二次手术。分离出的主要微生物为金黄色葡萄球菌，占81%，无耐甲氧西林菌，A组链球菌占7.5%。软组织S。金黄色葡萄球菌感染显示在89%的病例中存在Panton-Valentine杀白细胞素（PVL）基因。这些非常罕见的基因负责白细胞毒性细胞凋亡，产生杀白细胞素，引起局部急性侵袭性。一项进行了一年多的平行研究集中在检测S.从急性骨髓炎分离的金黄色葡萄球菌：在分析的前9名儿童中，同样在89%的金黄色葡萄球菌中检测到PVL基因。金黄色葡萄球菌分离，没有甲氧西林耐药性。超声检查允许64%的情况下，入院当天和84%的第二天的阳性诊断。由于这种非常早期的骨膜下脓肿的存在，在疾病的开始，和其他几个问题在本研究中提出的，我们认为，Trueta的理论急性骨髓炎发病机制不提供任何合理的解释，我们的解剖临床观察。我们认为感染的主要病灶是在骨骨膜区，而不是在干骺端骨的生长板下。因此，急性骨-骨膜炎的术语更为合适。在本系列中，63%的病例有钝性创伤史，并且经常在文献中报道。我们推测可能发生两种形式的感染固定：局部形式，即血流携带的细菌到达继发于钝性创伤的骨膜下水肿或血肿，我们认为这是最常见的原因;和一般形式，即固定发生为单灶性或多灶性骨骨膜炎，以及严重形式的败血症的多内脏部位。温带国家和我们自己的热带太平洋地区在这种病理学上的差异当然是由于PVL阳性的S。金黄色葡萄球菌和种族因素。美拉尼西亚和波利尼西亚患者的高患病率证实，他们在新喀里多尼亚和其他太平洋国家一样，肌肉骨骼感染的风险很高，这些族裔群体可能在遗传上对PVL阳性菌株易感。证据等级：IV级。回顾性病例系列。(C)2010年Elsevier Masson SAS。All rights reserved.
Purpose of the study: The present study reviews our experience of acute hematogenous osteomyelitis in 450 children over a period of 20 years from 1985 to 2004 at the Noumea Territorial Hospital in New Caledonia. The objective was to formulate a new theory of the pathogenesis of this affection and to report our research on the disparity in the pathology between temperate countries and our own tropical Pacific area.Patient and methods: Only children with an initially normal X-ray and showing symptoms for less than one week were included in the study. Subacute osteomyelitis, infant osteoarthritis and spinal and sacroiliac joint infections were all excluded. All children were treated according to a preestablished protocol including: clinical examination; blood tests; ultrasound, to determine the presence and size of the periosteal elevation and to exclude soft tissue abscess and frequent pyomyositis. Ultrasound was used in the decision to treat with antibiotics alone or with surgery. Computed Tomography was used for deep structures assessment and medical therapy guidance Surgery was limited to open drainage of the subperiosteal abscess only. Regular follow-up of outpatients was continued until normal blood test and X-ray results were achieved.Results and discussion: Four hundred and fifty children with a diagnosis of acute hematogenous osteomyelitis were identified, giving an average incidence of 22 new cases per year (range, 12-35). This incidence was two to five times as high as found in Europe. Fifty-three percent of our cases required surgical drainage (vs. 20% in Europe). Ethnically, 60% of the children were Melanesian and 20% Polynesian (both represented less than 50% of the local population). A similar incidence, about four times as high as in the population of European descent, was reported in Polynesians by our neighbors in New Zealand. The limbs were affected in 90% of cases, and specifically lower limbs in 70%. Multiple osseous lesions and systemic infection were recorded in 43 children (9.5%). Blood cultures and surgical samples were positive in 80% of cases, and otherwise negative. All the children were successfully treated, without chronic evolution or sequelae needing secondary surgery. The predominant microorganisms isolated were Staphylococcus aureus, in 81% of cases, none of which were methicillin-resistant, and group A Streptococcus in 7.5% of cases. A previous study of soft-tissue S. aureus infection showed the presence of Panton-Valentine Leukocidin (PVL) genes in 89% of cases. These very infrequent genes are responsible for leukotoxic apoptosis, producing leukocidin, causing local acute aggressiveness. A parallel study, in progress for more than a year, is focusing on detecting PVL genes in S. aureus isolated from acute osteomyelitis: in the first nine children analyzed, PVL genes were likewise detected in 89% of the S. aureus isolated, with no methicillin resistance. Ultrasonography allowed positive diagnosis in 64% of cases on the day of admission and 84% by the second day. Because of this very early presence of subperiosteal abscess at the beginning of the disease, and several other issues raised in the present study, we believe that Trueta's theory of acute osteomyelitis pathogenesis does not provide any logical explanation for our anatomoclinical observations. We believe that the primary focus of infection is in the osteoperiosteal area rather than under the growth plate in the metaphyseal bone. The term of Acute Osteo-Periostitis would therefore be much more suitable. A history of blunt trauma was found in 63% of cases in the present series, and often reported in the literature. We speculate that two forms of infection fixation may develop: a local form, where bacteria carried by the blood stream reach a subperiosteal edema or hematoma secondary to blunt trauma, which is in our opinion the most frequent cause; and a general form, where fixation occurs as single or multifocal osteoperiostitis, and multivisceral locations in severe forms of septicemia. The disparity in this pathology between temperate countries and our own tropical Pacific area is certainly due to PVL-positive S. aureus and ethnic factors. The high prevalence of Melanesian and Polynesian patients confirms that they are at high risk of musculoskeletal infection in New Caledonia as in other Pacific countries, and it is possible that these ethnic groups are genetically susceptible to PVL-positive strains.Level of evidence: Level IV. Retrospective case series. (C) 2010 Elsevier Masson SAS. All rights reserved.