Age: 0.28
Sex: F
Vaccine: DTAPHEPBIP, HIBV, PNC
Symptoms: Incisional drainage, Irritability, Methicillin-resistant staphylococcal aureus test positive, Oedema peripheral, Osteomyelitis
Clinical narrative: This 3 mo 10 day old was seen at our facility on 10/24/05 and received the following: DTP, Hep B, IPV (Pediarix) in left thigh, and Hib, and Pneumococcal in right thigh.  She also received shots on 7/23/05, 4/07/06, and 7/31/07.  No reports of problems by mom to our facility. On 10/30/05 the patient was seen in the ER because of "crying all day and only had 3 wet diapers."  Her temp was 101.7 but child was wearing a "snowsuit".  Mom was instructed to remove clothing so she could cool off.  Her WBC was 11.7 with 63 segs, 31 L and she had a neg blood culture.  There was no mention of a swollen leg at that visit.  Pt. was seen at 11:15 PM and signed out AMA at 4:30 AM next day.  The ER was trying to obtain a UA.  Mom stated she would go see her own doctor that day.  Pt also had a nl chest X-ray. On 10/31/05 patient was seen at Clinic by pvt MD.  Her CC was "acts like stomach hurts, cranky, fever"  She was diagnosed with BOM and Rx with Amox. On 11/1/05 pt. was seen in pvt doc office for "soft tissue swelling of left upper leg"  (This was 7 days post vaccination).  X-rays were read as: increased density of soft tissues over the quadriceps muscle on the ant-lat margin of thigh.  Imp: No evidence of bony injury to left femur.  Soft tissue density findings which may represent edematous change in this area. On 11/2/05 the patient was seen in ER because of "left thigh swelling noted 2 days ago".  Patient was admitted with dx of possible osteo and possible UTI.  UA culture was neg but cultures of finger and leg grew MRSA. X-rays of the hips and lower extremity showed no evidence of fracture or dislocation. 11/3/05 X-rays: Marked swelling and stranding of sub Q and thigh musculature.  Linear metaphyseal lucency noted of distal femur. 11/3/05  Ultrasound guided I and D: Imp: Ultrasound guided aspiration of the large subperiosteal abscess overlying the mid to distal left femur.  A total of 32 ml of purulent fluid was aspirated from three different sites. 11/4/05  CT of left femur. Imp: Subperiosteal abscess seen involving the entire shaft of the left femur.  The abscess in the proximal half of the femur is present anterolaterally while more distally it is seen circumferentially.  Inflammatory changes are seen in the quadriceps musculature as well as the subQ fat. On 11/4/05 the patient went to surgery with the diagnosis of left femur osteo and left 5th digit abscess.  Extensive drainage was performed on the left femoral diaphysis and the pt. did well (see accompanying op note).  Orthopedic hand saw her on 11/7/05 and I and D her left fifth digit. She was discharged on 11/8/05 to receive a total of 6 weeks of IV Clindo.  Both ID clinic and Ortho clinic followed this patient closely.  The IV med was d/ced 12/20/05. On 12/06/05 x-ray showed: 1. Findings of healing osteo 2. Gap in the posterior aspect of the distal portion of the involucrum (covering or sheath) with question of underlying sequestrum (piece of dead bone that has become separated during the process of necrosis) formation. 3.  Lg. area of irregular bone destruction across the proximal femoral metaphysis raising concern for the possibility of an impending fracture. 4.  The left finger showed marked soft tissue swelling but no definite abnormality of underlying bone involvement. On 1/25/06 the patient was re-admitted because of a recurrence of her osteo.  X-ray at that time showed remodeling of her femur (healing).  Ultrasound showed subperiosteal abscess extending from mid thigh to just above the knee laterally. On 1/26/06 the patient had surgery where they found a large subperiosteal abscess about the distal half of her left femur.  A small intramuscular abscess was noted and drained also. On 1/30/06 the patient was D/Ced with the diagnosis of chronic osteo, on IV Vanc and po Rifampin for a total of 8 weeks. Her antibiotics were D/Ced on March 21, 06. 11/10/06 X-rays: Show an anterior bow of the femur and a little varus as well.  The distal femoral physis has almost a notched appearance centrally but there is no obvious growth arrest.  Proximally the physis is widened and irregular.  The proximal femur has what appears to be a deformity just like congenital coax vara. On 11/10/06 the pt was seen by Ortho doc who reviewed all the old x-rays from Dec 05.  He said they showed an apparent pathological fracture in the very proximal aspect of the proximal femoral metaphysis, which subsequently healed with coax vara (hip joint turning in) deformity. Assessment: 1.Coxa vara of left hip with secondary malunion of a pathological fracture. This results in some shortening of the left leg as well as increased adduction, decreased abduction, and significant external rotation deformity of the leg. 2. Generalized anterior bow of the femur, which further contributes to some shortening. 3. Irregularity of the physes particularly proximally but no obvious physeal arrest after extensive osteo. Physical exam-2007: Has a slight short leg limp and out toeing of the left leg. X-rays showed a right leg length of 367.5 and the left 350.3 accounting for a 12.2 mm leg length discrepancy.  Assessment: Left coax vara (turning in  probably due to pathological fracture through the femoral neck at the time of the original infection (meaning secondary to the infection itself) Minor leg length discrepancy and slight genu valgus which seems stable. 6/2/08-records received for DOS 11/3-11/8/05-DC DX: Left femur osteomyelitis with subperiosteal abscess. Left fifth digit abscess. Presented to ED with 2 day history of fever and left leg swelling. Left leg swelling present since date of vaccination but worsened over last 48 hours. Bilateral otitis media. Leg swelling increased, fever, decreased po intake with vomiting and loose stools after amoxicillin. Pain with movement of left leg, generalized fussiness. X-ray of hips and lower extremity showed no evidence fo fracture. Ultrasound suggestive of osteomyelitis of femur. Incision, debridement, irrigation and Needle aspiration of abscess.