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Osteitis

Osteitis describes an inflammation of the bone and is most commonly caused by infection, metabolic abnormalities or trauma.


Presentation

Presenting signs and symptoms of osteomyelitics include fatigue and irritability in children, fever, chills, pain, erythema, edema and warmth around the infected area. In rare cases, osteomyelitis may be asymptomatic and may be difficult to distinguish from other diseases.

Most patients with osteitis deformans are mostly asymptomatic and are diagnosed incidentally with an X-ray performed for another cause or when high calcium levels are being investigated. Patients can generally complain from an increased risk of fractures, a noticed decrease in height, bone pain associated with warm skin over the affected area, headache, neck pain, arthralgia with joint stiffness, bone deformities (particularly bowing of the legs), hearing loss and skull deformities, chiefly manifested with an enlarged head.

Osteitis pubis presents with bilateral or unilateral progressive pain around the groin area. The pain may also be localized in the lower abdomen or the pelvis and is usually elicited by palpation over the pubic bone. In the most extreme cases, the patient may limp from the pain.

Pleural Effusion
  • Physicians should consider the possibility of SAPHO syndrome in patients with anterior chest pain and pleural effusions.[ncbi.nlm.nih.gov]
Collapse
  • Asymptomatic chronic rhinosinusitis with osteitis and gradual collapse of the maxillary sinus cavity can be anticipated.[ncbi.nlm.nih.gov]
Kidney Failure
  • Complications of osteitis fibrosa include any of the following: Bone fractures Deformities of bone Pain Problems due to hyperparathyroidism, such as kidney stones and kidney failure Call your health care provider if you have bone pain, tenderness, or[medlineplus.gov]

Workup

Workup of infectious osteitis starts with a focused physical exam that may show tenderness, erythema and edema in surrounding areas close to the bone. When a high index of suspicion is present, additional radiologic and blood tests may be performed and they include: bone X-ray, bone scan, bone MRI, blood cultures, needle aspiration of areas around the affected bone, blood cultures, complete blood count (CBC), measurement of C-reactive protein levels (CRP) and erythrocyte sedimentation rate (ESR).

Osteitis deformans can be diagnosed with a bone x-ray or a bone scan, in addition to blood tests that show elevation in serum calcium, alkaline phosphatase (ALP) and markers for bone breakdown such as N-telopeptide.

A thorough physical exam is critical for the diagnosis of osteitis pubis. Imaging modalities such as X-ray, CT-scan and MRI can also be useful in establishing the diagnosis. X-ray images will generally show evidence of joint irregularity, manifested by erosion and sclerosis in the subchondral regions that can develop ultimately into ankylosis. These changes, nonetheless, only appear after four weeks from the initial symptoms. MRI is beneficial in determining the presence of bone edema, particularly in the early stages of the disease. Finally, a bone scan may display increased signal in the pubis symphysis although it can also be negative.

Atelectasis
  • Atelectasis occurred in 15 sinuses. Twelve patients reported unaltered nasal and sinus status.[ncbi.nlm.nih.gov]
Pleural Effusion
  • Physicians should consider the possibility of SAPHO syndrome in patients with anterior chest pain and pleural effusions.[ncbi.nlm.nih.gov]

Treatment

Antibiotics are the cornerstone of treatment for infectious osteitis. Frequently, more than one antibiotic at a time may be required and long term IV treatment over at least 4 to 6 weeks is necessary. Surgery can sometimes be used to complement antibiotic treatment, particularly if there are metal plates near the site of infection requiring removal. Diabetic patients frequently develop infections due to poor blood supply and may require vascular surgery to improve blood perfusion to infected areas.

Osteitis deformans is usually not treated if it is asymptomatic or if it only manifests with abnormalities in laboratory tests. Treatment is indicated in case of involvement of weight bearing bone, development of bone deformities, bone pain, bone changes that are progressing rapidly and thus increasing the risk of fractures and if the skull is affected because of the risk of hearing loss if treatment is not administered. Osteitis deformans is usually treated with either bisphophonates or calcitonin. Bisphosphonates can be taken orally or parenterally and work by decreasing bone remodeling. Calciton is a hormone involved in bone metabolism and can be administered as subcutaneous injections (calcimar or mithracin) or as a nasal spray (miacalcin). Pain associated with osteitis deformans successfully responds to non-steroidal anti-inflammatory drugs (NSAIDs) or paracetamol.

Osteitis pubis is only treated if symptoms are present. Ice and medications are first line choices to lessen the accompanying inflammation. Activities that increase the pain should be eliminated, and patients are advised to undergo strengthening and stretching exercises. Corticosteroids in the form of injections or pills may be useful in reducing the inflammation. Patients should not return to sporting activity until symptoms completely resolve. Resistant cases may require surgery, by fusing or cleaning the joint.

Prognosis

Patients with osteomyelitis have a favorable prognosis when adequately treated. Those who develop chronic osteomyelitis tend to fare worse and suffer from a high rate of recurrence of symptoms despite repeated surgeries. Diabetic patients may have to undergo amputations due to impaired blood circulation.

Most patients with Osteitis deformans have a good prognosis and their condition can be controlled with medication, although there is a higher risk for osteosarcomas and some patients will require surgery to replace damaged joints.

Osteitis pubis has a good prognosis, with most patients able to fully recover with adequate treatment and physiotherapy. In most cases recovery time is around a few weeks but severe cases can require up to 6 months.

Etiology

Infectious osteitis may result from either direct inoculation of the bone with bacteria, contiguous spread from nearby infected structures or transfer of bacteria from distant locations through the blood. Hematogenous spread can be caused by a seemingly benign skin infection, IV drug use or a more serious condition such as endocarditis. IV drug abuse particularly targets vertebra and the long bones [1].

The cause of osteitis deformans remains unclear. It can be transmitted genetically in an autosomal dominant fashion but with variable penetrance. Patients tend to have an increased level of IgM proteins and the disease has been linked to infections with certain viruses. Environmental factors are also thought to be involved, particularly exposure to arsenic, dogs, cattle and other pets, although many of these associations remain controversial [2].

On the other hand, abnormalities in joints, muscles and flexibility are thought to underlie osteitis pubis. These result in high shearing forces and cumulative microtraumas over the pubis symphysis, ultimately leading to inflammatory reactions and muscle spasms. Osteitis pubis is also associated with surgeries of the reproductive and urinary tracts, trauma, childbirth, rheumatologic disease or performance of certain athletic activities such as running, football and tennis [3].

Epidemiology

Infectious osteitis is responsible for about 50,000 hospital admissions in the United States [4]. Methicillin-resistant Staphylococcus aureus (MRSA) remains a significant cause for nosocomial infections and targets especially diabetics, immunocompromised patients and IV drug users.

Osteitis deformans is thought to occur in 3.5% of individuals older than 45 years in the United States. Its incidence has been consistently decreasing but it remains one of the major chronic bone remodeling disorders. The disease targets men and women equally, has no predilection for a certain ethnic group and tends to affect older individuals, with a mean age of onset of 55 years [5].

Osteitis pubis is thought to be about 5 times more prevalent in men than women, although the exact incidence and prevalence are difficult to estimate. It may also be more common in Europe than the United States because of the popularity of soccer [6]. 

Sex distribution
Age distribution

Pathophysiology

The pathophysiological mechanisms underlying acute osteomyelitis include vascular compromise to the bone tissue, combined with edema and thrombosis of small vessels. There is loss of adequate blood supply in the early stages to nearby soft tissue followed by a further spread into medullary and periosteal areas. The process manifests on the longer term with chronic inflammatory cells and fibrous tissue surrounding dead bone along with granulation tissue [7]. The progression of the infection can be successfully arrested with aggressive and timely treatment with antibiotics and, occasionally, surgery.

Osteitis deformans is due to metabolic abnormalities in born resorption and formation. The first stage of the disease involves increased metabolic activities of the osteoclasts, the cell line normally responsible for bone resorption. Abnormal osteoclasts, characterized by an increase in size, activity, quantity and excess nuclei, create large cavities in bony structures that are subsequently filled with ostebolasts and fibrotic tissue. In the second stage, osteoblasts start a process of bone formation to replace lost bone caused by osteoclast resorption. The newly formed bone is not as strong as the original lamellar bone and is chiefly characterized by reduced resistance and increased elasticity. Pain is ultimately caused by microfractures and increased vascularity. The high burn turnover also results in elevated serum alkaline phosphatase, one of the diagnostic markers of the disease. Bone deformity as well as changes in the biochemical environment of joints lead in turn to arthritis. The arthritic changes in the skull and the vertebra result in chronic inflammation and the narrowing of foramina, with the newly formed tissue impinging on cranial and spinal nerves. The increased metabolic demand associated with elevated blood perfusion to the bone result in diminished supply to the nerve structures, leading to ischemic myelitis and further aggravating the neurological manifestations of the disease [8].

Osteitis pubis is caused by inflammation and sclerosis over the pubis symphysis. It is due to microtraumas associated with sports that involve lateral movements, kicking or running [9]. Athletes practicing ice hockey, American football, soccer or sprinting are particularly vulnerable [10].

Prevention

Infectious osteitis can be prevented most successfully by reducing the risk of acquiring general infections. Avoiding scrapes and cuts is important, as well as subsequent cleaning and bandage application in case they do occur.

No specific preventive measures are available for osteitis deformans, although patients with family members who suffer from the disease are advised to have blood tests every 2 to 3 years after the age of 40.

Osteitis pubis can be prevented chiefly by the maintenance of overall physical fitness as well as through the avoidance of hip trauma.

Summary

Osteitis is an inflammation of the bone and refers generally to a range of disorders, the most common of which are infectious osteitis, osteitis deformans and osteitis pubis. Infectious osteitis, also known as osteomyelitis, is due to a bacterial infection of the bone that arises either through direct inoculation of microorganisms or is spread from surrounding tissues and the blood stream. Osteitis deformans (Paget's disease) is a metabolic disease that results in increased bone resorption followed by disorganized bone remodeling, leading to weakened bone structure, abnormal bone growth and an increased risk of fracture. Osteitis pubis is a condition that describes inflammatory changes in the pubis symphysis in the pelvis, and is thought to arise from an accumulation of microtraumas to the joint, particularly during the performance of certain sporting activities.

Patient Information

Osteitis refers to an inflammation of the bone and is mainly caused by three conditions: infectious osteitis, osteitis deformans and osteitis pubis.

Infectious osteitis, also known as osteomyelitis, is an infection of the bone that results from direct inoculation of microorganisms or spread of the infection through the blood or from surrounding tissues. Osteomeolytis most frequently affects the long bones in children (such as the bones in the forearms and thighs) and the bones that form the spine in adults (vertebra). Diabetic patients may also suffer from bone infection in their feet due to impairment in blood circulation and the development of ulcers. Infectious osteitis can be effectively treated with a combination of antibiotic therapy and surgery. Treatment with antibiotics is usually delivered through the blood and may last 4 to 6 weeks.

Osteitis deformans, also known as Paget's disease, is a disease that affects bone metabolism. It begins with increased bone resorption followed by the deposition of structural weak and disorganized bone. This ultimately leads to abnormalities in bone structure, in addition to pain, fractures and inflammation of the nearby joints. It can also very rarely lead to a type of bone cancer called Paget's sarcoma. Osteitis deformans does not need treatment if it is asymptomatic.

Osteitis pubis is due to inflammation of a joint in the pelvis called symphysis pubis. This inflammation follows extensive overuse of the joint, particularly in sporting activities that involve kicking, running or abrupt lateral movements such as soccer, American football or ice hockey. The exact cause of osteitis pubis remains unknown, but the inflammation is thought to result from the accumulation of small traumatic events (microtraumas) to the symphysis pubis.

References

Article

  1. Beronius M, Bergman B, Andersson R. Vertebral osteomyelitis in Goteborg, Sweden: a retrospective study of patients during 1990-95. Scand J Infect Dis. 2001;33:527-532.
  2. Siris ES, Kelsey JL, Flaster E, et al. Paget's disease of bone and previous pet ownership in the United States: dogs exonerated. Int J Epidemiol. 1990;19:455-458.
  3. Garvey JF, Read JW, Turner A. Sportsman hernia: what can we do?. Hernia. 2010 Feb. 14(1):17-25.
  4. Rubin RJ, Harrington CA, Poon A, et al. The economic impact of Staphylococcus aureus infection in New York City hospitals. Emerg Infect Dis. 1999;5:9-17.
  5. Monsell EM, Cody DD, Bone HG, et al. Hearing loss as a complication of Paget's disease of bone. J Bone Miner Res. 1999;14:92-95.
  6. Westlin N. Groin pain in athletes from southern Sweden. Sports Med Arthroscopy Rev. 1997. 5:280-4.
  7. Ciampolini J, Harding KG. Pathophysiology of chronic bacterial osteomyelitis. Why do antibiotics fail so often? Postgrad Med J. 2000;76:479-483.
  8. Yost JH, Spencer-Green G, Krant JD. Vascular steal mimicking compression myelopathy in Paget's disease of bone: rapid reversal with calcitonin and systemic steroids. J Rheumatol. 1993;20:1064-1065.
  9. Robertson BA, Barker PJ, Fahrer M, Schache AG. The anatomy of the pubic region revisited: implications for the pathogenesis and clinical management of chronic groin pain in athletes. Sports Med. 2009. 39(3):225-34.
  10. Batt ME, McShane JM, Dillingham MF. Osteitis pubis in collegiate football players. Med Sci Sports Exerc. 1995 May. 27(5):629-33.

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Last updated: 2017-08-09 18:07