Ghorashi et al. Journal of Medical Case Reports 2011, 5:241 http://www.jmedicalcasereports.com/content/5/1/241 signs, including pulse rate, respiratory rate, body tem- perature, O2 saturation under the oxygen hood and without using the oxygen hood were 158/min, 48/min, 38.6°C, 95% and 89%, respectively. Her cerebrospinal fluid (CSF) was purulent, and CSF analysis showed 520 mg/dL protein; 16 mg/dL glucose; many white blood cells (WBCs), with 85% polymorpho- nuclear cells and 15% lymphocytes; and 25 red blood cells (RBCs)/mm3. The results of the other laboratory tests are shown in Table 1. In the CSF and blood cul- ture, K. pneumonia was resistant to most of the antibio- tics and sensitive only to ciprofloxacin and co- trimoxazole. Her chest X-ray showed bilateral humeral osteomyelitis and bilateral glenohumeral joint arthritis (Figure 1). On the basis of the paraclinical evidence, diagnoses of K. pneumoniae septicemia, meningitis, arthritis and osteomyelitis were made, and a treatment protocol with a combination of intravenous ciprofloxacin and co-tri- moxazole antibiotics was started (for 28 days). At the end of the intravenous treatment period, she weighed 2420 g, and her CSF analysis and culture were within normal range. Afterward, she was discharged with oral ciprofloxacin, co-trimoxazole and rifampicin for another 28-day period. Figures 2 and 3 show her chest X-rays obtained on the seventh and 28th days of oral antibiotic therapy, respectively. At the end of 28 days of oral anti- biotic therapy (when the patient was 88 days old), her weight had reached 4250 g and normal glenohumeral joints and humerus bones were shown on her chest X- ray. During three years of follow-up, she had normal developmental milestones and was not readmitted to the hospital. Discussion Prolonged hospital stay, decreased gestational age, pro- longed use of broad-spectrum antibiotics and Table 1 Laboratory tests and results on admissiona Complete blood cell count WBC count (cells/ 6500 μL) Hb, g/Dl 7.8 Platelets, n/μL PMN cells, % Eosinophils, % Lymphocytes, % Monocytes, % Band cells, % 773 × 103 51 1% 24% 2% 21% Arterial blood gas Biochemical analysis FBG (mg/ 42 pH 7.29 dL) Cr (mg/dL) 0.5 HCO3- (mmol/ 20 L) BUN (mg/ 24 PCO2 (mmHg) 43 dL) Electrolytes Other Na (mEa/L) 136 CRP K (mEa/L) 45 Blood group Ca (mg/dL) 10.8 2+ A+ aWBC, white blood cells; Hb, hemoglobin; PMN, polymorphonuclear cells; CRP, C-reactive protein; Na, sodium; K, potassium; BUN, blood urea nitrogen; FPG, fasting plasma glucose; Ca, calcium. Page 2 of 4 Figure 1 Chest X-ray obtained at the time of admission. Bilateral osteomyelitis in the humerus presented as osteolysis and involucrum. Also, there is sequestration because of osteonecrosis and a pathologic fracture in the proximal part of the humerus. Dislocation of right glenohumeral joint brings up the arthritis diagnosis. There is complete osteolysis in proximal metaphysis in the left humerus and arthritis in the left glenohumeral joint. The heart, lung and pleural space have a normal appearance, while the thymus is atrophic. inadequacy of some basic facilities and staffing carry the risk of introduction of resistant hospital pathogens [4-6]. In the present case, all of the above-mentioned factors, combined with prematurity, predisposed the neonate to a higher risk of contracting nosocomial K. pneumoniae arthritis, osteomyelitis, septicemia and meningitis, although the common cause of osteoarthritis is Gram- positive cocci [7]. Adeyemo et al. [8] reported an outbreak of bone infections associated with neonatal septicemia by K. pneumoniae in 12 neonates over a six month period at the Special Care Baby Unit, University College Hospital, Ibadan, Nigeria. All patients had septic arthritis, 10 of them had osteomyelitis and 50% had multiple-joint involvement. Hospital-acquired K. pneumoniae has been reported to be resistant to multiple antibiotics [8,9]. In addition, Ghahramani and Nahaie [10] showed that K. pneumo- niae is the most common cause of septicemia in the neonatal ward of the Tabriz Al-Zahra Gynecology and Obstetrics Referral Hospital in Tabriz, Iran. The parenteral third-generation cephalosporins appear to be a major therapeutic advance in the