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5/24/16 ChiefComplaint ! A15yearoldhighschoolwrestlerpresentswithachiefcomplaintof sharpsternalchestpain JKendallChristensen,DO EdwinKornoelje,DO BrianHinkley,DO http://www.methalab.net/health/cancer-patient-receives-3d-printed-sternum-ribs-in-first-of-its-kind-surgery/ http://medicalpicturesinfo.com/sternum/ History History ! Days1–2 ! Day1 ! Days3–4 ! Overthenext2dayspaincontinuedtoworsenandwaswakinghimfrom sleep. ! ! Patientwasatwrestlingpracticewhenhenoticedgraduallyworseningsternalchest painafter5-6take-downdrills. Sternalchestpaincontinuedthroughoutpracticeandgraduallyworsenedovernight. ! Day2 ! ! Hedevelopedfever Hisparentstookhimtoseetheirchiropractorwhichresultedinsignificant worseningofhispain. 1 5/24/16 2viewchest History ! Day4 ! Hewastakentoorthopedicurgentcareclinicandevaluatedwithplainfilms andanMRI ! Bothwerereadasnormal ! HewassenttohisPCPtobeworkedupforpneumonia ! ! ! EmergencyDepartment ! ! Noacutecardiopulmonaryprocess identified. examnotconsistentwithpneumonia Hislabswerenormalatthattime History ! Day5 ! ! FINDINGS: ! Visualizedsternumappearsgrossly intact. Labs–Normal ! TroponinT–<0.011 CTChestwithContrast ! FINDINGS: ! Regardingtheosseousstructures,thereareallgrossly intactandage-appropriate.Specificallythesternum showsnodisplacedfractureorcorticaldisruption. Developingossificationcentersofthesternumall appearintactandage-appropriate. EKG–Normal ! ! NSR,HR82,RVRinV1(normalinathlete) NootheracuteST/Twavechangesnoted,orevidenceof ischemia. ! CXRrepeated–normal ! CT–readasnormal ! IMPRESSION: ! Normalfindings. ! Specificallythereisnoevidenceofdisplacedor deformingsternal,riborvertebralbodyfracture. ! Noacutecardiopulmonaryprocess. 2 5/24/16 History History ! Days6–8 ! Day7 ! BloodculturesorderedbyPCP ! Painandfevercontinued ! Feversreaching104.5F ! ! Developed ! Myalgias ! Dizziness ! anorexia ! Intermittentnauseaandvomiting ! Grampositivecocciinclusters ! Day8 ! Senttotheemergencydepartmentatalocalchildren’shospital ! Admittedtohospitalwithpediatricinfectiousdiseaseconsult PossiblysecondarytoTylenol#3 ByZorin09-Ownwork,CCBY-SA3.0,https://commons.wikimedia.org/w/index.php?curid=22027665 PhysicalExam ! Vitals: ! Temperature PhysicalExam ! Cardiovascular:Normalrate,regularrhythmandnormalheartsounds. -38ºC ! Bloodpressure -114/54 ! Pulse -78 ! SpO2 -96% ! Respiratoryrate ! Pulmonary:pooreffortsecondarytopain.Hehasnowheezes, rhonchi,orrales. ! Chestwall:Heexhibitstendernessofthesternumandsurrounding tissues.Nomass,laceration,crepitus,edema,deformity,swelling,or retractionsnoted. -20 3 5/24/16 DifferenBalDiagnosis TestsandResults ! Sternalosteomyelitis ! Labs: ! WBC–5.79 ! Bands–17% ! Sedrate–20 ! CRP–188.4 ! Endocarditis ! Infectedretrosternalhematoma ! Pericarditis/myocarditis ! Infectedpericardialeffusion ! Malignancy ! ECHO:Structurallynormalwithnoevidenceofvegetation sternum.(n.d.)Mosby'sMedicalDictionary,8thedition.(2009).RetrievedMay62016from http://medical-dictionary.thefreedictionary.com/sternum TestsandResults Final/WorkingDiagnosis ! MRIwithandwithoutcontrast ! Primarysternalosteomyelitiscomplicatedbystaphylococcusaureus ! Findings:MinimalT2andpostgadoliniumhyperintensityinthefirstandsecondsternalsegmentswith bacteremia. surroundingedema,includingtheretrosternalspaceandpectoralisinsertions;noosteonecrosisor periostealabscess.MinimalfocalT2andpostgadoliniumhyperintensitysuperiorlyinthemidlineofthe manubriumbutnoadjacentsofttissueabnormality.Normalappearanceofthecostalcartilageandcostosternal junctions.Nopericardialeffusion.Smallrightpleuraleffusion.Streakylowerlobediseasemayrepresent pneumoniaoratelectasis.Theupperabdomenasvisualizedisnormal. ! IMPRESSION:Probablesternalosteomyelitis. http://www.gettyimages.com/detail/photo/staphylococcus-aureus-high-resstock-photography/128578136 4 5/24/16 Treatment Outcome&Follow-up ! IVVancomycinuntilsensitivitieswereavailable ! Follow-updonebypediatricinfectiousdiseaseafter4weeksoforal ! IVAncef(cefazolin)for2weeksfollowedbyoralKeflex(cephalexin)for4 weeks. ! Surgicalinterventionwasnotfoundtobenecessary. Keflex. ! Hewasfeelingmuchbetteranddeniedanypainordifficultybreathing ! Appetitehadimprovedandinflammatorymarkershadreturnedtonormal ! Hewasdischargedfromthepediatricinfectiousdiseasepractice ReturntoacBvity PRIMARYSTERNALOSTEOMYELITIS ! Hehadgraduallyreturnedtosportsundersupervisionoforthopedics ! Rarecondition afterremovalofPICCline ! Whenheexerciseshefeelsoutofshapebuthasnomarkedfatigue ! IntheUSitisusuallycausedbyStaphaureus ! Secondmostcommonpathogenispseudomonasaeruginosa ! Intravenousheroinusers ! Mayormaynotfollowblunttraumatothechest 5 5/24/16 PRIMARYSTERNALOSTEOMYELITIS ! Rarecauses ! Aspergillus ! Nocardia ! ActinomycesIsraelii PRIMARYSTERNALOSTEOMYELITIS TREATMENT ! Incisionanddrainagewithsurgicaldebridement ! Effortstakentokeepposteriorperiosteumintact ! Mildcasescanbetreatedwithappropriateantibiotictherapyalone ! Lessaggressivethansecondaryosteomyelitis ! SternalosteomyelitissecondarytoTuberculosisisacauseinendemic areas. ! Hyperbaricoxygentherapy ! Mayspeedrecoveryanddecreaseneedforreconstructivetherapy. SecondarySternalOsteomyeliBs SecondarySternalOsteomyeliBs ! Causes: ! Causes: ! Complicationofopenheartsurgery ! Complicationofopenheartsurgery ! Penetratingtrauma ! Penetratingtrauma ! Whateverthisis! ! Whateverthisis! http://skullappreciationsociety.com/sternum-skull-implant/ 6 5/24/16 https://3dprint.com/95371/3d-printed-ribs-and-sternum/ References ! KellyCA,ChettyMN.Primarysternalosteomyelitis.Thorax.1985; 40.11:872-873. ! MeldrumWH,HasanZ.PrimarySternalOsteomyelitis:ACaseReport andReviewoftheLiterature.Journalofcardio-thoracicmedicine.2016; winter,vol.4iss.1:418-421. ! MittapalliMR.PrimaryOsteomyelitisoftheSternum.Thorax.1979; 34:680-681. ! WilenskyAO,SamuelsSS.Osteomyelitisofthesternum.AnnSurg.1926; 83:206-16. ThankYou! 7