Posttraumatic chronic cranial osteomyelitis due to a superficial wound - A clinical and neuroradiological case report
- Department of Biomedical Sciences and Morphological and Functional Imaging, Palermo, Italy
- Department of Section of Neurosurgery, University of Messina, Messina, Palermo, Italy
- Department of Neurosurgical Clinic, Department of Biomedicine, Neurosciences and Applied Diagnostics, University of Palermo, Palermo, Italy
Department of Biomedical Sciences and Morphological and Functional Imaging, Palermo, Italy
DOI:10.25259/SNI-35-2019Copyright: © 2019 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Antonella Cinquegrani, Concetta Alafaci, Ketty Galletta, Santi Racchiusa, Francesco Salpietro, Marcello Longo, Giovanni Grasso, Francesca Granata. Posttraumatic chronic cranial osteomyelitis due to a superficial wound - A clinical and neuroradiological case report. 24-Apr-2019;10:53
How to cite this URL: Antonella Cinquegrani, Concetta Alafaci, Ketty Galletta, Santi Racchiusa, Francesco Salpietro, Marcello Longo, Giovanni Grasso, Francesca Granata. Posttraumatic chronic cranial osteomyelitis due to a superficial wound - A clinical and neuroradiological case report. 24-Apr-2019;10:53. Available from: http://surgicalneurologyint.com/surgicalint-articles/9298/
Background:Osteomyelitis is a progressive infection of bone and bone marrow by microorganisms, resulting in inflammatory destruction of bone, bone necrosis, and new bone formation. Skull involvement is a rare occurrence which mainly affects children with chronic inflammatory diseases of paranasal sinusitis, or malignant otitis. In adults, cranial vault osteomyelitis can occur after cranial surgery or head trauma.
Case Description:We describe an unusual case of chronic cranial osteomyelitis occurred 3 months following a mild traumatic brain injury. The causative mechanisms along with the diagnostic modalities are discussed.
Conclusion:Focal cranial vault osteomyelitis, in the absence of severe trauma, can be challenging to diagnose. Imaging findings and patient history should be carefully investigated to make a correct diagnosis.
Keywords: Cranial vault osteomyelitis, head injury complication skull osteomyelitis, posttraumatic osteomyelitis, posttraumatic skull osteomyelitis
Osteomyelitis is an inflammatory process accompanied by bone destruction caused by an infecting microorganism. The decline of fulminant osteomyelitis of the skull from a routine event to a rare occurrence has largely paralleled the emergence of potent antibiotics. Today, osteomyelitis of the skull usually presents as a chronic process that occasionally complicates craniotomies and scalp injuries.[
We report a case of 45-year-old medical nun, involved in a car accident while being in a humanitarian mission in Senegal. She presented with a superficial skin wound in a cranial vault at the right parietal level that, after prompt disinfection, was treated with 2 days antibiotic regimen (two caps of amoxicillin 1 g). 3 months later, she came back to Italy and started to complain of a slight persistent headache with a sense of oppression, apparently not related to the previous head trauma. At admission, no fever, no soft tissue swelling neither skin infectionwas present. The previous superficial wound, reported in anamnesis, was completely healed. Neurological examination was normal.
Laboratory tests showed: hemoglobin 13.3 g/dL, total leukocyte count of 9000/uL, neutrophils 67%, lymphocytes 24% with erythrocyte sedimentation rate of 22 mm/h, C-reactive protein (CRP) 0.5 mg/dL, and procalcitonin <0.05 ng/mL. Blood cultures tests were negative for bacteria, although IgG and IgM were positive for Mycoplasma pneumoniae.
The patient underwent brain magnetic resonance imaging (MRI) with the following protocol: axial and coronal FSE T2-weighted images; 3D-fluid-attenuated inversion recovery, diffusion-weighted imaging, and multiplanar T1-weighted images, before and after Gadolinium-DTPA (Gadovist 0.1 mg/kg) administration.
On T2-weighted images, MRI examination showed a high signal diploic area in the right parietal bone, with an extension from the outer cortical bone to the inner table. After gadolinium administration, an intense and homogeneous enhancement of the diploic lesion was depicted. The pathological process involved the galea and the underneath dura mater. A slight contrast-enhancement inside the surrounding diploe, next to the main lesion, was present [
Magnetic resonance imaging (MRI) examination at clinical onset. (a and b) Coronal fluid-attenuated inversion recovery. A focal high signal intensity at the soft subgaleal extracranial structures in the right parietal bone is well depicted (white arrow). (c and d) Coronal Dixon T1-weigthed images after Gadolinium-DTPA administration. The diploic lesion shows intense and homogeneous contrast-enhancement. Fat suppression technique well demonstrates the involvement of the galea (white arrows) and the subjacent dura mater (red arrows). A slight contrast-enhancement inside the surrounding diploe, next to the main lesion, was present.
For a better evaluation of the bone involvement, the patient underwent brain computed tomography (CT) which showed a circumscribed bone lytic defect with jagged edges. The osteolytic area was better depicted by volume rendering technique reconstruction that showed a “hole-like” image, without debris within the parietal bone. Slightly suffusion in the near soft tissues was also present [
Taken together the neuroradiological findings along with the history of traumatic head injury, a circumscribed osteomyelitis lesion was strongly suspected. A biopsy for microbiological testing and histopathological studies was proposed, but the patient refused to give consent.
Considering that no consensus exists regarding the duration of antibiotic treatment for osteomyelitis,[
Computed tomography (CT) and magnetic resonance imaging (MRI) at 1-year follow-up showing a complete regression of the lesion. A, CT scan showing a minimal bone irregularity; (b and c) postcontrast T1 WI-weighted MRI images showing a complete regression of the lesion with a normal inner and outer cortical tables. Only a slightly contrast-enhancement of the parietal diploe was observed at the pathological area (white arrow).
Osteomyelitis is a bone marrow infection related to different pathogenetic mechanisms potentially affecting any anatomic district.[
Osteomyelitis mainly affects a child with chronic inflammatory disease of paranasal sinuses.[
According to the literature, based on the site of the infection and the pathogenesis, cranial osteomyelitis can be divided into two main categories. Accordingly, the can be distinguished as sino-rhino-otogenic (SRO) and non-SRO (NSRO).[
NSROs, an object of our interest, are divided into iatrogenic, posttraumatic, and hematologic.
In adults, posttraumatic skull osteomyelitis generally occurs as a complication of minor or major head injuries associated with cranial fractures, mainly determined by direct bacteria penetration after skull injuries.[
Only one report, published, in particular, in 1998, it was described as a case of infected wound complicated by frontal osteomyelitis.[
The basis of appropriate therapy for cranial osteomyelitis is a precise diagnosis. Treatment of this infectious disease cannot be standardized due to the variable clinical presentations, locations, severities, etiologies, and the lack of data from randomized controlled trials. The spectrum of treatment goes from antibiotic therapy alone to combination with simple incision and drainage to invasive surgery. However, most diagnoses are delayed needing a combination of surgical debridement, correction of the primary source of infection and long-term use of antimicrobial agents. Patients with extracranial involvement or with acute localized osteomyelitis tend to be managed more conservatively than those with an intracranial extension or with chronic destructive forms. In these cases, the infected foci should be cleaned out thoroughly as early as possible, and the skin flap or myocutaneous flap should be to repair the wounds; thus, the good results can be achieved. There are various standard skull base approaches available for the removal of involved bones. These techniques require special care for the type of procedure and the appropriate timing of surgery. Surgical procedures may involve debridement of necrotic tissue, bone biopsy and culture, handling of the dead space after surgery, and when required, and bone stabilization.[
The treatment for cranial osteomyelitis includes a course of culture-guided long-term intravenous broad-spectrum antibiotic therapy which can take several months before a complete resolution is achieved.[
To the best of our knowledge, our case is the first reporting late osteomyelitis after a soft tissue trauma becoming symptomatic following a complete wound healing.
In our case, the mechanism underlying the bony infection can be related to the microorganism penetration from the skin with initial infection of the galea. Subsequently, extended from the galea to the diploe bone through the Haversian canal.[
In these cases, physical examination, and patient history may provide information to guide the diagnosis. In this scenario, neuroradiological investigations have an important role for the diagnosis of osteomyelitis, since laboratory testing (i.e., erythrocyte sedimentation rate, CRP levels, white blood cell, and procalcitonin) could not be helpful. In bone tissue diseases, CT and MRI are able to identify the site and the extension of the infection, showing benign or malignant features.[
Bone marrow edema can be detected in the early stage of disease (1–2 days after the onset of infection), and an early diagnosis prevents osteomyelitis complication such as bone and soft tissues abscess, chronic osteomyelitis, osteonecrosis, and cranial structures involvement with subdural or brain abscess.[
Focal cranial vault osteomyelitis, in the absence of severe trauma, is challenging to diagnose. Imaging findings and patient history can help in making a correct diagnosis. In uncertain cases, labeled leukocyte scintigraphy or bone biopsy can confirm the diagnosis.[
Finally, serial MRI examinations will provide information about the infection progression and its response to antibiotic therapy.
Osteomyelitis is a well-known inflammatory process accompanied by bone destruction. Early recognition of initial nonspecific symptoms is key to diagnosing and managing this treatable but life-threatening condition. Our case demonstrates that cranial osteomyelitis can occur even months later following a mild TBI. Accordingly, imaging findings and patient history should be carefully investigated to make a correct diagnosis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understand that her name and initial will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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