Osteomyelitis - symptoms, causes and treatment

Osteomyelitis - an inflammation of the bone marrow

In osteomyelitis is an acute or chronic bone marrow infection, which usually brings a bone inflammation (osteitis) with it. Due to different ways of developing it, many different forms of this disease exist, which can cause bone pain and other symptoms in children and adults. A common trigger is a bacterial infection with staphylococci. Common therapy methods include antibiotic treatment and, in more severe cases, surgical intervention.

contents

• Osteomyelitis - an inflammation of the bone marrow
• A short overview
• definition
• symptoms
• causes
• diagnosis
• treatment
• Naturopathic treatment
• Current state of research

A short overview

The following summary provides a quick overview of osteomyelitis. The further article also contains detailed information about this disease of the musculoskeletal system.

• definition: The term osteomyelitis (bone marrow inflammation) is increasingly equated with the term osteitis (bone inflammation), since in an existing infection of the bone marrow most of the bones are affected. Cause-specific distinction is made between different acute, subacute and chronic inflammatory processes, which also include special forms (such as spondylodiscitis).
• symptoms: Often local bone pain occurs and the affected parts of the body may show redness and swelling. If it comes to pronounced general symptoms, such as fever, chills, fatigue and weakness, an acute infection is obvious. In addition, abscesses and fistulas can occur with pus.
• causes: Triggers are pathogens that spread through the bloodstream, get into the bone during operations or open fractures, or are transmitted through infections of surrounding structures. In most cases, it is a bacterial infection with Staphylococcus aureus.
• diagnosis: In the relatively nonspecific symptomatology certain blood tests that detect inflammation, in combination with imaging procedures that make the affected areas of the bones and soft tissues recognizable serve to ensure a reliable diagnosis.
• treatment: The treatment relies mainly on antibiotic therapy. In more complicated cases, surgery may be necessary. Supportive alternative treatments of natural medicine help strengthen the immune system and heal the infections.

In osteomyelitis, infections occur in the bone marrow and adjacent bone areas. (Image: Peter Hermes Furian / fotolia.com)

definition

The term osteomyelitis (plural: osteomyelitis) is derived from the Greek and is the medical term for an infection of the bone marrow. However, the term osteitis (bone inflammation) is also used more and more frequently, since most of the bone is affected in addition to the bone marrow.

Various pathogens can cause the infection and subsequently cause acute, subacute or chronic disease processes. In the acute form, the disease manifests within two weeks of infection. In the subacute and chronic variant, however, it occurs only after one to several months and can show a long-lasting and recurring course. In addition, a specific distinction is made between different forms of illness, depending on the cause of the disease.

An endogenous infection by germs that enter the bone marrow via the bloodstream (hematogenous), for example after a previous general infection, mostly affects children and adolescents. Especially many cases of illness were registered for the eighth year of life. In adults, by contrast, exogenous infections are far more common, in which the pathogens reach the bones and sometimes the bone marrow through, for example, open fractures or operations. As a result, more boys and men are diagnosed with osteomyelitis than girls and women.

Delineation of osteomyelitis is the SAPHO syndrome, which is attributed to rheumatic diseases. This includes the chronic recurrent multifocal osteomyelitis (CRMO) of unknown cause, usually occurring only in children.

Bone marrow infections can occur in many forms and are differentiated according to the causes and course of the disease. (Image: designua / fotolia.com)

symptoms

The symptoms are individually very different and depending among other things on the type of pathogen and the respective course of disease linked. The most common is a bacterial infection, which superficially determines the symptoms.

In acute osteomyelitis, there are often inflammations on the arms and legs that cause local bone pain, especially under pressure and during exercise. The affected parts of the body can also be red, warm and swollen. As a rule, pronounced general symptoms occur, such as (high) fever, chills, fatigue and weakness. It can also form abscesses in the tissue. In endogenous infections in childhood and adolescence, the shins or thigh bones are particularly often affected.

If the (untreated) infection spreads, joints can be affected (septic arthritis) or it even comes to a dangerous blood poisoning (sepsis).

Chronic osteomyelitis can be symptom-free for a long time. Less common than in the acute variant is general pain. Symptoms are more likely to be recurrent, dull pain. The cause for this is the blazing inflammation, which can also be accompanied by fistula formation from the bone to the skin and pus secretions. In addition, it can lead to damage to the bone (deformations or thickening). Other possible complications include hard-healing fractures and pseudarthrosis.

A special form is the so-called Brodie abscess in childhood. This is shown by a distinct, painful swelling in the area of ​​the focus, which is usually in the growth zone of the long bones (especially on the tibia) and is of a chronic nature.

In adulthood, in addition to discomfort on the long bones, it also partially affects the spine. This is called a kind of special form, the vertebral osteomyelitis or spondylodiscitis. This usually causes persistent back pain, aggravated by exercise and does not decrease at rest or with common methods (heat, painkillers). Vertebral osteomyelitis is rare overall, but it is one of the most common forms in old age (over 50 years).

Local bone pain is common symptoms in addition to general symptoms. (Image: yodiyim / fotolia.com)

causes

In principle, bones and the bone marrow can only be infected by pathogens if they spread through the bloodstream, get directly into the bone during operations or open fractures and injuries, or are transmitted by surrounding structures such as soft tissue or (artificial) joints.

Spread over the blood

If a pathogen spread through the bloodstream is called a hematogenous (endogenous) osteomyelitis. In up to 80 percent of cases, the infection is caused by the bacterium Staphylococcus aureus triggered. Far less common is infection with other bacteria, such as tuberculosis bacteria (especially spondylodiscitis), or viruses. Fungal infections are more common in certain regions, but on the whole they are rare and usually affect people with a weakened immune system, such as HIV-infected or cancer patients.

Inflammation in the arm and leg bones most often occurs in children or in the vertebral bones in adults (vertebral osteomyelitis). High-risk groups for a spinal disease include, in particular, elderly and debilitated people, sickle-cell disease sufferers, persons undergoing dialysis and drug addicts (non-sterile needles).

Direct infestation

In an open fracture or during an operation on the bone, germs can enter the bone and cause a so-called post-traumatic or postoperative osteomyelitis. Some bone damage requires surgery and the introduction of foreign material (nails, screws, plates) into the body. At the contact points with the foreign material, the immune system of the body is unable to fight pathogens, which is an increased risk of infection.

Also, when inserting artificial joints and endoprostheses, pathogens can enter bone areas around the implant. An infection can occur immediately or at a later date. If the bone is inflamed directly on a joint prosthesis, it is also called infectious arthritis (of an artificial joint).

Osteomyelitis in the jaw differs from the other osteomyelitis due to peculiarities in the microbiological and immunological conditions of the oral cavity, the supply of blood vessels and the involvement of bony teeth.

Most often, osteomyelitis can be attributed to a staphylococcal infection. (Image: Kateryna_Kon / fotolia.com)

Spread of surrounding structures

Bone and bone marrow can also be inflamed from infection of the surrounding soft tissue, which occurs especially in advanced age. If a tissue is injured or otherwise damaged (for example, cancer, surgery, radiation), infection may result. Even a skin ulcer can lead to osteomyelitis, often in an additional circulatory disorder or in diabetes (diabetic foot). Inflammation centers in the head area (for example, paranasal sinuses) can spread to the skull bones. If the initial infection is due to the teeth or the gums, this is also called odontogenic osteomyelitis.

A variety of specific underlying diseases and risk factors increase the risk of developing osteomyelitis. These include the following circumstances:

• Systemic diseases such as diabetes mellitus or arteriosclerosis,
• Immunodeficiency (HIV, immunosuppressive treatment),
• Circulatory disorders,
• Organ dysfunction (kidney, liver, lung),
• Substance dependence (nicotine, alcohol, drugs),
• malnutrition,
• old age,
• triggering pathogen with high virulence.

diagnosis

Patients often report ailments such as bone pain, chronic fatigue and, if necessary, fever during a medical examination. If there is a suspicion of osteomyelitis after a thorough history and physical examination, further examinations are made to confirm the diagnosis. These include primarily blood tests and imaging procedures.

In addition to blood tests, especially diagnostic imaging techniques are used. (Image: andriano_cz / fotolia.com)

laboratory tests

As a rule, the investigations focus on the determination of various inflammatory parameters in blood samples taken. These include the measurement of the blood cell lowering rate (ESR) and the determination of the concentration of the C-reactive protein (CRP), which is a component of the immune system. Increased values ​​of both parameters indicate an inflammation, but no further statements can be made about the causes.

In a small blood picture, the proportion of white blood cells (leukocytes) is determined. Leukocytes are important for the immune defense and the fight against pathogens. Many white blood cells therefore indicate infection or inflammation in the body.

If these values ​​are in the normal range, osteomyelitis is very unlikely. If the values ​​point to an inflammation, further examinations - especially of the bones - are necessary.

Imaging diagnostics

In the first place, there is always an X-ray image, which can visualize typical changes in the bone by osteomyelitis. However, the radiological appearance of an acute form is very different and not always clearly determinable. In chronic osteomyelitis sclerosis (bone compaction) is often seen, which develops as a result of the body's defense reaction. In the early stages of the disease, the radiographs may be inconspicuous. If this is the case or if the results of the X-ray examination do not allow a clear diagnosis, computer tomography or magnetic resonance imaging (with contrast agents) is usually used for the further examinations. The infected areas and possible abscesses (soft tissue findings) can usually be well mapped using these procedures.

Alternatively, nuclear medicine examinations can make the infections visible, such as the performance of a bone scintigram. In particular, scintigraphy with radiolabelled leukocytes may be helpful in distinguishing between infections and other bone diseases. Delineated are diseases with similar symptoms and findings, such as diabetic neuropathic osteoarthropathy (Charcot foot as a special form of the diabetic foot) or the Ewing's sarcoma.

For further diagnosis of bone marrow inflammation and pathogen determination, samples of pus, synovial fluid or bone tissue (bone biopsy) may also be taken.

The usual therapy method provides the treatment with an antibiotic, which can also be administered intravenously, especially in lengthy healing processes. (Image: ReaLiia / fotolia.com)

treatment

If an acute osteomyelitis is detected in time and treated accordingly, there are very good chances of recovery. More difficult to treat are the chronic forms, which can lead to a repeated flare-up of the disease (even after a long time). The treatment of osteomyelitis can be tedious. The treatment goal is to completely heal the bone damage and possible wounds.

In most cases, antibiotics (bacterial infections) or antimycotics (fungal infections) are used in the treatment of osteomyelitis. But surgical intervention and the drainage of fluid accumulation (drainage) may be necessary. If the disease is diagnosed at an early stage, surgery can often be bypassed.

antibiotic therapy

Antibiotics are the most effective form of therapy, especially in the initial stage and in hematogenous osteomyelitis. If the pathogen can be determined exactly, a special drug is used. In all other cases, a broad spectrum antibiotic is prescribed, which is the bacterium Staphylococcus aureus and fight as many other bacteria as possible. In addition to oral administration, the antibiotic can also be administered intravenously for a long time in severe forms. In chronic osteomyelitis, the treatment may take several months.

In some cases, vertebral osteomyelitis requires bed rest and spinal immobilization. If necessary, it also comes to an operation.

surgery

Severe courses and complicated cases of disease may require surgery to remove pus from abscesses, to remove fistulas, or to clear and stabilize affected bone areas. The treatment of inflammation often proves to be difficult when it comes from the surrounding soft tissue. Then, dead tissue and diseased bone areas must be surgically removed.

The surgical intervention is usually followed by an antibiotic treatment, whereby locally introduced antibiotic carriers are used. In subsequent care, bone defects sometimes need to be replenished or even bone grafted. Newer methods also use antibiotic-impregnated bone grafts.

Many naturopathic treatments can help fight infection and strengthen the body's own defenses, such as mistletoe therapy. (Image: PhotoSG / fotolia.com)

Naturopathic treatment

To combat inflammation and bacterial infections (or their symptoms), there are a variety of natural remedies and natural remedies. Various application forms of medicinal plants or medicinal herbs with anti-inflammatory and antibacterial action (for example angelica, arnica, devil's claw or horsetail) are generally known. Mistletoe therapy is said to be highly effective in this regard to improve the ability of the immune system to regenerate after surgery.

In addition to conventional treatments, hyperbaric oxygen (HBO) therapy can help prevent the spread of infections. In this case, medically pure oxygen is inhaled in a special pressure chamber in order, among other things, to achieve an improvement in the oxygen supply of tissues, the immune defense and bone healing.

To activate the body's own defenses also the self-blood therapy and self-urine therapy and thymus therapy are used. Furthermore, many home remedies are known to strengthen the immune system and also homeopathy and Schuessler salts offer opportunities for alternative treatment of bone disease. Generally, a balanced vitamin and mineral balance and a healthy diet promote healing.

Current state of research

Infections caused by surgical implant placement and especially in open (already contaminated) fractures are not uncommon. In order to counteract this risk, an article in the OP Journal has long been testing antibiotic-coated implants. In recent years, first successes have been demonstrated in the use of implants with poly-D, L-lactide and gentamicin coating, especially in high-risk patients. (tf, cs; updated on 16/01/2019)

Additional information:
Guideline: Acute and chronic exogenous osteomyelitis of long bones of the adult