Correspondence

Case 23-2000: Osteomyelitis in HIV-Infected Patients

N Engl J Med 2001; 344:66-67January 4, 2001

Article

To the Editor:

The July 27 Case Record1 involved a patient with human immunodeficiency virus (HIV) infection who was given a diagnosis of osteomyelitis due to infection with Mycobacterium avium complex. The discussant stated that fewer than 50 cases of osteomyelitis associated with HIV have been reported, and he was surprised that M. avium complex had been isolated on culture in only 5 of these cases despite its importance as an opportunistic pathogen in patients with AIDS.2 But this finding is supported by data from the Adult/Adolescent Spectrum of HIV Disease project of the Centers for Disease Control and Prevention. The project is a longitudinal, multicenter surveillance initiative that reviews medical records in 11 cities in the United States. The methods used in the project have been described previously.3,4

Among 51,531 HIV-infected patients observed during at least one year between 1990 and June 2000, we identified 330 patients with osteomyelitis (cumulative prevalence, 0.6 percent). Information about causative organisms was available for only 88 patients (27 percent). We found that 48 percent of the identified organisms were Staphylococcus aureus, 14 percent were pseudomonas species, 7 percent were streptococcus species, 7 percent were other or unspecified staphylococcus species, and 23 percent were other organisms. In eight patients, two organisms were identified. Only one case of osteomyelitis was attributed to M. avium complex. Among all the patients with osteomyelitis, the median CD4+ count within six months of the time of diagnosis was 169 cells per cubic millimeter. Injection-drug use was documented among 60 percent of the patients with osteomyelitis.

Osteomyelitis is an uncommon condition among HIV-infected patients, although in our study it was reported more commonly among injection-drug users. Despite some limitations, our data support the finding that unusual pathogens such as M. avium complex are not common causes of osteomyelitis in HIV-infected patients. Because the association between injection-drug use and osteomyelitis was frequently found in our study population, and S. aureus and pseudomonas species are frequently reported among injection-drug users with infectious diseases,5 effective prevention programs that target injection-drug users should include drug-replacement programs that could reduce morbidity from the diverse infectious diseases affecting injection-drug users.

A.D. McNaghten, Ph.D.
Michael R. Adams, M.S.
Mark S. Dworkin, M.D., M.P.H.T.M.
Centers for Disease Control and Prevention, Atlanta, GA 30333

for the Adult/Adolescent Spectrum of HIV Disease Project Group

5 References

1. 1

   Case Records of the Massachusetts General Hospital (Case 23-2000). N Engl J Med 2000;343:281-287
   Full Text | Web of Science | Medline

2. 2

   Vassilopoulos D, Chalasani P, Jurado RL, Workowski K, Agudelo CA. Musculoskeletal infections in patients with human immunodeficiency virus infection. Medicine (Baltimore) 1997;76:284-294
   CrossRef | Web of Science | Medline

3. 3

   Farizo KM, Buehler JW, Chamberland ME, et al. Spectrum of disease in persons with human immunodeficiency virus infection in the United States. JAMA 1992;267:1798-1805
   CrossRef | Web of Science | Medline

4. 4

   Dworkin MS, Wan PCT, Hanson DL, Jones JL. Progressive multifocal leukoencephalopathy: improved survival of human immunodeficiency virus-infected patients in the protease inhibitor era. J Infect Dis 1999;180:621-625
   CrossRef | Web of Science | Medline

5. 5

   Crane LR, Levine DP, Zervos MJ, Cummings G. Bacteremia in narcotic addicts at the Detroit Medical Center. I. Microbiology, epidemiology, risk factors, and empiric therapy. Rev Infect Dis 1986;8:364-373
   CrossRef | Medline

To the Editor:

In his interesting discussion in the July 27 Case Record, Mayer describes the causes of osteomyelitis in HIV disease but does not mention gonococcus. We recently saw a 37-year-old homosexual man with Candida albicans esophagitis and HIV infection that were diagnosed in another hospital in December 1999, who had acute polyarticular pain that had started 24 hours earlier. He did not have any ureteral, rectal, or pharyngeal symptoms. On physical examination, he was found to have polyarthritis and two painful subcutaneous nodules (one in the left leg and one in the right foot). The radiographic examination showed local osteoporosis. A purified-protein-derivative test was negative. The CD4+ T-cell count was 25×10⁶ per liter, and the plasma HIV RNA level was 450,000 copies per milliliter (the patient was not receiving highly active antiretroviral therapy).

Neisseria gonorrhoeae was isolated in cultures of an exudate aspirated from the nodule in the foot but not from other anatomical sites. A diagnosis of disseminated gonococcal infection was established, and the patient was treated with ceftriaxone (2 g four times a day) and doxycycline (100 mg twice a day). One month later, edema and pain developed in the left foot. Results of computed tomography and bone scanning (with technetium Tc 99m) were compatible with the presence of osteomyelitis (Figure 1Figure 1Bone Scan with Technetium Tc 99m (Panel A) and Computed Tomographic Scan (Panel B) of the Feet That Demonstrate Osteomyelitis of the Left Scaphoid Bone (Arrow, Panel B).). He was treated with oral ciprofloxacin (200 mg twice a day) with very good response.

As Mayer points out, the causes of osteomyelitis in HIV disease are normally related to the risk factors for HIV infection: intravenous drug use (in which case common causes are staphylococcus species, gram-negative rods, and C. albicans); travel or residence in regions where HIV infection is endemic (common causes are blastomyces and Coccidioides immitis); and immunosuppression (common causes are Histoplasma capsulatum, Cryptococcus neoformans, and mycobacteria).

When HIV has been sexually transmitted, microorganisms linked to sexually transmitted diseases should be included in the differential diagnosis. Our case indicates that the association of HIV infection and N. gonorrhoeae osteomyelitis should be considered in the appropriate clinical context.1

Agustín Muñoz-Sanz, M.D.
Araceli Vera, M.D.
Francisco R. Vidigal, M.D.
Hospital Universitario Infanta Cristina, 06080 Badajoz, Spain

1 References

1. 1

   Vassilopoulos D, Chalasani P, Jurado RL, Workowski K, Agudelo CA. Musculoskeletal infections in patients with human immunodeficiency virus infection. Medicine (Baltimore) 1997;76:284-294
   CrossRef | Web of Science | Medline

Citing Articles (5)

Citing Articles

1. 1

   Tetsuya Suzuki, Hajime Murai, Naohisa Miyakoshi, Michio Hongo, Eiji Itoi, Yoichi Shimada. (2011) Osteomyelitis of the spine caused by mycobacterium avium complex in an immunocompetent patient. Journal of Orthopaedic Science
   CrossRef

2. 2

   A. Vera-Tomé, F.F. Rodríguez-Vidigal, A. Muñoz Sanz. (2006) Infecciones por gonococo. Medicine - Programa de Formación Médica Continuada Acreditado 9:55, 3585-3590
   CrossRef

3. 3

   Charalampos G Zalavras, Neeraj Gupta, Michael J Patzakis, Paul D Holtom. (2005) Microbiology of Osteomyelitis in Patients Infected with the Human Immunodeficiency Virus. Clinical Orthopaedics and Related Research 439:&NA;, 97-100
   CrossRef

4. 4

   Tomofumi YANO, Sachiko OKUDA, Ken-Ichi KATO, Katsuya KATO, Takumi KISHIMOTO. (2004) Mycobacterium kansasii Osteomyelitis in a Patient with AIDS on Highly Active Antiretroviral Therapy. Internal Medicine 43:11, 1084-1086
   CrossRef

5. 5

   Thomas G. Fraser, Michele Till. (2002) Vertebral Osteomyelitis Due to Mycobacterium avium Complex in a Patient With AIDS. Infectious Diseases in Clinical Practice 11:7, 385-389
   CrossRef