Inadvertent self-healing in desperate times

Correspondence to: Dr Sean X Leng, Johns Hopkins University School of Medicine, 5505 Hopkins Bayview Circle, Baltimore, MD 21224, USA sleng@jhmi.edu In February, 2007, a 47-year-old woman was admitted to our hospital, with stage IV pressure ulcers. She had become paraplegic in 1999, after a bullet damaged the spine at the level of the 9th thoracic vertebra. Pressure ulcers developed in 2006. In December, 2006, the patient devel oped a high fever and was found to have worsening pressure ulcers and meticillin-resistant Staphylococcus aureus bacteraemia. Her condition improved with intravenous vancomycin and wound debridement. Because she was doubly incontinent, a Foley catheter was inserted, and a colostomy was done to reduce wound contamination. The patient was transferred to a nursing home, but developed intermittent fever, anorexia, and severe left hip pain. After several weeks, she was transferred to our hospital. On admission, she was cachectic, at 48·2 kg, and had fi ve large stage IV pressure ulcers on the lower back and hips (fi gure). Her white-blood-cell count, and serum concentration of C-reactive protein (CRP) were 14·2×10 per L, and 167 mg/L, respectively. Her serum concentrations of haemoglobin and albumin were only 87 g/L and 19 g/L, respectively. We started to treat her with vancomycin. For wound care, we used an antimicrobial gel. CT showed erosion of the femoral head and neck, inferior pubic ramus, and acetabulum, with fl uid and air in the left hip joint. CT-guided aspiration yielded clear liquid, cultures of which were negative. Despite treatment, the patient’s condition worsened. The hip pain and fever continued; the white-blood-cell count and serum concentration of CRP rose as high as 18·5×10 per L and 257 mg/L, respectively; the serum albumin concen tration fell to 13 g/L, and the patient’s weight to 43·6 kg. 6 weeks after admission, radiography showed that the femoral head and neck were separated from the rest of the femur, and medially displaced. Hours later, a bone fragment fell out of a pressure sore, while the dressing was being changed. The patient’s condition then started to improve. The fever and pain ceased immediately, and the pressure ulcers began to heal. 8 weeks after the fragment fell out, the patient’s weight had increased to 58·2 kg; the serum concentrations of haemoglobin and albumin were 128 g/L and 32 g/L, respectively; the white-blood-cell count and serum concentration of CRP were 8·25×10 per L and 22 mg/L, respectively. At the end of August, 2007, the patient remained in hospital; she had no fever, her weight was stable at 59 kg, and her wounds continued to heal. Pressure ulcers are common in elderly people, and people with spinal-cord injuries. For several years after being shot, our patient had been cared for by relatives and had been able to live at home. When a close relative died, the standard of care provided by her family decreased substantially, and a fragmented health system did not fully meet her needs. We think that the osteomyelitis was caused by infection spreading from an ulcer, either directly or through the bloodstream. The infected proximal femur developed avascular necrosis. Because the blood supply to the proximal femur was so poor, intravenous antibiotics were largely ineff ective. Ordinarily, we would have done an excision arthroplasty, known as the Girdlestone procedure, to remove the infected bone. However, the patient was so ill that surgery was judged to be unaccept ably risky. Fortunately, the necrotic bone dropped off , eerily mimicking the Girdlestone procedure.