Active Ingredients: Azithromycin
Bone scan showed chronic osteomyelitis involving the entire left femur.
A debridement of hip and knee joint was done. A cavity was seen in the greater trochanter and lateral condyle of femur intraoperatively.
The patient underwent multiple debridements and received multiple intravenous antibiotics along with anti-tubercular therapy ATT for two months. Repeat bone scan showed partial response. A diagnosis of chronic osteomyelitis refractory to sensitivity based antibiotics and ATT was made.
The following possibilities were kept for the etiology: Non tuberculous Mycobacteria NTM, multi-drug resistant tuberculosis MDR TB, deep seated bacterial infection and fungal infection.
The discharge from the sinuses were sent for bacterial and fungal culture, both of which turned out to be sterile.
Urine and Blood culture were sterile. Histopathological examination of the debrided tissue showed multinucleated giant cells. A provisional diagnosis of NTM osteomyelitis was made.
The Mycobacteria growth indicator tube MGIT 960 culture reports were awaited at the time of discharge.
MGIT Culture reports were traced to be positive in three of the debridement tissue samples.
Clarithromycin was replaced with azithromycin. A girdle stone arthroplasty was performed and an antibiotic impregnated nail 2 gm tobramycin into 40 g of cement.
The goal of this surgery was to decrease the disease load, to provide high dose of antibiotics locally, excision of sinus tracts and to get a tissue sample for further investigations.
In addition, biopsies taken before and 3 months after treatment were analyzed immunohistochemically for changes in substance P, calcitonin gene-related peptide, and vasoactive intestinal polypeptide, all of which are neuropeptides implicated in microvascular pathophysiology.
Dermal papillae demonstrated a statistically significant reduction in the number of substance P-positive nerve fibers; however, no effect was seen on either vasoactive intestinal polypeptide or calcitonin gene-related peptide immunoreactivity.