title: Delay in diagnosis of femoral hematogenous osteomyelitis in adults: an elusive disease with poor outcome.
abstract: BACKGROUND
  Hematogenous osteomyelitis of long bone is rare in adults, especially in the immune competent host. Only a few cases have been described to date.
  
  
  OBJECTIVE
  To present a case series of femoral hematogenous osteomyelitis in adults, a rare condition that is difficult to diagnose and may cause major morbidity and mortality.
  
  
  METHODS
  We reviewed three cases of femoral hematogenous osteomyelitis that occurred between 2007 and 2009. The course of the disease, physical findings, imaging modalities, laboratory analysis, culture results and functional outcomes were recorded.
  
  
  RESULTS
  In all cases the diagnosis was delayed after symptoms were first attributed to radicular-like pain or lateral thigh pain due to an inflammatory non-infectious source. In all cases infection was caused by an unusual or fastidious bacterium. The pathogen was Haemophilus aphrophilus in one case, and Streptococcus specimens were found in the other two. Pathological fracture occurred in two of the cases despite culture-specific antibiotic treatment and a non-weight bearing treatment protocol. It took five surgical interventions on average to reach full recovery from infection, but residual disability was still noted at the last follow-up.
  
  
  CONCLUSIONS
  Clinicians should be aware that although femoral hematogenous osteomyelitis is a rare condition in adults, its ability to mimic other pathologies can result in delayed diagnosis and major morbidity. In our series the pathogen was different in each case and was cultured only from the infected site. Pathological fracture is a devastating complication but we do not recommend prophylactic stabilization at this point.
authors.affiliation: Department of Orthopedics, Sheba Medical Center, Tel Hashomer, Israel. ranthein@gmail.com
authors.forename: Ran
authors.initials: R
authors.lastname: Thein
authors.forename: Shay
authors.initials: S
authors.lastname: Tenenbaum
authors.forename: Ofir
authors.initials: O
authors.lastname: Chechick
authors.forename: Eyal
authors.initials: E
authors.lastname: Leshem
authors.forename: Aharon
authors.initials: A
authors.lastname: Chechik
authors.forename: Boaz
authors.initials: B
authors.lastname: Liberman
mesh_terms: D001706:Biopsy; D003646:Debridement; D003937:Diagnosis, Differential; D003952:Diagnostic Imaging; D005260:Female; D005269:Femur / Q000473:pathology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010019:Osteomyelitis / Q000175:diagnosis* / Q000382:microbiology / Q000601:surgery*