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Sara Dong: Hi everyone.

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Welcome to Febrile, a cultured podcast
about all things infectious disease.

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We use consult questions to dive into
ID clinical reasoning, diagnostics,

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and antimicrobial management.

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I'm Sara Dong, your host.

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I'll start by introducing
our guests for this episode.

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First up is Dr. Veronica Santos.

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She completed medical school at the
University of Puerto Rico and is currently

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a second year in pediatrics residency at
University Texas or UT Health Houston.

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Veronica Santos: Hi, I am Veronica Santos.

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Sara Dong: We have a returning
guest, Dr. Misti Ellsworth.

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She's an Associate Professor of
Pediatric Infectious Diseases at McGovern

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Medical School and UT Health Houston.

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Misti Ellsworth: Hi, Misti Ellsworth!

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Sara Dong: And rounding out the
team, we have Dr. Sebastian Shrager.

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He completed his pediatric residency
at Broward Health in Fort Lauderdale,

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Florida before completing a fellowship in
Infectious Diseases at the University of

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Texas Medical Center in Houston, Texas.

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He just started his job as an
attending at Wolfson Children's

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Hospital in Jacksonville, Florida.

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Sebastian Shrager: Hi,
I am Sebastian Shrager.

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Sara Dong: As everyone's favorite
cultured podcast, we like to kick

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off the show by asking our guests to
talk about a little piece of culture.

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Really just something
non-work, non-medical related

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that brings you happiness.

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So, Veronica, maybe I'll start with you.

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Veronica Santos: Sure.

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Um, I've been reading a book, We Are
Liars, which is now a Hulu series.

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I've been really enjoying this book and
plan on reading the pre sequel after this.

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Sara Dong: Very nice.

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Sebastian, how about you?

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Sebastian Shrager: Yeah, so, uh, I'm,
I'm really excited for the World Cup.

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It's coming to the United States this
summer, and I have, uh, tickets to

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Germany-Ecuador, and France-Norway.

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I'm super pumped.

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I'm a big soccer fan and I can't wait.

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Sara Dong: It's so exciting.

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Yeah.

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It's gonna be, it's gonna be awesome.

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Um, and Misti, how about you?

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Misti Ellsworth: So I spend most
of my free time attending and

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embarrassing my tweens and teenagers
at sporting events and performances.

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When I'm not embarrassing my kids,
I like to read and I'm also really

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enjoying the, uh, Shrinking series.

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Sara Dong: All right, well, today's
consult question I have heard is about

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ankle pain, so I will hand it over to
Veronica to tell us about this patient.

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Veronica Santos: Yes.

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So to start with, we have
a 14-year-old female.

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She came in with chronic, intermittent
right ankle pain for the past three

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years, and she presented with acute
worsening over the last 10 days.

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Her right ankle pain was
intensified during soccer practice.

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Three days later, pain worsened
and she was now unable to

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bear weight on her right foot.

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She had two separate visits to urgent
care where x-rays were normal and her

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pain was attributed to tendonitis.

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On day nine, after orthopedics evaluation,
MRI of the right foot and labs were done.

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On initial exam, her vitals were notable
for temperature of 98.2, heart rate of 84,

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blood pressure of 115/60, respiratory rate
of 15 and saturating at 97% in room air.

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On focused physical exam, she had
swelling diffusely about the right

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heel with tenderness to palpation
and a positive squeeze test.

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There was no erythema, warmth, or
induration noticed and sensation

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and active movements were intact.

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Her initial labs were significant
for a marked increase in inflammatory

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markers with no leukocytosis.

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Her CRP was 115 and her ESR was 39.

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She had slight decrease of hemoglobin
to 11.8 with normal platelet count.

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Further workup included right ankle
MRI, which was remarkable for a

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3.8 cm proteinaceous cyst in the
calcaneal tuberosity with adjacent

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patchy marrow edema and enhancement
suggestive of a Brodie's abscess.

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The MRI was also notable for edema and
enhancement of the quadratus plantae

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muscle with a intramuscular fluid
collection suggestive of myositis

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with possible early polymyositis.

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Sebastian, based on this initial
presentation, what is your

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differential diagnosis so far
and would you treat empirically?

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Sebastian Shrager: Yeah, so great history.

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So Staph aureus is king here.

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That's the most common organism by far.

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You can also see Group A Strep and
Strep pneumo, which still show up.

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She's a little too old for Kingella.

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Um, so that's lower in the differential
and she's not immunocompromised or using

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IV drugs, so Pseudomonas is less likely.

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And then without sickle cell disease,
Salmonella drops way down the list.

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That said, Brodie abscesses can
be absolutely polymicrobial.

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Management wise, this is where people
sometimes jump too fast for antibiotics.

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If the kid looks stable and not
septic, I'd actually hold antibiotics

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and call our friends in orthopedics.

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Incision and drainage gives you the best
chance of finding a bug and holding off

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on antibiotics will increase that yield.

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Veronica Santos: What if they say
no to an I&D (incision & drainage)?

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Sebastian Shrager: Yeah.

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Um, well, I'll try to persuade them
first, but if they still say no, then

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cefazolin alone is totally reasonable.

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It covers MSSA well and makes oral
step down easy to cephalexin, or

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cefadroxil, which are great PO options.

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If you're living in a MRSA heavy
area, then vancomycin makes sense.

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And then if you want to also cover
gram-negatives and MRSA, you could

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do ceftriaxone and vancomycin.

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Veronica Santos: Those are
all great differentials.

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Now how about I give you more history
to see if we can add anything else?

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She was born term with no complications.

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Her only medical history is tendinitis of
her right ankle for the past three years.

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She has no pertinent surgical
history or family history.

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Her vaccines are up to date.

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She does have pertinent travel history
that include a trip to Galveston

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Beach in Texas where she stabbed
her right ankle on a piece of wood.

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The piece of wood was
spontaneously expelled from the

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puncture site two weeks later.

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About five months prior to presentation,
she also went swimming in Pensacola

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Beach, Florida, and about two
and a half months prior, she went

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swimming on Canvasback Lake, Texas.

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She refers exposure to multiple
animals, including ticks, fleas,

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mosquitoes, horses, cattle, chickens,
possums, iguanas, and even field mice.

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And she also has two vaccinated dogs.

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How does your differential change now
with this additional history, Sebastian?

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Sebastian Shrager: So be careful when
you go to Galveston Beach, it looks like,

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'cause you can get poked with a stick.

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Um, now this case gets more interesting
because of the water and wood exposure.

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Uh, you have to think about Mycobacteria
marinum, which loves salt and brackish

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waters, and fits a slow indolent course.

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The Vibrio species as well, especially
vulnificus and alginolyticus,

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even though we usually think
of them as more aggressive.

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She also swam in lakes, so Aeromonas
hydrophilia comes into play plus

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rapid growing mycobacteria, since
they're literally everywhere,

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everywhere in all water and soil.

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The wood exposure opens the door to
fungi like Sporothrix schenckii, probably

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lower on the list, but not zero, which
really drives home the key point.

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Send the bone.

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Get aerobic, anaerobic, AFB and fungal
cultures because with Brodie's abscesses,

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especially with environmental exposure,
the diagnosis lives in the microbiology.

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I'd also keep a sample on the
side to send the PCR testing, just

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in case the cultures don't grow.

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Veronica Santos: We really
do have a broad differential.

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I think at this point we're
all ready to get some answers.

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So our patient underwent
two I&Ds by orthopedics.

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To our surprise, the pathology and
cultures sent from the operating room

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revealed Vibrio vulnificus causing
acute osteomyelitis, Brodies abscesses,

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myositis and bursitis of the right ankle.

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The patient was then transitioned from
IV vancomycin and piperacillin-tazobactam

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to ceftriaxone and doxycycline.

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Sebastian, can you talk more on
Brodie's abscess, because this

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is one of those diagnoses that
feel rare and it actually is.

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Sebastian Shrager: Yeah, exactly.

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Yeah.

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So first off, pediatric osteomyelitis
overall isn't that common?

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It's only about 2 - 20 cases per a
hundred thousand kids, and Brodie abscess

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makes up only around 2% of those cases.

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So you're already dealing with something
pretty unusual, and what makes it

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tricky is that it's, it's not your
classic toxic looking osteomyelitis.

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A Brodie abscess is really a subacute
form of hematogenous osteomyelitis.

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Instead of widespread infection, you
get this localized intraosseous abscess,

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basically a smoldering infection that the
immune system has partially contained.

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Veronica Santos: Which
makes sense in kids, right?

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Sebastian Shrager: Yeah, totally.

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So most pediatric osteomyelitis
comes from the bloodstream, right?

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And the growth plates have this
unique vascular anatomy with

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slow flow, looping vessels.

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Bacteria get in.

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The immune system walls it off,
and instead of clearing it, you

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end up with the Brodie's abscess.

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Location wise, Brodie's
abscesses love long bones.

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Tibia is the big one, about half
of the cases, and then the femur.

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And interestingly, uh, Brodie abscesses
tend to involve the diaphysis more

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than the metaphysis, which is a little
different from what we usually think

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about with acute osteomyelitis in kids.

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Veronica Santos: We were all
surprised by Vibrio vulnificus

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being the causative agent.

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Dr. Ellsworth, can you share more on
why this was such an unusual case?

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Misti Ellsworth: So what made this
case really interesting to us is

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how completely un-Vibrio it was.

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So when we think about Vibrio
vulnificus, we usually think about

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very dramatic, very fast infections.

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So someone cuts their leg in seawater
and within days they're septic.

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They've got hemorrhagic
bullae, necrotizing fasciitis.

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Sometimes they end up even in the ICU.

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Osteomyelitis just isn't what comes
to mind when we think of this bug.

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And in fact, when you look
at the literature, Vibrio

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osteomyelitis is incredibly rare.

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Most of what's out there
are single case reports.

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There aren't any case series and there
aren't guidelines talking about it,

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and Vibrio doesn't even show up on the
usual list of osteomyelitis pathogens.

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One of the few detailed reports
is from the Journal of Infectious

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Diseases in 1990, and that case
really mirrors what we saw.

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In that report, the patient had a fairly
typical exposure, brackish water and a

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skin injury, but instead of progressing
rapidly, the infection kind of smoldered.

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He initially improved with the
antibiotics, but over the course

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of weeks to months, he developed
worsening pain and swelling and

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eventually imaging showed osteomyelitis.

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The total time course was about
13 weeks, which is just not how

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we're taught that Vibrio behaves.

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That's what made our
patients so challenging.

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There was no explosive
presentation, no early sepsis, no

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necrotizing soft tissue infection.

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It said it almost looked like
an orthopedic or an inflammatory

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condition at first with this chronic
pain, local tenderness, no skin

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findings, and that really delayed
the diagnosis in this patient.

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What's striking is that Vibrio infections
are usually the opposite of indolent.

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Large surveillance studies showed
that they present as gastroenteritis,

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wound infections, or primary
septicemia, not chronic bone disease.

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Even during outbreaks, osteomyelitis
is almost unheard of, and one Israeli

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outbreak with over 60 invasive
cases, only one patient developed

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osteomyelitis, and there's not a
whole lot of details in that case.

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So the big takeaway for us was this.

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Marine exposure plus persistent
focal symptoms should keep

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Vibrio on the differential, even
if the timeline feels wrong.

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Partial treatment, early antibiotics,
or lack of source control may

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blunt that classic fulminant course
and allow a deep infection like

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osteomyelitis to slowly declare itself.

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And finally, this case is a good reminder
that when symptoms don't resolve,

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especially pain, repeating imaging and
getting deep cultures really matter.

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Because even organisms we think of fast
and furious can occasionally surprise

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us by being slow, quiet, and sneaky.

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Veronica Santos: Thankfully
despite the chronicity of this

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infection and it being Vibrio, our
patient had really good outcomes.

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On day 15, the second OR culture
was positive for Vibrio vulnificus.

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On day 16, her inflammatory markers
were down trending, and the patient

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was doing better clinically.

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After completing three days of IV
antibiotics, she was sent home with

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one month supply of doxycycline.

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Patient was followed up
in clinic one month after.

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At this point, inflammatory markers
continue to downtrend with ESR

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at 41 and CRP less than three.

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The patient completed 12 more days of
doxycycline for a total of 42 days.

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00:12:53,871 --> 00:12:57,501
On day of completion, her
ESR level was at 19 and CRP

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continued to be less than three.

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The patient was later cleared by
orthopedics to return to soccer play.

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The takeaway from all of this is to think
that Brodie's abscess can be subacute,

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smoldering, a form of osteomylitis
that often lacks systemic toxicity.

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When able, as Sebastian said, always
send the bone, deep OR culture

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should include aerobic, anaerobic,
AFB, and fungal cultures, especially

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with environmental exposures.

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Plus marine exposures and persistent
focal pain should always keep

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Vibrio on the differential, even
when the timeline feels wrong.

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Misti Ellsworth: Thanks so much
to Veronica, Sebastian, and

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Misti for joining Febrile today.

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Don't forget to check out the
website febrilepodcast.com, where

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you'll find the Consult Notes, which
are our written show notes for the

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episodes with links to references,
our library of ID infographics,

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00:13:50,046 --> 00:13:51,296
and a link to our merch store.

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Febrile is produced with support from the
Infectious Diseases Society of America.

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Please reach out if you have any
suggestions for future shows or

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wanna be more involved with Febrile.

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Thanks for listening.

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Stay safe and I'll see you next time.