Acute respiratory distress syndrome associated with femoral osteomyelitis

作者：Tzeng Bo Wei; Liu Po Yu; Hu Sung Yuan^*

来源：BRITISH JOURNAL OF HOSPITAL MEDICINE, 2018, 79(3): 170-171.

DOI：10.12968/hmed.2018.79.3.170

A 58-year-old healthy Taiwanese man had received traditional manoeuvres for muscle strain of the right leg 2 weeks previously. He suffered from fever and shortness of breath 3 days before admission. Abnormal chest X-ray and plain film of the right femoral shaft were noted at a rural hospital.
He was referred to the authors' hospital after endotracheal intubation for acute respiratory distress syndrome caused by emphysematous osteomyelitis of the right femur complicated with septic shock. On arrival, his vital signs were respiratory rate 34 breaths/min, heart rate 114 beats/min, blood pressure 56 mmHg and temperature 38.5 degrees C. Physical examination showed crackles over both lungs and local swelling of the right thigh.
Laboratory investigations were white blood cell counts 22 100/mm(3) with segmented neutrophils of 84%, haemoglobin 10.6 g/dl, platelet counts 425x10(3)/mm(3), blood urea nitrogen 28 mg/dl, creatinine 1.4 mg/dl, calcium 8.6 mg/dl, lactate 17.5 mg/dl (reference range 8-12 mg/dl), alkaline phosphatase 259 U/litre (reference range < 190 U/litre), albumin 2.7 g/ dl, glutamic-oxaloacetic transaminase 28 U/litre, glutamic pyruvic transaminase 42 U/litre, lactate dehydrogenase 313 U/litre (reference range < 240 U/litre), C-reactive protein 37.13 mg/dl (reference range < 0.4 mg/dl), blood glucose 130 mg/dl and glycated haemoglobin 8.5%. Arterial blood gas was pH 7.469, arterial partial pressure of oxygen 63 mmHg, arterial partial pressure of carbon dioxide 34.2 mmHg, oxygen saturation 93% and bicarbonate 24.3 mmol/litre.
Multidetector computed tomography showed consolidation of both lungs, numerous small nodules in the bilateral lung fields (Figure 1), and air bubbles within the femur and quadriceps muscle (Figure 2).
Early goal-directed therapy with empiric antibiotics, fluid resuscitation and vasopressor for septic shock and the lung protective strategy with prone position for acute respiratory distress syndrome were applied. Debridement was carried out for emphysematous femoral osteomyelitis and the pathological report showed acute suppurative osteomyelitis with new bone formation. Culture of the abscess grew Klebsiella pneumoniae and cefazolin 1000 mg was given every 6 hours for 2 weeks. Anaerobic bacterial, fungal culture, acid-fast stain and culture for tuberculosis from the abscess and a biopsy from the emphysematous osteomyelitis were negative.
He was discharged on the 57th hospital day after debridement, wound care and a full course of intravenous antibiotics.

• 出版日期2018-3
• 单位河北医科大学