Culture-negative chronic osteomyelitis of the tibia with a Brodie’s abscess

Evan Wasserman, MD, and Ajit Fernandez, MD, Norwalk Hospital, Norwalk, CT

View content online at: http://www.appliedradiology.com/Issues/2011/07/Cases/Culture-negative-chronic-osteomyelitis-of-the-tibia-with-a-Brodie’s-abscess.aspx

Abstract:  n otherwise healthy 24-year-old Columbian woman presented to her primary care physician with a 1-year history of progressive pain and palpable abnormality in the proximal left tibia. On physical exam, the anterior portion of the tibia demonstrated mild erythema, with a vague palpable abnormality. The patient was afebrile. Laboratory results yielded a mild leukocytosis and elevated sedimentation rate. The patient denied any history of trauma.

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Diagnosis

Culture-negative chronic osteomyelitis of the tibia with a Brodie’s abscess

Findings

 Initial radiographs demonstrated an expansile, sclerotic lesion in the proximal diaphysis of the left tibia, with a subtle tubular focus of lucency in the central portion of the medullary shaft (Figure 1). The radiographic findings were considered highly suspicious for chronic osteomyelitis with a possible intra-osseous bone abscess (Brodie’s abscess). Magnetic resonance (MR) imaging with gadolinium was performed for further evaluation.

The MR demonstrated patchy marrow edema and enhancement within the proximal diaphysis of the left tibia. In addition, in the central portion of the medullary canal, there was an 8.5 cm x 0.5 cm focus of linear signal abnormality, and enhancement, suspicious for an intra-osseous abscess (Brodie’s abscess). There was also mild thickening of the adjacent cortical bone (likely related to chronic periosteal reaction), and minimal edema in the adjacent subcutaneous soft tissues (Figures 2-4). Overall, the constellation of findings was nearly diagnostic of chronic osteomyelitis with a Brodie’s abscess.

Discussion

There are 4 routes of contamination in the development of osteomyelitis, including hematogenous, spread from a contiguous source, direct implantation, and post-operative.1 The most common pathogens are somewhat age dependent, but the most common is Staphylococcus aureus.

The term Brodie’s abscess was initially described by Sir Benjamin Collins Brodie in 1832.2 A Brodie’s abscess can be seen in both the subacute and chronic stages of osteomyelitis. These lesions, which are more commonly seen in children, typically demonstrate an elliptical or tubular shape, and are most commonly located near the metaphysis. A Brodie’s abscess is a cavity containing purulent fluid or mucus, lined with granulation tissue, and surrounded by sclerotic bone. This often produces characteristic radiographic features, which can facilitate the diagnosis and treatment plan. MR is also useful for accurately characterizing the size and shape of a Brodie’s abscess,to guide therapy and to help plan for surgery.3-5 If not diagnosed properly, osteomyelitis can progress and become more difficult to eradicate.

Conclusion

The radiographic findings of chronic osteomyelitis with a Brodie’s abscess are often characteristic. In the proper clinical setting,identification of an elliptical or tubular-shaped lytic lesion, with adjacent sclerotic changes, is highly suspicious for infection. MR is also useful for more accurately characterizing the size and shape of a Brodie’s abscess. Radiology can play a key role in making the diagnosis and in determining the most effective treatment plan.

 

  1. Resnick D. Osteomyelitis. Septic arthritis, and soft tissue infection: Axial skeleton. In: Bone and Joint Imaging. 2nd ed. Philadelphia, Pa: W.B. Saunders; 1996:674-683.
  2. Brodie BC. An account of some cases of chronic abscess of the tibia. Med Chir Trans. London, 1832;17:239-249.
  3. Bohndorf K. Infection of the appendicular skeleton. Eur Radiol. 2004;14;suppl 3:E53-E63. Review.
  4. Gold RH, Hawkin RA, Katz RD. Bacterial osteomyelitis: Findings on plain radiography, CT, MR and scintigraphy. AJR Am J Roentgenol. 1991;157:365-370.
  5. Erdman WA, Tamburoo F, Jayson HT, et al. Osteomyelitis: Characteristics and pitfalls with MR imaging. Radiology. 1991;180:533-539.

Tables & Figures

  • Figure 1A.  AP and lateral radiographs of the left tibia and fibula (A and B). The radiographs demonstrate an expansile, sclerotic lesion in the proximal diaphysis of the left tibia, with a subtle linear focus of lucency in the central portion of the medullary shaft.
    Figure 1A.
  • Figure 1B.
    Figure 1B.
  • Figure 2. Coronal T1. The image demonstrates a linear and serpiginous focus of T1 hypointense within the medullary canal of the proximal tibia, representing a Brodie’s abscess. There is also T1 hypointense thickening of the cortical bone related to a chronic periosteal reaction.
    Figure 2.
  • Figure 3A. Sagittal T1, sagittal STIR, and sagittal T1 with fat saturation following IV gadolinium administration (A, B, and C). These sequences depict a T2 hyperintense, enhancing focus of linear signal abnormality in the central portion of the medullary canal of the proximal diaphsysis of the tibia. These images also demonstrate extensive edema and patchy enhancement of the medullary canal related to inflammation.
    Figure 3A.
  • Figure 3B.
    Figure 3B.
  • Figure 3C.
    Figure 3C.
  • Figure 4A. Axial T2 with fat saturation, axial T1, and axial T1 with fat saturation following IV gadolinium administration (A, B, and C). These images demonstrate a Brodies’s abscess, with elevated T2 signal hyperintensity and enhancement  in the central portion of the medullary canal. In addition, there is extensive adjacent marrow edema and edema within the anterior soft tissues. The axial T1 image (B) also demonstrates cortical thickening related to a chronic periosteal reaction.
    Figure 4A.
  • Figure 4B.
    Figure 4B.
  • Figure 4C.
    Figure 4C.