|Year : 2020 | Volume
| Issue : 3 | Page : 104-108
Brodie's abscess: Brief review of key updates from the year 2010
Ganesh Singh Dharmshaktu
Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand, India
|Date of Submission||09-Nov-2020|
|Date of Decision||02-Dec-2020|
|Date of Acceptance||02-Dec-2020|
|Date of Web Publication||31-Dec-2020|
Ganesh Singh Dharmshaktu
Department of Orthopaedics, Government Medical College, Haldwani - 263 139, Uttarakhand
Source of Support: None, Conflict of Interest: None
Brodie's abscess is an uncommon condition presenting as a subacute type of bone infection leading to localized pus collection. The common clinical presentation ranges from mild pain to serious functional impairment. The judicious radiological investigation helps in early diagnosis in suspected cases. The presence of a well-defined lytic lesion surrounded by sclerotic margins is a typical radiological feature that after exclusion may lead to a provisional diagnosis. The use of magnetic resonance imaging may prove supportive in further characterization of lesions and exclusion of related disorders. Final confirmation requires culture or histopathological evaluation following aspiration or biopsy following surgical drainage. The overall outcome has been good, following the appropriate diagnosis and management. This article attempts to give readers an overview of the reported cases or small series in the last decade (2010 onwards) in PubMed. This shall serve as a recollection of the spectrum of the clinical presentation and management of Brodie's abscess for educative purposes.
Keywords: Bone infection, curettage, drainage, osteomyelitis, pus, subacute osteomyelitis
|How to cite this article:|
Dharmshaktu GS. Brodie's abscess: Brief review of key updates from the year 2010. J Orthop Dis Traumatol 2020;3:104-8
| Introduction|| |
Brodie's abscess is an eponymous variant of bone infection named after Sir Benjamin Brodie who described a distinguished abscess formation involving tibia in 1832. Two of three cases described by Brodie were managed successfully with incision and drainage. The reported prevalence of this subacute form of osteomyelitis is 2.5%–42% of primary bone infections. In a recent systematic review of reported cases comprising a total of 70 articles (including 407 patients in total), important findings of the disease have been described. Young (mean age 17) and males are commonly affected, with pain and swelling being common complaints. Most cases were afebrile and only less than half of cases had raised inflammatory markers. Staphylococcus was the most common organism isolated and treatment outcome mostly consisted of surgical intervention and antibiotic therapy, leading to a favorable outcome in majority of cases. It is an uncommon disease as many large series report only a handful of cases. In a recent retrospective series, only 15 pediatric cases were reported in a span of 10 years from a dedicated children's hospital. Most of the literature we have on this entity is limited to anecdotal reports or small series. Some important updates are described in this review for an educational overview. The article is based on a literature search from 2010 onward from articles hosted in PubMed/PubMed Central done during the period of July 2020.
| Lower Extremity|| |
Hip and thigh
A recent report of a pediatric case with femoral capital epiphysis involvement was reported and the causative agent identified was Kingella kingae. A 2-year-old child with limp was found to have an epiphyseal abscess crossing into the physis and metaphysis of the femoral neck. The viral respiratory infection was suggested as the etiology of bone infection and the case was managed conservatively. In a different case, an adolescent with radiological features suggestive of an osteoid osteoma of the femoral neck was finally diagnosed as Brodie's abscess following histopathology and culture. The pain was insidious with nocturnal exacerbation but without associated features of acute infection or inflammation and a provisional diagnosis of osteoid osteoma was ascertained. Radiographs showed a 1-cm diameter lytic lesion at calcar region with surrounding periosteal reaction along with magnetic resonance imaging (MRI) evidence of a central nidus. With a working diagnosis of osteoid osteoma, radiofrequency ablation was planned but later replaced by histology confirmation first. Image-guided curettage was followed by culture and biopsy sampling which was positive for granulation tissue and Staphylococcus aureus, respectively. Appropriate antibiotics led to healing and MRI confirmation of disease healing in the follow-up. Another educative report highlighting the requirement of histopathological identification of osteoid osteoma before the start of ablation therapy is noteworthy. This case with a diagnosis of osteoid osteoma of femoral diaphysis was managed by computed tomography (CT)-guided radiofrequency ablation leading to worsening of symptom and complication into osteomyelitis. Repeated MRI suggested Brodie's abscess and appropriate surgical management was performed, leading to the healing of the infection.
Arthroscopic assisted the evacuation of Brodie's abscess of the distal femur in a young female was reported recently leading to pus evacuation from the lateral aspect of the medial femoral condyle and cavity curettage using an arthroscope. The arthroscopy was advocated in selected cases as a viable minimally invasive and useful procedure. A case with acute worsening of a progressive knee pain in the absence of relevant associated clinical features was found to have Brodie's abscess. The pain was nontraumatic and the child presented with limp that worsened over the last few days. The warmth over the tibia was clinically evident and ultrasound (USG) revealed fluid collection over the proximal tibia region with large septations. Contrast MRI showed focal inflamed region with eroding through anterior tibia into the adjacent area for which surgical debridement and antibiotic therapy resulted in complete recovery. Judicious use of investigation is required to diagnose Brodie's abscess in the absence of signs of infection, trauma, or other related physical signs. Multiple surgical debridements may also be required in some cases showing the importance of timely intervention as key to a good outcome.
Leg, ankle, and feet
A case with chronic pain and swelling of the ankle for 9 months had clinically apparent swelling posterior to both malleoli with limited range of ankle motion. A radiolucent punched-out lesion in distal tibia epiphysis was noted on radiology. Arthrotomy, debridement, irrigation, and cement-antibiotic fillers were used as infection control measures against positive culture for methicillin-resistant S. aureus. A child with limp, following episode of diarrohea and fever 4 weeks earlier, presented with erythema, pain, and purulent bulla over lateral foot region. MRI showed distal metaphysis of fifth metatarsal lesion and collection extending into subcutaneous tissue. Surgical drainage, debridement, decompression, and curettage were done and the culture later isolated Group B Salmonella More Details.
The location of Brodie's absess in proximal tibia in an elderly patient revealed penumbra sign on MRI followed by biopsy conformation of subacute osteomyelitis. There was a history of some infection in the knee region, for which some surgery was done more than 30 years back. The radiograph showed a lytic lesion with perilesional periosteal reaction and CT showed a central medullary cystic lesion with rim ossification and without cortical breach or soft tissue involvement. MRI demonstrated a penumbra sign that relates to the thin layer of granulation tissue lining the abscess cavity. Calcaneal involvement in an immunocompetent adult male was reported with a history of conservative treatment for heel spur for many years. A lytic lesion with perilesional edema was seen on radiology and intralesional debridement revealed purulent material for which antibiotic beads were placed following debridement leading to full recovery.
| Upper Extremity|| |
Presence of a lytic cavity and “penumbra sign” has been repeatedly found to be an important clue in diagnosing Brodie's abscess in many reports., Penumbra sign is seen in MRI images as rim enhancing periphery of the abscess cavity within the bone [Figure 1], [Figure 2], [Figure 3]. The presence of this sign should be investigated to confirm Brodie's abscess in suspected cases. An adolescent with a history of acute swollen shoulder 1 year back revealed superficial fluid collection in acromion and surrounding trapezius muscle with wall enhancement on MRI. S. aureus was isolated and surgical drainage and appropriate antibiotic therapy were given in previous treatment. The current radiographic evidence of lytic lesion in acromion process was seen with MRI delineating a sinus within the cavity along with the presence of “penumbra sign.” Repeat surgical drainage was done in the case leading to a gradual recovery.
|Figure 1: The coronal magnetic resonance imaging images showing a lesion within distal tibia metaphysis with ring-enhancing periphery surrounding a hypointense lesion in T1 view that is also called “Penumbra sign.” The lesion is seen hyperintense in T2 view and is suggestive of purulent collection within the lesion|
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|Figure 2: The axial view of the same case better delineating the well-defined lesion within the metaphyseal bone|
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|Figure 3: Another example showing sagittal magnetic resonance imaging images of the ankle region with a smaller well-defined lesion and localized abscess formation in distal tibia metaphyseal region|
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A case of radius bone involvement with a significant portion of longitudinal bony hypertrophy was reported in an adolescent girl who was managed by surgical evacuation of pus and sequestrum removal. Autologous bone grafting, typically done in the management of large bone defects following curettage, was not done on the basis of radius being a nonweight-bearing bone, and the results were promising at 1-year follow-up. Another report of an 8 cm lucent lesion in distal radius showing “penumbra sign” on T1-weighted image and ring enhancement on contrast-enhanced images also showed an uptake at margins of the radius on 18F-luorodeoxyglucose positron-emission tomography/CT images. Curettage was followed by iliac crest bone grafting and gradual healing without sequelae or recurrence.
| Pelvic Region|| |
Brodie's abscess of posterior iliac bone with the gluteal syndrome in a 9-year-old child presenting as intermittent low back pain has been reported. MRI showed two foci, one intramedullary, and one subcutaneous, which in contrast also showed phlegmonous foci. Open biopsy and curettage was done, leading to a good outcome. Another case of posterior ilium Brodie's abscess presenting as low back pain in a child is also reported. The pain was localized to the right side posterior superior iliac spine and treatment was similar to the above-mentioned patient.
| Unusual Presentation|| |
An interesting case of an acute leg pain resembling deep-vein thrombosis (DVT) and a beginning compartment syndrome due to associated ruptured Baker's cyst was reported which on MRI revealed Brodie abscess of proximal tibia metaphysic. The lesion was associated with reactive synovitis and suprapatellar effusion and was managed by surgical debridement. The authors recommended the exclusion of Brodie's abscess in acute calf pain cases as accompanying myositis and fasciitis may clinically occasionally mimic DVT. A diagnosis of Brodie's abscess as late sequelae of distal radius fracture in a teenager managed by percutaneous pinning was also reported more than 5 years after surgery. Pin site infection complicated the previous surgery and Brodie's abscess was found corresponding to previous pin sites and required surgical curettage. S. aureus and diphtheroid were isolated from the specimen that was more of a granulation tissue than frank pus material. Another case with unusual thigh collection of pus following a fistula (cloaca) formation through femoral cortical bone was described as an unreported presentation. The presentation of an intraosseus abscess communicating into extensive soft tissue collection was evident, but lack of bone marrow edema and the presence of osteoblastic rim around the lesion were outstanding features. Surgical pus drainage was done and cloaca curetted and S. aureus was identified.
In a 57-year-old patient with sickle cell disease, an unusual presentation of Brodie's abscess in the form of multiple painful large joints that was progressive with a mild cough but without other features such as fever, chills, nausea, chest pain, and palpitation. The sickle solubility test was positive suggesting active sickling, and working diagnosis of vaso-occlusive crisis was made. The white blood cells were elevated, whereas culture from everybody fluid was negative. MRI of the right hip revealed evidence of femoral and acetabular subacute osteomyelitis. Surgical drainage and antibiotic bead placement was done to improve clinical and leukocyte levels dramatically with final culture positive for Enterobacter cloacae and Citrobacter koseri. A similar report in a 20-year-old patient presenting as vaso-occlusive crisis in the setting of sickle cell disease is also reported with bilateral thigh pain, but in contrast to the above case, she was febrile and had tachycardia. A provisional diagnosis of vaso-occlusive crisis with systemic inflammatory response syndrome was made. MRI demonstrated two loculated collections in quadriceps and lateral thigh, respectively, along with proximal femur abscess with a communicating tract. Drainage of pus and drain placement was done and culture came negative despite the persisting problem. Repeat CT showed residual abscess necessitating USG-guided drainage and drain placement as successful management. A 6-year-old child with leg pain for a few days presented with acute painful swelling in the left ankle. Multifocal subacute osteomyelitis in distal tibia and fibula metadiphyseal area with multiple Brodie's abscess was noted in MRI but without septic joint involvement. The unique features of this case highlighted by the author were sparing of joint and late presentation of multifocal osteomyelitis. Fluoroscopy-guided aspiration and antibiotics therapy resulted in negative cultures and clinical remedies. An unusual case of posttraumatic Brodie's abscess following a previous penetrating injury with small iron nail 3 months before the current presentation was reported. Swelling and pain accompanied no signs of acute inflammation and a lytic lesion over cuboid bone with dense rim was seen on radiographs, whereas MRI was not done due to financial constraints. Curettage and biopsy was performed leading to frank pus evacuation before closure over drain. The histopathology and culture suggested chronic abscess and identified Streptococcus pyogenes. Another case of 10-year-old girl with a swollen, tenderfoot with raised temperature presenting as metatarsalgia was reported. Radiological presence of lytic second metatarsal lesion with periosteal apposition and abscess was followed by successful conservative treatment of the patient.
| Unusual Organisms|| |
A localized subacute abscess formation usually forms within the vascularity-rich metaphyseal region of the bone. Most cases are associated with Gram-positive organisms like S. aureus, Streptococcus species, but many without any organism isolated. A report of Brodie's abscess of talus in a child caused by Morganella morganii was reported as a rare case. Surgical drilling of talus resulted in pus egress and through irrigation and antibiotics led to uneventful recovery. A report of septic knee presentation of an adult with new-onset diabetes showed well-defined lucency in proximal tibia which was later identified in detail and confirmed on MRI. Salmonella Newport was isolated in blood and culture samples both. Knee aspiration followed by arthroscopic lavage and multiple debridements was done. In one rare case of pandiaphysitis of tiba, Salmonella saprophyticus was found as a cause of Brodie's abscess in an otherwise healthy patient. K. kingae has been found as another uncommon isolate involved in a case of invasive Brodie's abscess.
| Conditions Mimicking Brodie's Abscess|| |
Tubercular osteomyelitis may occasionally mimic this variant of osteomyelitis. The slow progression of tubercular infection may display radiological similarity to Brodie abscess. One case of tibial osteomyelitis, recalcitrant to conventional antibiotic therapy, underwent a biopsy to reveal tubercular bacilli. Histopathological or polymerase chain reaction confirmation was advocated by the authors in selected cases to rule out tuberculosis as an important differential diagnosis. A focal form of Langerhans cell histiocytosis (LCH), or histiocytosis X, an idiopathic proliferative disease of histiocytes, usually affects flat bones and has variable presentations. A localized LCH of the tibia in a 2-year-old child showed high rim enhancement suggesting “penumbra sign” on MRI and as the sign is also found in Brodie's abscess, a diagnosis of the same was made. MRI showed a localized lytic lesion in tibia metaphysis with cortical thinning, endosteal scalloping, and mild periosteal reaction. Open biopsy and frozen section was done followed by curettage and bone grafting and while the culture was negative, histology revealed features of histiocytosis coupled with CD1a and S-100 protein positivity.
| Novel Diagnostic or Treatment Advances|| |
A novel attempt of treating Brodie's abscess of the distal tibia in a 12-year-old patient showing intolerance to multiple antibiotic therapy regimens was reported. Surgical curettage, removal of infected material, copious lavage was followed by filling the cavitary void with a bioactive glass compound BAG-S53P4 (BonAlive, BonAlive Biomaterisls Ltd., Biolinja, Finland). The compound was found to be safe and effective. It does not require antibiotic addition, shows no adjacent soft tissue damage, and did not affect growth plate functions. The compound, however, has also been successfully used in cases of osteomyelitis in previous studies. Its use in Brodie's abscess was first as per the author's statement. Use of an improvised laminar suction catheter as a minimal invasive technique to drain pus from Brodie's abscess was reported. The patient had a history of pain and lytic lesion on the tibia for the past 1 year and this time, the pain increased to become throbbing and thus limiting the mobility. MRI confirmed osteolytic lesion with abscess formation extending into epiphysis and posterior soft tissues. Image-guided drilling of bone was followed by an 18G venous cannula attached to a syringe to evacuate pus. A laminar suction catheter modified by curving it to 90° was placed and normal saline cavitary lavage was performed followed by double drain placement. In a young patient with sickle cell disease presenting with vaso-occlusive crisis and persistent ankle pain, incidental detection of Brodie's abscess in talus was reported following single-photon emission CT (SPECT-CT). The report underlined the use of SPECT-CT in hidden lesions with high specificity. Surgical curettage following failed intravenous antibiotic therapy resulted in clinical remission.
Growth-related deformities were noted in a series of cases of Brodie's abscess, with some developing it up to 3 years after primary consultation, and thus, the authors recommended long-term follow-up and believed growth stimulation rather than growth retardation as probable etiology. Three of six cases of Brodie's abscess adjacent to growth plates showed growth deformities, with most being subtle and one requiring surgical correction of axial alignment.
| Conclusion|| |
Brodie's abscess, a subacute type of bone infection, is an uncommon but important clinical entity with varied clinical presentation. Frequent reports enrich the medical literature and improve our understanding of this condition which requires consensus and evidence-based guidelines on its diagnosis and treatment. One should always exclude this condition in cases with typical clinical or radiological presentations based on the knowledge of previously described cases in the medical literature.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]