Table of Contents
Credits
Hosts: Veronica Santos, Sara Dong
Discussants: Sebastian Shrager, Misti Ellsworth
Writing: Veronica Santos, Sebastian Shrager, Misti Ellsworth
Edited and Produced by Sara Dong with support from the Infectious Diseases Society of America (IDSA)
Our Guests
Veronica Santos-Cañellas, MD
Dr. Veronica Santos is currently in her second year of Pediatrics Residency at UT Health Houston. She completed medical school at the University of Puerto Rico.
Sebastian Shrager, MD
Dr. Sebastian Shrager completed his pediatric residency at Broward Health in Fort Lauderdale, FL, before recently completing his fellowship in pediatric infectious diseases at the University of Texas Medical Center in Houston TX. He just started a job as an attending at Wolfson’s Children’s Hospital in Jacksonville, FL.
Misti Ellsworth, DO
Dr. Misti Ellsworth is a pediatric ID physician and Associate Professor of Pediatric Infectious Diseases at McGovern Medical School and UT Health Houston. She is Director of Pediatric Infection Prevention for McGovern Medical School and Children’s Memorial Hermann Hospital. After finishing an undergraduate degree in nutrition at Texas A&M University, Dr. Misti Ellsworth earned her medical degree at the University of North Texas Health Science Center College of Osteopathic Medicine in Fort Worth. She completed a residency in pediatrics at UT Health San Antonio Long School of Medicine, followed by a fellowship in pediatric infectious diseases at McGovern Medical School at UTHealth Houston. Her primary interests are infection prevention, quality improvement and mentorship. Check her out on prior Febrile episode #105 (On Flea-k) for an unusual case of fever of unknown origin.
Culture
Veronica has been reading We Are Liars, which is also a Hulu series now
Sebastian is excited about his upcoming tickets to the World Cup
Misti loves spending time with and embarrassing her kids. She has recently been enjoying the Shrinking series too
Consult Notes
Case Summary
14 yo F who presents with right ankle pain and is found to have Brodie’s abscess, myositis, and bursitis due to Vibrio vulnificus
Key Points
What is a Brodie abscess?
- This episode focused on an intraosseous abscess (Brodie abscess) that is a form of subacute osteomyelitis —> an area of suppuration and necrosis is contained and encapsulated by granulation tissue and sclerosis
- In children and adolescents, the metaphyseal cortex is thicker with a dense fibrous periosteum —> bacteria can get in and the immune system walls it off, leading to this intraosseous abscess
- Brodie abscess can be mistaken for a bone tumor and frequently is observed to involve the metaphysis of bones (especially the tibia)
- Patients may remain afebrile without systemic signs of illness and unremarkable inflammatory markers
- Treatment options usually involve surgery/I&D with long term antibiotics
- Prognosis is generally good with rare recurrences or major impariments
- Here’s a PIDJ article with a review of Brodie abscess in children: Foster CE, Taylor M, Schallert EK, Rosenfeld S, King KY. Brodie Abscess in Children: A 10-Year Single Institution Retrospective Review. Pediatr Infect Dis J. 2019;38(2):e32-e34. doi:10.1097/INF.0000000000002062
- Here’s another review: van der Naald N, Smeeing DPJ, Houwert RM, Hietbrink F, Govaert GAM, van der Velde D. Brodie’s Abscess: A Systematic Review of Reported Cases. J Bone Jt Infect. 2019;4(1):33-39. Published 2019 Jan 24. doi:10.7150/jbji.31843
- Radiopaedia has several example cases and images that you can check out
What are the common microbiologic causes of osteomyelitis?
- Sebastian provided an overview of common causes of hematogenous osteomyelitis in children
- S.aureus remains king and is the most common cause of osteomyelitis in children
- Grp A and B Strep as well as Strep pneumoniae are possible as well
- Kingella kingae is a Gram negative oragnisms that is a common cause of osteomyelitis in younger children (~6-36 months of age) —> check out our prior episode #10 for more an unusual case of Kingella. You’ll find notes on acute hematogenous osteomyelitis in that episode and Consult notes as well!
- Other bacteria and fungi are possible as well, and this case identified quite an atypical bug!
- Don’t forget to check out the newest guidelines on osteomyelitis as well: Woods CR, Bradley JS, Chatterjee A, et al. Clinical Practice Guideline by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America: 2021 Guideline on Diagnosis and Management of Acute Hematogenous Osteomyelitis in Pediatrics. J Pediatric Infect Dis Soc. 2021;10(8):801-844. doi:10.1093/jpids/piab027
This case found Vibrio vulnificus as the causative agent, which is quite unusual!
- As Misti discussed, Vibrio tends to bring to mind rapidly progressive infections often after exposure to brackish water
- Here is the case from 1990 that was reference: Vartian CV, Septimus EJ. Osteomyelitis caused by Vibrio vulnificus. J Infect Dis. 1990;161(2):363. doi:10.1093/infdis/161.2.363
- Here is the outbreak of V.vulnificus including 62 cases, where only 1 patient had osteomyelitis: Bisharat N, Agmon V, Finkelstein R, et al. Clinical, epidemiological, and microbiological features of Vibrio vulnificus biogroup 3 causing outbreaks of wound infection and bacteraemia in Israel. Israel Vibrio Study Group. Lancet. 1999;354(9188):1421-1424. doi:10.1016/s0140-6736(99)02471-x
Here are the episode take-aways that our guests reinforced!
- Brodie abscess can be a subacute, smoldering form of hematogenous osteomyelitis that often lacks systemic toxicity
- When able, send the bone. Deep operative cultures should include aerobic, anaerobic, AFB, and fungal cultures, especially with environmental exposures
- Marine exposure + persistent focal pain should keep Vibrio on the differential, even when the timeline feels “wrong.”
Infographics
Goal
Listeners will be able to describe the features of Brodie abscess in children.
Learning Objectives
After listening to this episode, listeners will be able to:
- Compare and contrast Brodie abscess to acute hematogenous osteomyelitis
- Describe the typical microbiology differential for osteomyelitis in children
- Describe the typical presentation of Vibrio vulnificus infection
Disclosures
Our guests as well as Febrile podcast and hosts report no relevant financial disclosures
Citation
Santos, V., Shrager, S., Ellsworth, M., Dong, S. “#132: Not Your Average Brodie”. Febrile: A Cultured Podcast. https://player.captivate.fm/episode/fdc789e7-dc3b-4cf0-9fac-a017dbd6b07b/