HEMOGLOBINOPATHY AND PATTERN OF MUSCULOSKELETAL INFECTION IN CHILDREN: Results

A total of 119 patients were studied. Their mean age was 7.9±5.6 years. Sixty-eight (57.1%) of them were males and 51 (42.9%) were females, giving a male-female ratio of 1.3:1 As shown in Table 1, among 78 patients whose genotype were determined, 49 (62.8%) had hemoglobin genotype AA (HbAA) and 16 (20.5%) had HbSS, while seven (9%) and six (7.7%) had HbAS and HbAC, respectively. My Canadian Order net

Table 1. Clinical and Demographic Features of the 119 Patients

Number (%) Age
<13 years 57
13-18 years 62
Sex
Male 68 (57.1)
Female 51 (42.9)
Genotype
HbAA 49 (62.8)
HbSS 16 (20.5)
HbAS 7(9)
HbAC 6 (7.7)
Signs and Symptoms
Pain 83 (69.7)
Swelling 79 (66.4)
Tenderness 69 (58)
Sinus 31 (26.1)
Ulcer 13 (10.9)
Limp 4 (3.4)
Temperature
Mean 38.6°C±0.7°C
Range 37.4°C-40.5°C

The most common MSS infection was COM— 53.8%. The least common were tuberculous arthri­tis and necrotizing fasciitis—one patient each— Table 2. Others include pyomyositis (17.6%), septic arthritis (10.1%), and cellulitis (5.9%). Septic arthritis affected the knee in 55.6% of patients, while the hip, elbow, and shoulder joints were affected in 22.2%, 11.1 %, and 11.1 %, respectively.
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Table 2. Prevalence of Musculoskeletal Infections and Bacterial Pathogens

Number %
Diagnosis
Chronic osteomyelitis

64

53.8

Acute osteomyelitis

13

10.9

Pyomyositis

21

17.6

Cellulitis

7

5.9

Septic arthritis

12

10.1

Tuberculous arthritis

1

0.8

Necrotizing fasciitis

1

0.8

Bacterial Isolate
Staphylococcus aureus

38

47.5

Klebsiella sp

11

13.8

Pseudomonas sp

9

11.3

Proteus sp

5

6.3

Non hemolytic streptococcus

2

2.5

E. coli

1

1.3

No growth

14

17.5

Total

80

100

Sixty-six bacterial pathogens were isolated from 59 patients. Fifty-two were isolated in single cultures and 14 in mixed cultures. Staphylococcus aureus (S. aureus) was the most common pathogen—57.6% (38/66). Others were Klebsiella sp—16.7% (11/66), Pseudomonas sp—13.6% (9/66) and Escherichia coli (E. coli)—1.5% (1/66). S. aureus accounted for 62% (29/47) of the pathogens isolated in COM and 58% (7/12) in pyomyositis. On the other hand, Gram-negative bacilli accounted for 34% (16/47) and 42% (5/12) of these infections respectively. S. aureus was the most common single pathogen isolated from patients with HbAA—63% (17/27), HbSS—40% (4/10), and from those with HbAC and HbAS— 58% (7/12). The prevalence of Gram-negative bacilli in these groups of patients was 33%, 60%, and 33%, respectively (Table 3).

Table 3. Distribution of Bacterial Pathogens by Genotype

Bacterial Pathogens
Genotype

S. aureus

Pseudomonas

Klebsiella

E. coli

Proteus

Nonhem. Str.

No growth

HbAA

17

4

5

0

0

1

9

HbSS

4

3

1

1

1

0

2

HbAS

4

2

0

0

0

0

0

HbAC

3

0

1

0

1

1

1

Total

28

9

7

1

2

2

12

S. aureus: Staphylococcus aureus
E. coli: Escherichia coli
Nonhem str: Nonhemolytic streptococcus

Pain and swelling were the most frequent presenting complaint, occurring in 83 (69.7%) and 79 (66.4%) patients, respectively. Fever was present on admission in 42 patients. The mean temperature on admission was 38.6°C±0.7°C (range 37.4°C-40.5°C). Thirty-one (26%) patients presented with a discharging sinus, while 13 (10.9%) had an ulcer (Table 1). Radiographic evidence of COM was documented in 33 (51.6%) of the 64 patients with this condition. Total leucocyte count ranged between 2,700 and 26,390 per cumm (mean 8,796±5,056 per cumm). Erythrocyte sedimentation rate (ESR) on admission ranged from 2- to 80 mm/hour (mean 53±14 mm/hour).
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Table 4. Distribution of MSS Infections by Genotype

Genotype (%)
Diagnosis

HbAA

HbSS HbAS

HbAC

Total
Chronic osteomyelitis

31 (63.3)

8 (50) 4(57)

4(67)

47

Acute osteomyelitis

4 (8.2)

6 (38) 0

0

10

Pyomyositis

7(14.3)

1 (6) 2 (29)

0

10

Cellulitis

3(6.1)

1 (6) 0

0

4

Septic arthritis

3(6.1)

0 1 (14)

2 (33)

6

Necrotizing fasciitis

1(2.0)

0 0

0

1

Total

49

16 7

6

78

Table 4 shows that COM was the most common MSS infection in all patients irrespective of genotype. It accounted for 63% (31/49) of the infections in those with HbAA, 50% (8/16) in those with HbSS, 57% (4/7) in those with HbAS, and 67% (4/6) in those with HbAC. Patients with hemoglobinopathies in general seem to be equally as likely as those with normal genotype to have osteomyelitis rather than pyomyositis—22/25 versus 35/42 (RR=1.29; 95% CI 0.47-3.50), P=0.4. Also they appear to be equally likely to have osteomyelitis compared with soft tissue infections generally, 22/29 versus 35/49 (RR=1.16; 95% CI 0.39-4.11), P=0.9. The likelihood of having osteomyelitis among hospitalized patients with HbSS is twice that of those with HbAA, 14/16 versus 35/49 (RR2.29; 95% CI 0.58-8.99) p=0.3. Also patients with HbSS are twice as likely, as those with the other hemoglobinopathies, to have osteomyelitis 14/16 versus 8/13 (RR=2.23; 95% CI 0.66-7.49) p=0.2. These differences are not statistically significant.
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