Osteomyelitis and Arthritis by Atypical Mycobacteria in Children: Three Cases

Abstract

Introduction Osteoarticular infections caused by atypical mycobacteria are uncommon, with osteitis being more common and arthritis being rare. We describe two cases of subacute osteomyelitis and one of chronic osteomyelitis with arthritis.

Case Reports Three boys, aged between 7 and 20 months. Clinical presentations: case 1—swelling of right forearm; case 2—limping and swelling of right hallux; case 3—pain and restriction of motion of right lower limb with effusion. None had fever. All had received Bacillus Calmette–Guérin (BCG) and none had contact with tuberculosis. All had thrombocytosis, and erythrocyte sedimentation rate was between 17 and 44 mm/1st hour. All had osteolytic lesions on X-ray with a sclerotic halo and swelling of the surrounding soft tissues, and invasion of the metaphysis and/or epiphysis. Bone histopathological studies revealed granulomatous inflammation or epithelioid cells in all cases. Microbiological identification was positive by culture in one case (Mycobacterium bovis) and by polymerase chain reaction in two cases (Mycobacterium spp. and M. avium). Immunodeficiency screening was negative in all cases. All were treated with antituberculous agents and made good clinical and radiological recoveries.

Discussion Osteolytic lesions should raise suspicion of mycobacterial infection, including BCG vaccine, particularly in the presence of granulomatous inflammation. The prognosis was favorable in all patients. Although immune deficits were not identified in any of our three patients, it should be routinely tested for in such cases.

Keywords

BCG - osteitis - subacute osteomyelitis - chronic osteomyelitis - mycobacteria

• References

• 1 Thavagnanam S, McLoughlin LM, Hill C, Jackson PT. Atypical Mycobacterial infections in children: the case for early diagnosis. Ulster Med J 2006; 75 (03) 192-194
• 2 Al Yazidi LS, Marais BJ, Hazelton B, Outhred A, Kesson A. Nontuberculous mycobacteria in children: a focus on bloodstream infections. Pediatr Infect Dis J 2017; 36 (04) 374-378
• 3 El Houmami N, Minodier P, Bouvier C. , et al. Primary subacute epiphyseal osteomyelitis caused by Mycobacterium species in young children: a modern diagnostic approach. Eur J Clin Microbiol Infect Dis 2017; 36 (05) 771-777
• 4 Cruz AT, Starke JR. Tuberculosis. In: Feigin RD, Cherry JD, Demmler-Harrison GJ, Kaplan SL. , eds. Textbook of Pediatric Infectious Diseases. 7th ed. Philadelphia: Elsevier; 2014: 1335-1380
• 5 Copley LAB, Herring JA. Infections of the musculoskeletal system. In: Herring JA. , ed. Tachdjian'sPediatric Orthopaedics from the Texas Scottish Rite Hospital from Children. 5th ed. Philadelphia: Elsevier; 2014: 1024-1076
• 6 Yamada AF, Pellegrini JB, Cunha LM, Fernandes AdaR. Osteitis after BCG vaccination. J Bras Pneumol 2009; 35 (03) 285-289
• 7 Morrone N, António CdoA, Santilli C, Costa-Carvalho BT, Rodrigues D. Osteitis in a female infant after vaccination with BCG Moreau in the neonatal period. J Bras Pneumol 2012; 38 (05) 674-676
• 8 Gradl G, Postl LK, Lenze U. , et al. Long-term functional outcome and quality of life following rotationplasty for treatment of malignant tumors. BMC Musculoskelet Disord 2015; 16: 262
• 9 Pena CR, Costa GLB, Gomides APM, Goulart FB, Coelho DL, Quintero MV. Sarcoidosis in childhood with rare manifestations: vasculites, central nervous system, bone and genital involvement. Rev Bras Reumatol 2005; 45 (05) 327-330
• 10 Costa-Reis P, Sullivan KE. Chronic recurrent multifocal osteomyelitis. J Clin Immunol 2013; 33 (06) 1043-1056
• 11 Laxer RM, Wright J, Lindsley CB. Infectious arthritis and osteomyelitis. In: Laxer P, Wedderburn L. , eds. Textbook of Pediatric Rheumatology. 7th ed. Philadelphia: Elsevier; 2016: 533-550
• 12 Breda L, de Michele G, Nozzi M, De Sanctis S, Di Marzio D, Chiarelli F. Non-tuberculous mycobacterial osteomyelitis: an unusual cause of hip pain in immunocompetent children. Rheumatol Int 2009; 29 (12) 1487-1489
• 13 Jones AR, Bartlett J, McCormack JG. Mycobacterium avium complex (MAC) osteomyelitis and septic arthritis in an immunocompetent host. J Infect 1995; 30 (01) 59-62
• 14 Lin CJ, Yang WS, Yan JJ, Liu CC. Mycobacterium bovis osteomyelitis as a complication of Bacille Calmette-Guérin (BCG) vaccination: rapid diagnosis with use of DNA sequencing analysis: a case report. J Bone Joint Surg Am 1999; 81 (09) 1305-1311
• 15 Chang EC, Liu CC, Lee YC. Mycobacterium bovis Bacillus Calmette-Guérin vaccination-associated osteomyelitis, arthritis, and tenosynovitis on the thumb of a 2-year-old boy. J Hand Surg Eur Vol 2016; 41 (09) 997-998
• 16 Rafiqi K, Yousri B, Arihi M, Bjitro C, Aboumaarouf M, El Andaloussi M. Unusual locations of osteoarticular tuberculosis in children: a report of 12 cases. Orthop Traumatol Surg Res 2013; 99 (03) 347-351
• 17 Carneiro-Sampaio M, Coutinho A. Immunity to microbes: lessons from primary immunodeficiencies. Infect Immun 2007; 75 (04) 1545-1555