Atypical forms of osteomyelitis in children.

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Intussusception in Children

Intussusception is a serious problem in the intestine. It occurs when one part of the intestine slides inside another part. The intestine then folds into itself like a telescope. This creates a blockage or obstruction. It stops food that is being digested from passing through the intestine.

Intussusception is the most common cause of intestinal blockage in children between ages 3 months and 3 years. It is rare in newborn babies. But it can also occur in older children, teenagers, and adults.

Intussusception is a medical emergency. It's the most common abdominal emergency in early childhood. If not treated, it can cause infection or even death.

Causes

Experts don’t know what causes intussusception. It may occur more often in children who have a family history of the disorder.

Experts have found a link in some cases with other conditions. These include viral infection, abdominal or intestinal tumors or masses, appendicitis, parasites, celiac disease, cystic fibrosis, and Crohn's disease.

Symptoms

Intussusception is a medical emergency. If you think your child may have the disorder, see your child's healthcare provider right away.

Each child’s symptoms may vary. The most common symptom is sudden, loud crying. This is caused by sudden, severe belly (abdominal) pain in an otherwise healthy child.

This belly pain occurs often. At first it may seem to be colic. Infants or children may strain, draw their knees up, act very irritable, and cry loudly. Your child may feel better and be playful between bouts of pain. Or your child may become tired and weak from crying.

Other symptoms include:

· Vomiting

· Bloody stool

· Red, jelly-like stool

· Fever

· Extreme tiredness or lethargy

· Vomiting bile

· Diarrhea

· Sweating

· Dehydration

· Swollen belly

Symptoms of intussusception may seem like other health problems. See your child's healthcare provider for a diagnosis.

Diagnosis

Your child’s healthcare provider will take a health history and give your child a physical exam. Imaging studies are also done to check the belly (abdominal) organs. These tests may include:

· Abdominal X-ray. A diagnostic test that may show intestinal blockage.

· Ultrasound.A diagnostic imaging technique that uses high frequency sound waves and a computer to create images of blood vessels, tissues, and organs. Ultrasounds are used to view organs as they work and to check blood flow through various vessels.

· Upper GI series or barium swallow.This test looks at the organs of the top part of the digestive system. It checks the food pipe (esophagus), the stomach, and the first part of the small intestine (duodenum). Your child will swallow a metallic fluid called barium. Barium coats the organs so that they can be seen on an X-ray. Then X-rays are taken to check the digestive organs.

· Barium enema or lower GI series.This is an X-ray exam of the rectum, the large intestine, and the lower part of the small intestine. Your child will be given a metallic fluid called barium. Barium coats the organs so they can be seen on an X-ray. The barium is put into a tube and inserted into your child’s rectum as an enema. An X-ray of the belly will show if there are any narrowed areas called strictures, any blockages, or other problems. In some cases, the intussusception fixes itself during this test. The intestine may go back into place on its own. This can happen because of the pressure put on the intestine while the barium is inserted.

Treatment

Treatment will depend on your child’s symptoms, age, and general health. It will also depend on how severe the condition is.

Sometimes intussusception will repair itself while a child has a barium enema. In many cases, the healthcare provider can correct the problem by giving an air enema or saline enema. This is done by placing a small tube in your child's rectum. The healthcare provider uses ultrasound or X-rays (fluoroscope) to help place the tube. Air is inserted in the tube. The air may help move the intestine back into its normal position. But if your child is very ill with an abdominal infection or other problems, the provider may choose not to do this.

Your child will need surgery if the intussusception is not repaired with a barium enema. Your child will also need surgery they are too ill to have a barium enema, saline enema, or air enema. For the surgery, your child will be given anesthesia. The surgeon will make a cut or incision in the belly. The surgeon will find the intussusception, and push the parts of the intestine back into place. The intestine will be checked for damage. If any sections are not working properly, they will be removed.

If your child’s intestine is damaged and the part removed is small, the two sections of healthy intestine will be sewn back together.

In very rare cases, a large amount of intestine may be removed. This happens if the damaged section of intestine is large. In this case, surgery can’t link together the parts of the intestine that remain after the damaged section is removed. An ileostomy may be done so that the digestive process can continue. With an ileostomy, the two remaining healthy ends of intestine are brought through openings in the belly. Stool will pass through the opening (stoma). It will then collect in a bag on the outside of the body. The ileostomy may be short-term. Or in very rare cases it may be long-lasting or permanent. It depends on how much intestine was removed.

ATYPICAL FORMS OF OSTEOMYELITIS IN CHILDREN

 • Brodie’s abscess

• Albuminous osteomyelitis • Sclerosing osteomyelitis

• Antibiotic osteomyelitis

BRODIE’S ABSCESS

Brodie's abscess is a rare form of osteomyelitis. It involves a subacute or chronic infection of the bone with development of a localized abscess, usually within the metaphysis of long bones. The tibia is the most common bone involved and staphylococcus aureus is the most common organism identified

ETIOLOGY

S. aureus (most common); cultures often negative

Location

It has a predilection for ends (metaphysis) of tubular bones:

• proximal/distal tibial metaphysis (most common)

• carpal and tarsal bones

Rarely traversing the open growth plate; epiphysis (in children and infants) CLASSIFICATION


• Type I (metaphyseal lesion) - Type Ia is a central metaphyseal lesion that is seen as a punched-out radiolucency, often suggestive of Langerhans cell histiocytosis; type Ib is a metaphyseal lesion eccentrically located with cortical erosion, which may give the appearance of osteogenic sarcoma


• Type II (diaphyseal lesion) - Type IIa is a localized cortical and periosteal reaction that simulates osteoid osteoma; a type IIb lesion is a medullary abscess in the diaphysis without cortical destruction but with onionskin periosteal reaction that resembles Ewing sarcoma


• Type III (epiphyseal lesion) - Type IIIa is a primary epiphyseal osteomyelitis and appears as a concentric radiolucency, usually seen in children younger than 4-5 years; type IIIb is a subacute infection that crosses the epiphysis and involves both the epiphysis and metaphysis


 • Type IV (metaphyseal-equivalent lesion, defined as the portion of a flat or irregular bone that borders cartilage [apophyseal growth plates, articular cartilage, or fibrocartilage], such as the vertebrae, the pelvis, and small bones [eg, tarsal bones and clavicle]) - Type IVa involves the vertebral body with an erosive or destructive process; type IVb involves the flat bones of the pelvis and is mostly sclerotic, with neither erosion nor destructive processes ; type IVc involves the small bones (eg, tarsal bones, clavicle)


SIGNS AND SYMPTOMS

HISTORY: Presenting symptoms of subacute osteomyelitis include mild-to- moderate localized pain. Pain is the most consistent complaint in most patients, and it may at times become more intense or remit and is frequently exacerbated following a period of unusual activity. Night pain that is relieved with aspirin is frequently reported. Minimal loss of function is another common symptom (eg, limping in a patient with a lower-limb lesion), with no history of systemic toxicity.

Because the symptoms of subacute osteomyelitis are vague, an accurate diagnosis is usually delayed. The bone lesion may also not be readily apparent on plain radiographs for some time. The average duration of symptoms before diagnosis is 1-6 months, but symptoms may be present longer before the diagnosis.

PHYSICAL EXAMINATION: On clinical examination, localized tenderness may only occasionally be associated with warmth, redness, and soft-tissue swelling with the involvement of subcutaneous bone. This finding seems to increase and subside with activity. Pain may occur with movement of the adjacent joint, and some joint effusion may be present, but the pain and effusion are usually mild. The surrounding muscles may occasionally demonstrate some wasting.

DIAGNOSIS

Radiographic features

Plain radiograph

• lytic lesion often in an oval configuration that is orientated along the long

axis of the bone

• surrounded by a thick dense rim of reactive sclerosis that fades imperceptibly into surrounding bone lucent tortuous channel extending toward growth plate prior to physeal closure (pathognomonic)periosteal new-bone formation +/- adjacent soft-tissue swelling may persist for many months


CT

central intramedullary hypodense cystic lesion with thick rim ossification

extensive thick well-circumscribed periosteal reaction and bone sclerosis around the lesion could be seen

MRI

The “ penumbra sign” on magnetic resonance (MR) imaging is useful for discriminating subacute osteomyelitis from other bone lesions. The penumbra sign is a rim lining of an abscess cavity with higher signal intensity than that of the main abscess on T1-weighted images with strongly and rapidly enhance after contrast.

TREATMENT

Once the diagnosis is established, appropriate antibiotic therapy (with the dose adjusted according to the patient's weight and age) based on Gram stain, culture, and sensitivity results should be initially started intravenously (IV) for 2-7 days, followed generally by 6 weeks of oral antibiotic therapy.

It has been suggested that surgery should be reserved for aggressive lesions.

In case of aggressive subacute osteomyelitis with an ESR higher than 40 mm/hr, an abscess larger than 3 cm, or a lesion indistinguishable from a tumor, open biopsy for culture and histology is indicated. Other lesions are incised and drained when indicated, the granulation tissue present in the lesion is curetted and cultured, and antibiotics are started immediately after biopsy.

In pediatric patients with typical cavities in the metaphysis, the epiphysis, or both, surgery is undertaken only for specific indications. When clinical signs of subperiosteal pus are present, treatment consists of incision and drainage. When clinical signs of synovitis are present, with a possibility of pus within a joint, arthrotomy is performed and synovium is sent for culture and histology studies

SCLEROSING OSTEOMYELITIS

Garre's sclerosing osteomyelitis is a type of chronic osteomyelitis also called periostitis ossificans and Garré's sclerosing osteomyelitis. It is a rare disease. It mainly affects children and young adults. It is associated with a low grade infection, which may be due to dental caries (cavities in the teeth)

Radiographic features

Orthopantomogram (OPG)

A localised overgrowth of bone on the outer surface of the cortex. This mass of bone, which is supracortical but subperiosteal, is smooth, fairly calcified, and is often described as a duplication of the cortical layer of the mandible.

The redundant cortical layering of the bone (onion skinning) is often considered a pathognomonic feature.

ALBUMINOUS OSTEOMYELITIS

This is a very rare disease. The clinical manifestations are similar to those of other forms of atypical osteomyelitis though in some cases they are more pronounced. The bone is sclerosed and the marrow canal which contains white or yellow fluid is narrowed

The process is predominantly localised in distal department of femur. There are complains for a constant pain in the femur.

Treatment consists of trepanation of the bone with removal of albuminous fluid and tight filling of the cavity with antibiotics.

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