Beydoun Tammam,  Pokorney Amber,  Keehn Brian,  Hu Houchun,  Patel Mittun,  Barnes Craig

Final Pr. ID: Poster #: SCI-047

To compare image quality ratings between 3D gradient echo mDIXON (GRE) vs. 2D turbo-spin-echo mDIXON (TSE) in pediatric patients with osteomyelitis. Read More

Authors:  Beydoun Tammam , Pokorney Amber , Keehn Brian , Hu Houchun , Patel Mittun , Barnes Craig

Keywords:  mDIXON GRE, Osteomyelitis

Jen Aaron,  Iskander Paul,  Ghahremani Shahnaz

Final Pr. ID: Poster #: CR-079

Case Report:
A 14 year-old previously healthy male presented to the emergency department with weakness, fever, diarrhea, lateral right eye deviation and transient vision loss, following a week of headaches and dizziness. The symptoms began following a recent camping trip to Yosemite National Park with friends, where distant contact with squirrels and several bug bites were noted. The initial physical examination revealed additional photophobia, limited neck flexion secondary to pain, and a raised, non-tender soft tissue mass over the anterior right shin. Soon after admission, the patient developed pain in the right hip and left leg and significant lower extremity weakness. A chest X-ray demonstrated left lower lobe consolidation, a left upper lobe lung nodule, and a right upper lobe lung nodule. MRI showed multifocal osteomyelitis and multiple intraosseous, intramuscular and soft tissue abscesses. Contrast-enhanced CT angiogram demonstrated septic emboli, scarring, and atelectasis within the left lower lung with a small hydropneumothorax. Lucent lesions were also noticed in the T3-T6 vertebral bodies with increased prominence of the paravertebral soft tissue.

A lumbar puncture was found consistent with bacterial meningitis. A blood culture, CSF culture, and culture of abscess fluid from the right hip were all found to be PCR positive for Yersinia pestis, and the patient was placed on a treatment regimen of ciprofloxacin, gentamicin, and tetracycline.

Discussion:
Plague, colloquial known as the Black Death, is a zoonosis caused by the gram-negative bacterium Yersinia pestis and endemic to the Western United States and developing countries. In the modern day, plague is typically found in infected rodents and spread to humans through fleas. Three forms of plague are reported in humans: bubonic, septicemic, and pneumonic. Our patient’s presented primary septicemic plague complicated by secondary pneumonia, meningitis, and osteomyelitis. Notably, Yersinia osteomyelitis has been reported only once in the historical literature, and was likely underappreciated before the advent of MRI. This case presentation will highlight the unique imaging manifestations of the patient’s disseminated disease. Read More

Authors:  Jen Aaron , Iskander Paul , Ghahremani Shahnaz

Keywords:  plague, osteomyelitis, pneumonia, meningitis, sepsis

Guarilha Taísa,  Di Puglia Elazir

Final Pr. ID: Poster #: CR-011 (S)

A four-year-old girl was referred to our service to investigate a mass in her left forearm. About a year before she had cellulitis in the same place which was treated and resolved with antibiotics. A month previous to our consult she notices a soft tissue swelling in her left forearm and a pediatrician referred her to an oncologist for investigation.
On physical examination, she presented with a medial bulging in her left forearm with local pain and no inflammatory signs. There was no history of fever.
The plain radiograph showed a lytic lesion oriented along the axis of the ulna surrounded by fading sclerosis. In the Computed Tomography there was a lytic lesion with periosteal new bone formation.
The diagnosis was Brodie’s abscess which is a form of subacute osteomyelitis. It is a collection of purulent material surrounded by granulation tissue and reparative sclerotic bone. Staphylococcal Aureus is the most common organism to lead to this entity but any pyogenic organism can cause it. Osteomyelitis is the result of bone infection being the trabecular and cortical involved. It can be spread by exogenous and contiguous or endogenous due to hematogenous spread. Read More

Authors:  Guarilha Taísa , Di Puglia Elazir

Keywords:  Osteomyelitis, Brodie's abscess, musculoskeletal

Mowrer Gregory,  Jaramillo Diego,  Restrepo Ricardo,  Imundo Lisa,  Flemming Don,  Chauvin Nancy

Final Pr. ID: Poster #: EDU-038

Chronic nonbacterial osteomyelitis (CNO) is an aseptic auto-inflammatory condition that affects children and presents with insidious bone pain. Children present with a variable clinical spectrum of disease with either unifocal or multifocal pain and acute (duration < 6months) or chronic (>6 months) symptoms. The disease course may be recurrent. In some cases, patients endure multiple lesions over a course of exacerbations and remissions. Bone lesions are often in symmetrical regions. Interestingly, clinically asymptomatic bone lesions are discovered during the imaging evaluation. Patient symptoms and clinical course may mimic other diseases, making CNO often difficult to diagnose with a consequent delay in diagnosis. Children with CNO may also develop arthritis and demonstrate similar cytokine profiles with children with juvenile idiopathic arthritis (JIA), suggesting at least a partial common disease pathway. Read More

Authors:  Mowrer Gregory , Jaramillo Diego , Restrepo Ricardo , Imundo Lisa , Flemming Don , Chauvin Nancy

Keywords:  chronic nonbacterial osteomyelitis, osteitis, CRMO

Ciotola-koch Jason,  Yu Brian,  Edquist Mitchell,  Thomas Richard,  Pierce Drew

Final Pr. ID: Poster #: CR-015

Emphysematous osteomyelitis is a known, though rare, diagnosis which can occur in pediatric patients and can be definitively diagnosed on computed tomography (CT). To our knowledge, only 30 cases had been reported as of 2018. Our objective is to raise awareness of emphysematous osteomyelitis as an important imaging diagnosis with high morbidity and mortality. Additionally, we aim to describe the characteristic appearance utilizing CT as a gold standard, discuss underlying etiologies, and describe associated systemic findings illustrated in a case example. In pediatric patients without comorbidities, the most common causative organism of emphysematous osteomyelitis is Fusobacterium necrophorum. F. necrophorum infection commonly causes Lemierre’s syndrome, however, the two diagnoses can coexist. With the distinct CT appearance of emphysematous osteomyelitis, radiologists can alert clinicians to the diagnosis and expedite aggressive treatment.

Our patient, an 18-year-old male with a recent outpatient diagnosis of mononucleosis, presented to the emergency department (ED) for throat pain and fever. Physical examination and lab values were remarkable for posterior pharyngeal erythema and elevated serum creatinine (1.44). He was discharged with supportive management and corticosteroids. Ten days later, he returned to the ED with worsening symptoms including right hip and right ankle pain and swelling, chest pain, and dark urine output. Physical exam was significant for tachycardia, tachypnea, and right lower quadrant abdominal pain. Laboratory evaluation showed increasing serum creatinine of 2.9, leukocytosis, thrombocytopenia, and lactic acidosis. Workup showed right lung consolidation, right pleural effusion, retroperitoneal inflammation, and emphysema about the right psoas major, as well as intramedullary air within the right ilium. The patient was admitted to the pediatric intensive care unit (PICU), received broad-spectrum intravenous antibiotics, and underwent CT-guided right ilium biopsy. Bone marrow culture grew F. necrophorum, prompting additional workup including a chest CT and head and neck CTA to assess for Lemierre’s Disease. Exams demonstrated a left parapharyngeal abscess, left internal jugular vein thrombosis, multiple cavitating pulmonary septic emboli, and bilateral pleural effusions. Anticoagulation was initiated and antibiotics were narrowed to culture sensitivities. The patient improved, allowing transfer out of the PICU to the medicine floor. Read More

Authors:  Ciotola-koch Jason , Yu Brian , Edquist Mitchell , Thomas Richard , Pierce Drew

Keywords:  Osteomyelitis, Lemierre's, Fusobacterium

Yen Christopher,  Hernandez Alberto,  Gardner Gregory,  Nazario Maricarmen,  Kukreja Kamlesh,  Desai Sudhen

Final Pr. ID: Paper #: 073

Bone biopsy for histopathology and tissue culture remains the gold standard for diagnosis of osteomyelitis. However, MRI often results in a radiologic diagnosis of osteomyelitis preceding biopsy. The purpose of this study is to examine the diagnostic yield of percutaneous bone biopsies and the effect of biopsy results on clinical management in children with suspected osteomyelitis and positive MRI findings. Read More

Authors:  Yen Christopher , Hernandez Alberto , Gardner Gregory , Nazario Maricarmen , Kukreja Kamlesh , Desai Sudhen

Keywords:  Biopsy, Osteomyelitis, MRI

Liang Teresa,  Joshi Madalsa,  Bray Heather

Final Pr. ID: Poster #: EDU-062

1. Discuss the pathophysiology and review the imaging modalities used to identify pelvic osteomyelitis in children
2. Demonstrate the spectrum of imaging findings in children with pelvic osteomyelitis
3. Review the diagnostic challenges and how to differentiate pediatric pelvic osteomyelitis from imaging mimics Read More

Authors:  Liang Teresa , Joshi Madalsa , Bray Heather

Keywords:  Osteomyelitis

Regmi Pradeep,  Amatya Isha

Final Pr. ID: Poster #: CR-019

Primary tubercular osteomyelitis accounts for less than 10% of extra-pulmonary tuberculosis (TB) in childhooduMultifocal tuberculosis with more than one site especially in immune-competent children is rare. Very few cases of multifocal involvement of ribs and sternum are reported. We are presenting a case of a 14-year-old boy presented with painless swelling in the chest.
Clinical history
The 4-year-old child presented with painless swelling on his anterior chest in midline and back pain on and off for 3 months duration. No history of trauma. However, he lost about 3 kilograms of his weight in this duration. On examination, the swelling was soft and painless on palpation. No exit points in the skin. There was no lymphadenopathy. However, other systemic examinations were unremarkable. Lab parameters revealed a WBC count of 11,000 with lymphocyte-predominant.
In children, the bones most commonly affected are the metaphysis of the long bones (femur, tibia, fibula, radius, ulna and humerus), spine, pelvic girdle and skull bones. Multifocal skeletal tuberculosis is uncommon in children and accounts for less than 10% of skeletal tuberculosis. Sternum TB commonly occurs by reactivation of latent focuses formed throughout the course of hematogenous or lymphatic dissemination of primary tuberculosis. Extra-pulmonary tuberculosis in children varies from 21-44%. Pericardial involvement is one of the crucial sites of involvement. About 10% of children develop constrictive pericarditis in follow up for pericardial effusion.
The diagnosis of bone tuberculosis is particularly challenging as the presentation of skeletal tuberculosis is often insidious, with an absence of the classical features of pulmonary tuberculosis or typical systemic features such as fever, cough, night sweats or weight loss (history of localized painless swelling and weight loss were present in our case). The gold standard for diagnosis comprises histological examination verification. Needle aspiration or excisional biopsy for histopathological diagnosis of sternum TB is obligatory. Both Needle aspiration and biopsy were performed in our case.
The clinical presentation in patients with multifocal musculoskeletal tuberculosis may closely mimic that in patients with multiple bone metastases, which makes the accurate clinical diagnosis challenging. Clinical and even radiological findings may be indistinguishable from malignant disease, so histopathological evaluation is warranted in such cases. Read More

Authors:  Regmi Pradeep , Amatya Isha

Keywords:  Multifocal osteomyelitis, Tubercular, Children

Aguet Julien,  Zimmermann Petra,  Stranzinger Enno

Final Pr. ID: Poster #: EDU-018

Odontoid osteomyelitis is a rare disease in children. As the condition is not commonly known, children are frequently initially misdiagnosed with torticollis and treated symptomatically, leading to delayed diagnosis. We present two illustrative cases of odontoid osteomyelitis and a literature review summarizing clinical presentation, risk factors, diagnostic methods, radiological findings and therapies of all previously reported cases. Read More

Authors:  Aguet Julien , Zimmermann Petra , Stranzinger Enno

Keywords:  odontoid, osteomyelitis

Milks Kathryn,  Rees Mitchell,  Krishnamurthy Ramkumar,  Hu Houchun,  Krishnamurthy Rajesh

Final Pr. ID: Poster #: SCI-050

To determine if a 3-minute Golden-angle RAdial Sparse Parallel (GRASP) dynamic contrast enhanced (DCE) MRI sequence with 8-10 second temporal resolution is equivalent in diagnostic performance to a conventional MR sequences (CS) in the assessment of osteomyelitis (OM) in children.
Read More

Authors:  Milks Kathryn , Rees Mitchell , Krishnamurthy Ramkumar , Hu Houchun , Krishnamurthy Rajesh

Keywords:  osteomyelitis, GRASP, MRI

Gandor Patricia

Final Pr. ID: Poster #: EDU-011 (R)

A nine year old female presents to the emergency room with midline forehead soft tissue swelling. One month prior she experienced a period of identical swelling without any other associated event. After three days, the swelling spontaneously resolved. She continued to be asymptomatic until the morning of this admission when she woke up with swelling in the same location as one month prior. She again denied any other symptoms. Read More

Authors:  Gandor Patricia

Keywords:  Osteomyelitis, Pott's Puffy Tumor

Baja Manish,  Sato T Shawn,  Sato Yutaka,  Kao Simon,  Ferguson Polly

Final Pr. ID: Poster #: EDU-136

This educational exhibit aims to :
1. Discuss the pathogenesis of Chronic Recurrent Multifocal Osteomyelitis (CRMO) with enumeration of Diagnostic Clinical Criteria
2. Describe pertinent findings on whole body Short tau Inversion Recovery (STIR) MR Imaging.
3. Illustrate evolution of MR findings on follow up imaging.
4. Identify common imaging differentials to be considered and pitfalls to be avoided Read More

Authors:  Baja Manish , Sato T Shawn , Sato Yutaka , Kao Simon , Ferguson Polly

Keywords:  Recurrent, Multifocal, Osteomyelitis

Miyazaki Osamu,  Aoki Hidekazu,  Miyasaka Mikiko,  Okamoto Reiko,  Tsutsumi Yoshiyuki,  Nosaka Shunsuke

Final Pr. ID: Poster #: SCI-040

MRI is the gold standard for the diagnosis of acute septic sacroiliitis. However, appropriate timing of the procedure has not been addressed in the literature. MRI is highly sensitive for detecting long tubular bone osteomyelitis as early as 24-48 hours of symptom onset. The hypothesis of this study is that the onset of bone marrow edema of acute hematogenous osteomyelitis (AHO) of pelvis might be delayed as compared with long bone. The purpose of this study is to evaluate the optimum timing of MRI examination from the onset of disease. Read More

Authors:  Miyazaki Osamu , Aoki Hidekazu , Miyasaka Mikiko , Okamoto Reiko , Tsutsumi Yoshiyuki , Nosaka Shunsuke

Keywords:  scroiliitis, osteomyelitis, MRI