Osteomyelitis: Fill & Download for Free

It was during my “infectious diseases” rotation.It was the first day of the new rotation.There were 24 beds in the ward and two attendings. I had been assigned to the attending rounding beds 13–24. It was about 8:30 am and we medical students decided to divide the beds between us. We had just survived the first “morning report”, and witnessed an intern get fried while presenting an overnight admission.So, we divided the beds among us, each got 1 or 2 patients. I got the one at bed 13. We each visited our patients and wrote extensive notes. My own patient was a case of septic arthritis.So, we had almost finished doing our thing when the attending arrived to start rounding for the day. He’s a very respected ID specialist and indeed a great teacher. He also happened to be chief of the department. He introduced himself, talked a bit about the ward, and what he expected us to do, and then started presenting the patients and discussed relevant caveats (or clinical pearls as we call it) for each patient.The patient of bed #17 was an 18-year old girl. She had left thigh pain, which was more severe during the night. This and a couple other details and then the attending revealed the diagnosis to be an “osteomyelitis” of femur. She had had the symptoms for the last six months, but to no avail. She wasn’t better, if not worse. The plan was to continue the IV (intravenous) antibiotics, and she was to get discharged in a couple of days. She was already there a couple of weeks before that day.He was just about to move to the next patient as I raised my hand:“Sir, what if it’s not infectious at all?”It startled all in the room. Even the patient of bed #18 saw the seriousness of the situation and put down her cellphone, wondering what was coming. Medical students are at the lowest low of hospital hierarchy. No one expects us to know anything, and in the operating rooms or busy clinics, we’re just asked to leave for the day, because in a highly specialized medical center, the training of residents get precedence. After all, we’ll end up being lowly GPs (general practitioners) and provide primary care. That’s how the system looks at us.So, we were just expected to shut up for good. The attending said: “What do you mean, not infectious?”I said: “I mean like some growth, like Ewing’s.” I kept myself from blurting out “sarcoma”.The room was perfectly still. The residents rolled their eyes menacingly, because they had all sorts of duties like consultations from other wards and clinic after the rounds. I can’t exactly describe what happened for the next 20 minutes, as I was challenging the diagnosis, and having a heated discussion with the attending.Now that I look back, I wonder how I had the courage. I didn’t know the patient, hadn’t examined her, hadn’t seen the cultures, hadn’t even talked to her! It might just as well have been a nasty case of tough garden-variety osteomyelitis. What did I know?!What the attending said next shocked us all: “So let’s request an ortho consultation and ask for a biopsy, but Dr. Kaushansky if it turns out to be osteomyelitis, you have to pay the biopsy and pathology costs from your own pocket.”As department chief, he sure was teaching me a lesson there. Never contradict your elders, especially in front of the patients.So for the next 11 days, I had the nickname of Dr. Ewing. When I walked past the nursing station, I could hear giggles. That patient had to stay like a couple of weeks more and that cost was on me too. Man, we don’t even get paid. During the next days, when I was presenting my case at Bed 13, the residents would amusedly say: “Dr. Ewing, what was the temperature, again?”. And the attending would grin. I was sure I had already failed and was going to repeat this rotation.And then came the judgment day. It was the eleventh day. I went to the pathology department to fetch the results. I couldn’t stop myself from opening the envelope. The last line was something like:“Small blue round tumor cells. Probable dx: Ewing’s sarcoma. Consider requesting IHC.” (Immunohistochemistry was costly and they wouldn’t do it unless we specifically requested it.)That literally saved the patient. Once we asked for a chest CT, there were already metastases in the lungs. But we had caught it, relatively early, and it was treatable.I still bear the nickname Dr. Ewing. But now it’s my pride. I was the med student who had found it. I got the best grades from the chief. The patient was saved.So, despite all the grim despair in between, this turned out to be one of my best experiences in medical school.Biblio note: Dr. James Ewing (1866–1943) was a renowned clinical pathologist and oncologist and he’s a founding father of the American Cancer Society, American Association of Cancer Research, and Memorial Sloan Kettering Cancer Center. In 1921, he discovered a new bone tumor that now bears his name: Ewing’s Sarcoma. Wikipedia

We don’t know for sure. We can only take his symptoms and match them to a disease. One thing we do know for sure is that the Tudor diet was terrible. What Henry ate may have contributed to his leg ulcers and a host of other illnesses.At Henry VIII’s court, a staggering range of meats and fowl would be enjoyed, including brawn, beef, mutton, bacon, goose, veal and lamb. Kid, hens, capons and peacocks also featured, as did cygnet, mallard, teal, woodcock, ousels, thrush, robins, cranes, bitterns, buzzards and venison of all sorts. Venison was the king of meats – not available to buy, it was hunted in the deer parks of the king and his nobles, and frequently given as a present. Henry VIII sent a hart to Anne Boleyn as a symbol of courtship.During Lent and on fasting days, meat was replaced by an extraordinary array of fish and other seafoods, including seal and porpoise, the latter apparently a great favourite of Katharine of Aragon.The Tudor diet was 80% protein and may have contained an astonishing 5,000 calories per serving.“And if they [nobles and many of their servants] do not have 20 varied meat dishes at dinner and supper, they consider themselves slighted.“Thomas Starkey, Oxford lecturer, c1529For formal feasts, each course was heralded by the entrance of the ‘subtlety’. This was an extraordinary decorative art form, the creation of wonderful representations of castles, cathedrals, hunting scenes or similar, made of marzipan and spun sugar for the most important feasts, and of wax for lesser occasions.Modern day recreation of a subtlety showing the Greek sorceress Circe transforming Odysseus’ men into swine. It is made entirely of sugar and is edible.In 1527, Cardinal Wolsey served a superlative feast for the French embassy, including subtleties of castles, of the church and spire of St Paul’s, of “beasts, birds, fowls of diverse kinds, personages… some fighting… some leaping… some dancing”, and a whole chess set of sugar paste, which the French delighted in so much it was boxed up and sent home with them.Consequently, Henry may have had uncontrolled diabetes. Any small cut on the foot or leg could be dangerous. The cut may not heal. It could grow larger and become infected. In some cases amputation is the only cure, even today.The great wound in his thigh may have been osteomyelitis. Osteomyelitis is an infection of the bone, a rare but serious condition. In most cases, a bacteria called Staphylococcus aureus, a type of staph bacteria, causes osteomyelitis.Certain chronic conditions like diabetes may increase your risk for osteomyelitis. Henry’s wound needed to be kept open so the pus could continually drain out. It was lanced several times with a red hot poker. It was said that the wound could be smelled three rooms away.Henry may also have had varicosities that ulcerated and never healed. We cannot rule out deep vein thrombosis (DVT) or gout. Both of which are extraordinarily painful. DVT may result in a pulmonary embolism, which would be deadly.Gout is caused initially by an excess of uric acid in the blood, or hyperuricemia. It causes intense pain in the joints, often the joint of the big toe, but all joints can be affected. If left untreated, gout can cause erosion and destruction of a joint. Uric acid is produced in the body during the breakdown of purines - chemical compounds that are found in high amounts in certain foods such as meat, poultry, and seafood, which constituted much of Henry’s diet.Recently historians have looked at the garters Henry wore under his knees. He was inordinately proud of his calves and the garters showed them off to great effect. They have debated how tight the garters were and if they could have also contributed to his leg ulcerations. You can see the garters here:Henry continued to eat the same amount of food, maybe even more, than he had as an athletic young man. That, and his forced immobility, caused him to ballon up to 400 lbs. His waist went from 34” to 54”. He had to be winched up onto his horse and was moved from room to room with a rudimentary wheelchair.Henry VIII had the misfortune of living in a time without antibiotics or painkillers. He died in agony, 28 January 1547, at the Palace of Whitehall, London.

Difficult, but most often possible.We give antibiotics longtime, preferably those that can penetrate bone tissue well.The infected often dead bone often needs to be surgically removed extensively.Recommendations for the treatment of osteomyelitisAccording to http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3336146/ the rate of success of osteomyelitis treatments is between 75 to 90%.