Relapsed boyhood tibia polymicrobial osteomyelitis linked to dermatophytosis: a case report

Abstract

Background: Relapsed childhood polymicrobial osteomyelitis associated with dermatophytosis has not been reported in the literature.

Case presentation: Here we report on a case of a 45-year-old man who had left tibial osteomyelitis for 29 years, accompanied by skin fungal infection of the ipsilateral heel for 20 years, and underwent a second operation due to recurrence of polymicrobial infection 6 years ago. The patient had a history of injury from a rusty object, which penetrated the anterior skin of the left tibia middle segment causing subsequent bone infection, but was asymptomatic after receiving treatments in 1983. The patient was physically normal until dermatophytosis occurred on the ipsilateral heel skin in 1998. The patient complained that the dermatophytosis was gradually getting worse, and the tibial wound site became itchy, red, and swollen. The left tibial infection resurged in May 2012, leading to the patient receiving debridement and antibiotic treatment. H&E and Gram-stained histology was performed on biopsy specimens of sequestrum and surrounding inflammatory tissue. Tissue culture and microbiology examination confirmed polymicrobial infection with Staphylococcus aureus (S. aureus) and Corynebacterium and a fungus. Additionally, the patient also received potassium permanganate for dermatophytosis when he was admitted into the hospital.

Conclusions: Together with longitudinal follow-up of medical history, surgical findings, histopathological and microbiology culture evidence, we conclude that boyhood tibia polymicrobial osteomyelitis with S. aureus and Corynebacterium occurred in this patient, and the fungal activation of dermatophytosis may have led to osteomyelitis relapse.

Keywords: Corynebacterium; Dermatophytosis; Polymicrobial osteomyelitis; Relapse; Staphylococcus aureus.

Fig. 1

Preoperative imaging evaluation determined osteomyelitis lesion range and severity in 2012. The plain radiography of left tibial approximal diaphysis showed a central area of radiolucency with a surrounding thick rim of reactive bone sclerosis (A, B white arrows). CT scan found a cloaca (C, D white arrows) and adjacent reactive bone (E–G, red areas) from lesion area of Panel B (red arrows). Then we performed 3D reconstruction analysis by using a software Amria to determine the reactive bone within the intramedullary (H tibial; I intramedullary reactive bone; J, K sagittal section of tibia). The infection was confirmed by the emission computed tomography (ECT) (L–O)

Fig. 2

Polymicrobial tibia infection confirmed by histopathological debrided sequestrum, and dermatophytosis confirmed by biopsy. The sequestrum (A–D) and surrounding inflammatory tissue (H) were collected during operation debridement, and Gram staining was performed (A) to show Gram-Positive staining in soft tissue (Yellow arrowheads) (A, B), and sequestrum bone (white and red arrowheads) (A, C, D), but adjacent skin shown chronic inflammatory cells and neutrophil infiltration (H) in 2012. The fellow-up (E–G) fungal culture-positive (I) from left heel skin biopsy in 2018

Fig. 3

Long-term follow-up shown limited tibial fistulous tract still remaining. The post operation follow-up were performed by plain radiography on May 25th (A, B) and June 18th, 2012 (C, D); and April 16th, 2018 (E, F), and MRI on April 24th, 2018 (G–K). There is an open window for decompression drainage on the left tibial anteromedial side (A–D) which gradually healed and recanalization of the medullary cavity (E, F). Although the bone infection lesions were not able to completely removed (G: white arrows, red segmentations in H–K), the abundant blood supply around the lesions limited the spread of the infection lesions to the surrounding shown in MRI 3D reconstruction (H–K)