Is my daughter suffering from acute osteomyelitis?
Q: About 20 days ago, my three and a half months old daughter was having recurring fever (3-4 times a day). Her right leg became swollen and tender and she stopped all movements in the leg. After 3-4 days of consulting a paediatrician and oral medication, she was taken to hospital. Her blood samples were taken and she was diagnosed with acute osteomyelitis of right lower limb. She was operated to drain pus formation around her femur bone. Histopathological examination of pus and bone tissue showed reactive right fibula, reactive periosteal new bone formation and no malignancy detected. She was administered Bioclox 250 mg (for a week), Cefriaxone 250 mg (still being given), amoxycillin and Potassium (clavulanate injection 150 mg) (started in 2nd week) and sy. Ibugesic plus (for fever). X-ray of affected leg also showed significant soft tissue swelling overlying right leg. Caffey's disease was also suspected but has been ruled out. Another doctor had suspected Scurvy (on the basis of X-ray) but attending paediatrician feels that it is not correlating with clinical symptoms. Medical examination of two blood sample taken 10 days apart showed following readings: Hb. 9.8, CRP 71 (Day 1) & 54 (Day 10), WBC 25,000 & 18,000, CR Protein 71.6 & 54 ESR 11 (Day 10). After 10 days of hospitalisation, she is now freely moving the right leg. The wound (cut for draining pus & biopsy of bone) is satisfactorily healing. However, her recurring fever continues, now twice a day, temperature rising up to 101 degree F. The doctors are unable to identify reason for recurring fever and are holding her back in hospital for this reason only. What is the possible reason for daily recurring fever? Does it have any other implications? Is the diagnosis correct? Will my daughter fully recover or will there be any long-term ill effects?
A:The diagnosis seems to be incorrect; probably this may be an error in your understanding. Osteomyelitis usually involves only one major bone at this age except in special circumstances. Acute osteomyelitis of the right lower limb is a bit nonspecific and vague. Your description of the surgery states that the right femur (thigh bone) was drained, but the histopathology report states "fibula", one of the lower leg bones. It is important to know whether more than one bone was involved in the disease process. The antibiotics used are appropriate for the disease; but most experts prefer a longer course. The fact that she is moving limbs and the scar is healing also indicates partial recovery.
Scurvy is rare in newborns, but can be excluded by expert radiologists. There are several reasons why the fever has not settled. The inflammatory process may not have completely subsided and the child may require a longer course of antibiotics. It is also important to check the antibiotic sensitivity pattern by blood or pus cultures. The child may have developed inflammation at the injection sites and/or venous infusion sites (thrombophlebitis). Some infants also develop fever during antibiotic therapy. It is also possible that she may have developed pus pockets elsewhere. These can be confirmed by a good clinical examination of the child for all possible sites of infection and appropriate lab tests. I would advise you to keep the infant in the hospital till the fever settle down and the tests for infections are negative.