Abstract: The purpose of this article is to describe the frequency of leukocytosis and elevated erythrocyte sedimentation rate in a series of diabetics with acute foot infections and osteomyelitis due to neuropathic foot ulcerations. The authors reviewed the admission records of 28 type II diabetic patients admitted to University Hospital in San Antonio, Texas between January 1, 1990 and December 30, 1992 with acute osteomyelitis of the foot secondary to neuropathic ulceration. The mean white blood cell count on admission for all subjects studied was calculated at 11.9 ± 5.4 × 10 3 cells/mm. 3 Of all white blood cell counts collected for patients admitted with acute osteomyelitis of the foot, 54% were within normal limits. Erythrocyte sedimentation rate was elevated in 96% of patients. Oral temperature was normal in 82% of patients. The authors conclude that a normal white cell count should not deter one from taking appropriate action to mitigate the propagation of a potentially limb-threatening foot infection.

Abstract: Distinguishing between osteomyelitis and neuropathic osteoarthropathy of the foot frequently presents a clinical and radiologic challenge in patients with diabetes. Magnetic resonance (MR) imaging was performed in 26 diabetic patients to observe changes in signal intensity in the complicated diabetic foot. In every patient with osteomyelitis (n = 13), signal intensity abnormalities were seen within the bone marrow (low signal intensity on T1-weighted images and high signal intensity on T2-weighted images in 12 cases). Most of these patients had cortical lesions (n = 9) or associated soft-tissue infection (n = 12). Normal bone marrow signal intensity was observed in three of the four patients without osteomyelitis. Characteristic MR imaging findings (decreased signal intensity in bone marrow regardless of pulse sequence) were seen in patients with chronic neuropathic osteoarthropathy (n = 7), who were easily distinguished from patients with osteomyelitis. Conversely, in patients with acutely evolving neuropathic osteoarthropathy (n = 2), signal intensity changes within the bone marrow were similar to those observed in osteomyelitis, leading to potential diagnostic pitfalls. Familiarity with MR imaging findings observed in osteomyelitis and neuropathic osteoarthropathy can help identify these two entities, allowing early diagnosis and appropriate therapy.

Abstract: Staphylococcus aureus is an important cause of bone and joint infections. In recent years, significant changes in the incidence of septic arthritis and osteomyelitis have occurred. Haematogenous osteomyelitis is now less common during childhood, but secondary spread of infection to bone or joint from a contiguous site in adults is increasing in incidence. Infection introduced at the time of surgery or arising by the haematogenous route is a significant complication of prosthetic joint implantation, and the effect of bone cement on local immune function may be important in this setting. ALthough S. epidermis is a more common cause of prosthetic joint infection, S. aureus is more difficult to treat. S. aureus produces a number of extracellular and cell-associated factors, but it is unclear what role these have as virulence factors in vivo. Furthermore, it is difficult in animal models to simulate transient bacteraemia followed by non-fulminating septic arthritis or osteomyelitis, as occurs in the patient. Surface factors which may be important in pathogenesis include the cell wall (activates complement and stimulates cytokine release), capsular polysaccharide (promotes adhesion to host cell surfaces), collagen receptors and fibronectin-binding protein. Staphylococcal toxic shock syndrome toxin (TSST-1) and the enterotoxins are superantigens and have the potential to suppress plasma cell differentiation and antibody responsiveness. TSST-1-positive isolates have been shown to cause more severe joint infection in one animal model, but most other studies to date have focused on in-vitro rather than in-vivo effects. There is little evidence supporting a role for coagulase, lipase and the haemolysins in staphylococcal bone and joint infections. Despite the clinical importance of these infections, surprisingly little is known about pathogenesis at the cellular level. Future research should focus on the role of the host immune system in limiting spread of infection, and the expression of virulence factors in animal or other models incorporating isogenic mutant strains.

Abstract: A woman presented with palmar pustulosis and deep chest pain in association with osteitic lesions in the lower part of the sternum. Propionibacterium acnes was isolated and grew in pure culture from 6 surgically obtained bone specimens. The patient received clindamycin treatment for 6 months. Synovitis in both her wrists persisted and, based on a clinical suspicion of seronegative rheumatoid arthritis, she was treated with intramuscular gold and methotrexate with no apparent benefit. Subsequently, she was diagnosed with SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, and osteomyelitis). Our patient provides further data on the potential association between P. acnes and SAPHO syndrome.

Abstract: Purpose. A retrospective study was carried out in order to determine the role of sonography in establishing the diagnosis in extremity osteomyelitis.Materials and methods. The imaging documents of 24 infants and children aged from 2 weeks to 13 years with osteomyelitis (acute 21, chronic 3) were reviewed. Sonograms and conventional radiographs were available in all patients. Additional skeletal scintigraphy had been performed in 13 patients and MRI in only 3. Special emphasis was put on the different ultrasound findings and their onset in the course of disease.Results. Intra-articular fluid collections (in 15 cases) and/or subperiosteal abscess formation (in 12) were the most frequent early sonographic findings, and preceded any radiographic changes by several days in 11 of these cases. Together with positive clinical signs of inflammation, they were usually sufficient to establish the correct diagnosis. In selected cases, fluid or abscess puncture for immediate microscopic and later bacteriological studies was carried out under sonographic control. In addition, sonography was also able to detect superficial cortical erosion and even an intramedullary focus in a very young patient.Conclusion. Ultrasonography is a very helpful tool for establishing the correct diagnosis in osteomyelitis and reducing the frequency of additional imaging studies.

Abstract: Objective. To describe unusual clinical and radiological features in patients with chronic recurrent multifocal osteomyelitis (CRMO). Design and subjects. Based on radiographic and microscopic findings, three patients were prospectively diagnosed as having chronic recurrent multifocal osteomyelitis (CRMO). They form the basis of this report because of either the unusualness of the clinical presentation, hitherto undescribed associated diseases or the unusual age of presentation and sites of lesions. Results. One patient developed pyoderma gangrenosum at the site of one of the skeletal lesions and then went on to develop ulcerative proctitis. A second patient presented with a soft tissue mass, which on MRI mimicked a sarcoma. The final patient presented with lesions in the wrist and phalanges of the toes at the unusual age of 38. None of the patients was treated with steroids or antibiotics for the skeletal lesions. Steroids were administered to one patient for treatment of pyoderma gangrenosum. Conclusions. The pattern and distribution of skeletal lesions in CRMO are well recognized in the pediatric age group. The unusual clinical and/or radiological features discussed herein suggests that this is a disease that continues to evolve with a broader spectrum of features than recognized.

Abstract: Pathogenesis of CRMO still remains unknown. Characteristic, but not pathognomonic for this syndrome are clinical course (age, sex, chronic recurrent, intermittent course), radiological findings (metaphyseal lesions), histology (chronic osteomyelitis without colliquation) and microbiological results (lack of pathogen, infectious agents). Favorable, self-limited long-term prognosis of CRMO has been assumed. Antibiotics provide no improvement. Course, severity and recurrency can be influenced positively by antiphlogistic substances, although this has not yet been proved. Whether surgical intervention beyond biopsies might cause improvement on the follow-up is unknown. Our experience (4 cases), and the literature demonstrate great clinical importance that unusual types of osteomyelitis (OM) can be within the differential diagnosis of multifocal osteolytic changes.

Abstract: The bony skeleton of the patient with sickle cell disease is a frequent target of the consequences of sickling Bone marrow necrosis, bone infarcts osteomyelitis, and aseptic necrosis are common complications in patients with sickle cell disease An understanding of the pathogenesis, prevalence, diagnosis, and management of these conditions is therefore important for those involved in the care of such patients

Abstract: Gentamicin-impregnated polymethylmethacrylate beads were used in the treatment of infective synovitis in 12 horses and 10 cattle. They had either proved refractory to standard treatments (lavage, debridement, joint drainage and systemic antibiotics) or had evidence of osteomyelitis adjacent to a synovial cavity. All the animals were severely lame. All the cattle and six of the horses had radiological evidence of osteomyelitis in communication with a synovial cavity. The beads were placed intrasynovially under general anaesthesia and left in place for 14 days. One horse and one calf were euthanased owing to continued infective arthritis. The infection was eliminated from the other 20 cases and six of the horses returned to full athletic use. Eight of nine calves with E-type infective arthritis and osteomyelitis returned to their intended food production or breeding programmes.

Abstract: Varicella, commonly known as chickenpox, is a common viral infection in children. An estimated 3.5 million cases occur annually in the United States. Serious musculoskeletal complications such as osteomyelitis and necrotizing fasciitis, although uncommon, can be life and limb-threatening. The purpose of the current study was to determine the association between varicella and serious musculoskeletal complications necessitating operative treatment and to characterize these infections in otherwise healthy children. We retrospectively reviewed the records of all patients who had been admitted to the Children's Hospital in San Diego because of varicella and its complications during the eleven-year period from 1984 through 1994. All records with an inpatient discharge diagnosis code for varicella were identified. Twenty-seven (6 per cent) of the 417 admissions for varicella were for musculoskeletal complications of the disease necessitating operative treatment. There were seven admissions for osteomyelitis, four for septic arthritis, five for necrotizing fasciitis, ten for a deep-tissue abscess, and one for toxic shock syndrome leading to multiple limb amputations. Seventy-nine (19 per cent) of the 417 admissions occurred in 1994. Eleven (41 per cent) of the twenty-seven musculoskeletal complications that led to operative treatment occurred in 1994, representing a significant increase in the number of such complications compared with the numbers in previous years of the study (p < 0.01). Bacterial pathogens were identified as the cause of twenty-five of the twenty-seven complications that led to operative treatment. Of these twenty-five, twenty-one (84 per cent) were found, on culture, to be caused by group-A β-hemolytic streptococcus. This pathogen was the cause of the infection in five of the seven patients who had osteomyelitis while Staphylococcus aureus was the cause in only one. Group-A βhemolytic streptococcus was also the causative organism in two of the four patients who had septic arthritis, three of the five who had necrotizing fasciitis, and all ten who had a deep-tissue abscess. Nine of the eleven musculoskeletal complications leading to operative treatment in 1994 had group-A β-hemolytic streptococcus as the causative organism. An understanding of the trends of and a high level of suspicion for potentially serious secondary infections in children who have varicella is necessary for prompt recognition and appropriate treatment.

Abstract: Purpose : Four children with an osteomyelitic process in the jaw bones while on cytotoxic chemotherapy were treated by radical surgery and antimicrobial chemotherapy. Patients and Methods : Symptoms (local swelling and pain in the jaw, necrotic gingivitis, and spontaneous loss of teeth) appeared 3 weeks, 4 weeks, and 8 months after diagnosis of leukemia, and 8 days posttransplant in a patient with severe aplastic anemia. Three had the process in the mandible and one in the maxilla. Specific diagnoses of Aspergillus flavus, Saccharomyces cerevisiae, and Actinomyces species were obtained histologically from surgical samples. Treatment was radical surgery to remove all infected and necrotic tissue : removal of a substantial part of the mandible and loss of seven to eight permanent teeth in those with mandibular lesions. Actinomycosis was treated with penicillin for 2 years. The patients with fungal lesions received amphotericin B for 2, 5, and 6 months, with adjuvant itraconazole, fluconazole, or 5-fluorocytosine for 9-12 months. Anticancer chemotherapy was continued. Results : All the bony lesions healed. The patient with acute myeloid leukemia died in relapse 1 year postdiagnosis ; her aspergillus osteomyelitis had been inactive for 8 months. The other three patients are alive and well 1.9, 2.1, and 1.9 years after termination of antimicrobial therapy. Conclusions : We emphasize the necessity of specific diagnosis from appropriate surgical samples and conclude that in patients undergoing chemotherapy bony lesions caused by opportunistic microorganisms may be curable with aggressive surgery and prolonged medication.

Abstract: A prospective study was carried out of 22 patients admitted with 25 diabetic foot infections. All had cellulitis, 12 had discharging ulcers and eight had digital gangrene. In one case magnetic resonance imaging (MRI) was unhelpful owing to patient movement. Thirteen scans suggested deep-seated infection, including abscess (ten), osteomyelitis (seven) and ankle effusion (one). Overall, imaging provided a specificity of 77 per cent, a positive predictive value of 77 per cent, a sensitivity of 91 per cent and a negative predictive value of 91 per cent. MRI is valuable in determining the presence and extent of infection, which allows appropriate planning of surgical intervention.

Abstract: Lemierre's syndrome, a systemic anaerobic infection caused by Fusobacterium necrophorum, is characterized by an acute oropharyngeal infection, septic thrombophlebitis of the internal jugular vein, sepsis, and multiple metastatic infections. It commonly leads to septic arthritis and occasionally to osteomyelitis. In the preantibiotic era, this infection was nearly universally fatal. Today it still poses a potentially grave threat to the young patients affected. Prompt recognition with appropriate debridement and antibiotic treatment results in complete recovery in most cases. We report a case of anaerobic septic arthritis and multifocal acute hematogenous osteomyelitis as part of a classic presentation of Lemierre's syndrome.

Abstract: A technique of computed tomography with intravenous contrast has proven useful in the differentiation between osteoid osteoma and other similar appearing lucent lesions of bone in 6 cases. The clinical evaluation of benign appearing radiolucent lesions of long bones has been greatly improved by the use of modern imaging techniques. The differential diagnosis often is narrowed to osteoid osteoma and osteomyelitis based on plain radiographs, computed tomography, or magnetic resonance imaging. The enhancement of the lucent center of the lesion was plotted against time. The rapid uptake of contrast medium by the osteoid osteoma was in sharp contrast to the much slower enhancement in osteomyelitis. The establishment of a preoperative diagnosis enabled the surgeon to excise the lesion without a biopsy. Histologic review verified the preoperative diagnosis in all cases.

Abstract: Downloaded from www.ajronline.org by UCLA Digital Coll SVCS on 05/06/15 from IP address 149.142.243.67. Copyright ARRS. For personal use only; all rights reserved Ribbing Disease (Multiple Diaphyseal Sclerosis): Imaging and Differential Diagnosis Leanne L. Seeger1 Keith C. Hewel OBJECTIVE. This study describes the clinical presentation ease in six patients and illustrates imaging features on plain and 99mTcmethylene Lawrence computed Richard MATERIALS AND sented with painful bony H. Gold1 Joseph M. Mirra2 Vi jay P Chandnani3 Jeffrey J. Eckardt4 tomography, affected: lateral tibiae both femur available in one. diphosphonate bone in three patients, a unilateral radiographs and tibia and either 99’’Tc-methylene in one, six female patients disease. Ten bones both femora diphosphonate (lack of systemic signs of infection disease), imaging, histologic evaluation, graphic studies showed benign-appearing uptake of radionuclide revealed specimens and endosteal tracer bone. These fracture, chronic disorder. Clinical R changes specimens disease ibbing tion 5. 1995 accepted after revision endosteal Patients Presented at the annual meeting of the American Roent- gen Ray Society. Washington, DC, April-May 1995 puberty 1UCLA School of Medicine, Department of Radiological diaphyses Sciences, 200 UCLA Medical Plaza, Ste. 165-59, Los Ange- es, CA 90095-6952 Address correspondence to L Seeger 2Orthopaedic Hospital, Department of Pathology, 2400 5 Flower St . Ste 524, Los Angeles, CA 90007 Army Medical Center, Department of Radiology, Bldg. 3600, 3851 Roger Brooke Dr., Fort Sam Houston, TX 3Brooke of in excluding I I I. The of long disease bones, features but benign I I 1. after new bone disease is confined especially Symptoms and abnormalities to the the tibia (pain seen and/or on imaging may remain unilateral or may be followed after a delay of months to years by symp- toms in the opposite extremity I 1-41. Radio- logically, the differential diagnosis of Ribbing osteoid osteoma. osteomyelitis, ture. and Camurati-Engelmann disease includes osteosarcoma, stress disease frac- (pro- 0361-803X/96/1673-689 diaphyseal sclerosis) I I , 4, 5-7]. Other sclerosing dysplasias and metabolic disorders associated with increased bone © American Roentgen Ray Society density gressive AJR1996,167 AJft167, September assisted patients. of clinical metabolic bones. increase bone All pathologic in the mass of cortical neoplastic may also be considered that, on imaging or infectious may suggest Materials Between with studies. or a systemic neoplasia, by the forma- exuberant 4UCLA School of Medicine, Department of Orthopaedic also is a rare condition Surgery, 10833 LeConte Ave., 62-258 CHS, Los Angeles, CA a slow bone-forming and imaging and periosteal contract Ribbing and the femur swelling) a combination suggesting to the shaft of all involved that included is a rare disorder infection, that is characterized Received September April 8. 1996 were for five for late stress endocrine values and a uni- and specimen cultures. Radiographs and tomo- endosteal and periosteal cortical thickening. Intense was confined nonspecific the new bone formation. CONCLUSION. Ribbing disease causes or laboratory pre- were tomography scans, bone All patients underwent open biopsy and/or surgical decompression. RESULTS. The diagnosis was reached in all patients through findings in one, or computed conventional dis- and scans. METHODS. Between 1982 and 1990, lesions that were believed to be Ribbing Plain for all patients and the course of Ribbing radiography, conventional the correct may simu- metabolic and Methods 1982 and chronic pain six unrelated in a lower extremity women presented for consultation with an orthopedic oncologic geon. Five of these patients were initially elsewhere tional to and were consultation produce or diagnosis. sent to our institution after outside a diagnosis that for addi- evaluation would sur- seen explain failed their continued pain. Original clinical diagnoses for these five patients were osteoid osteoma with retained nidus (n = 2). chronic osteomyelitis (n = I ). osteomyelitis versus tumor (a = I ), and scieros- ing osteitis (F: 1 ). All five patients had under- gone biopsy before coming to our institution; four specimens were interpreted as representing chronic osteomyelitis and one as sclerosing osteo- myelitis versus bone island. The disease involved the lower extremities in all patients. Of the 10 bones involved, lesions affected both tibiae in three patients. a unilateral tibia in one, both femora in one, and a unilateral femur in one.

Abstract: We studied 168 children with acute lymphoblastic leukemia (ALL) and 57 with acute nonlymphoblastic leukemia (ANLL) by retrospectively analyzing clinical symptoms, bone or joint involvement, and hematological findings to verify the clinical features and prognosis of children with acute leukemia who showed radiographic bone changes at the time of diagnosis. Of these, 36 with ALL (21.4%) and 6 with ANLL (10.5%) had symptoms referable to the bones or joints. Thirteen patients (7.7%) with ALL showed bone lesions radiographically. Phenotypically, 12 of the 13 had common ALL, 8 were incorrectly diagnosed and had received treatment for osteomyelitis or juvenile rheumatoid arthritis for 1 to 7 months prior to diagnosis of ALL. Leukocyte count was nearly normal with few or no blasts, and anemia and thrombocytopenia were mild or absent in all patients. Twelve of them remained in a complete remission for 26 to 148 months. Our data suggest that children with bone lesions related to acute leukemia exhibit clinical features that mimic infectious or collagen disease at diagnosis, and may belong to a subgroup of ALL with a better prognosis.

Abstract: To evaluate the diagnostic value of technetium-99md,l-hexamethylpropylene amine oxime (HMPAO) labelled leucocytes in combination with a99mTc-methylene diphosphonate (MDP) bone scan in the detection of chronic osteomyelitis, we retrospectively reviewed 55 patients. Prior to the99mTc-d,I-HMPAO labelled leucocyte scan, all patients underwent a99mTc-MDP bone scan. The correct diagnosis was confirmed by long-term clinical follow-up (n=29) or by bacteriological cultures (n=26). We found an overall sensitivity of 94%, a specificity of 91% and an accuracy of 92% for99mTc-d,l-HMPAO labelled leucocyte scintigraphy in the diagnosis of chronic osteomyelitis. When the patients were divided into three groups according to the location of the infection, our study results showed a sensitivity and specificity for the central location (containing active bone marrow) of 94% and 100% respectively; for the peripheral location (hands and feet) both parameters were 100%, and for the middle location (all sites between the central and the peripheral location) the values were 92% and 81% respectively. Specificity and accuracy were significantly lower in the middle location than in the central and peripheral locations. The results of our study confirm that a99mTc-d,l-HMPAO labelled leucocyte scan in combination with an99mTc-MDP bone scan is a reliable way to diagnose chronic osteomyelitis, except for vertebral osteomyelitis.

Abstract: Diabetic foot infections, a frequent and serious cause of morbidity in patients with diabetes mellitus, are caused by anaerobic and aerobic bacteria. Given the fact that seriously impaired host defense factors are almost always present in these patients, bactericidal agents with a broad spectrum of antimicrobial activity are required for their treatment. Seventy-four patients with diabetic foot infections were treated with parenteral sulbactam-ampicillin (1.5 g, q.i.d.). All patients were followed-up prospectively in order to determine the efficacy and safety of sulbactam-ampicillin. The mean duration (+/- SD) of treatment in patients with osteomyelitis (n = 49) and soft tissue infections (n = 25) was 41 +/- 5 and 14 +/- 3 days, respectively. Infected limbs were amputated at various levels in 14 patients (19%). Clinical cure rates were 86% and 100% in patients with osteomyelitis and with soft tissue infection, respectively. The most frequent side effect was diarrhea and observed in 10 patients (14%). The results of the present study indicate that sulbactam-ampicillin is safe and effective in the treatment of diabetic foot infections.

Abstract: One hundred seven combined In-111 WBC/Tc-99m MDP scans performed on 87 patients with a high clinical suspicion of osteomyelitis were retrospectively reviewed. An 86% sensitivity and a 94% specificity for detecting osteomyelitis were found. In addition, patients were grouped into one of five clinical settings for more detailed analysis : diabetic osteoarthropathy, previous arthroplasty, fracture, overlying skin ulcer, and other etiology. Forty-seven studies were performed while patlents received antibiotic therapy without loss of sensitivity for detecting osteomyelitis. Results obtained with scintigraphy compared favorably to other imaging and laboratory studies used to detect osteomyelitis. In conclusion, the combined In-111 WBC/Tc-99m MDP scan is a very sensitive and specific method to detect osteomyelitis in patients with concurrent diabetic osteoarthropathy, fracture, postoperative healing, and overlying skin ulcer. Antibiotic treatment does not appear to adversely affect the sensitivity of these scans.

Abstract: We report the cases of 28 patients with bacterial infections of the shoulder treated between 1979 and 1991. There were ten cases of septic arthritis, ten cases of simple osteomyelitis of the proximal humerus, four cases of septic arthritis and concomitant osteomyelitis of the proximal humerus and four cases of periarticular soft-tissue infection. The infections, except for the cases of osteomyelitis, were staged by a “Classification of Exogenic Bacterial Infections” (CEBI). In septic arthritis and in periarticular soft-tissue infection, the time between the initial symptoms of infection and diagnosis was about 20 days. In the cases with osteomyelitis, there was an average delay of 9 months, which was partly due to the slow evolution of plasmacellular osteomyelitis. Treatment was based on operative debridement and arthrotomy, the insertion of drains, the implantation of gentamicin-polymethylmethacrylate beads and the application of highdose parenteral antibiotics. In the postoperative period physiotherapy with early active and/or passive range-of-motion exercises favoured the draining of secretions and therefore gave better results than complete immobilisation. Treatment was evaluated using a modification of the shoulder score of Wulker et al. [17]. This study demonstrated that favourable results could only be obtained if the diagnosis was made early. This is particularly true for infections with Staphylococcus aureus (found in 19 patients). The overall result of the treatment of osteomyelitis and periarticular soft-tissue infection was good or satisfactory, while unsatisfactory results were noted for the patients with septic arthritis, particularly those with both septic arthritis and osteomyelitis.

Abstract: A case of isolated cryptococcal skull infection is presented in a patient with unexplained CD4 lymphopenia and chronic hepatitis B. All cases of this disease reported in the English literature from 1956 to the present are reviewed. The literature suggests that skeletal cryptococcosis is manifested in only 5% to 10% of recognized cases of disseminated cryptococcosis and that isolated skeletal disease without evidence of other tissue involvement is even less common. When isolated bony disease does occur it tends to occur in immunocompromised hosts, particularly those with defects of cell mediated immunity. Any bony site can be involved, most commonly the vertebrae, with the presentation often being a soft tissue swelling and pain in the affected area. Systemic constitutional symptoms occur in a minority of patients. Radiographic investigations are nonspecific and the gold standard of diagnosis remains culture isolation from bone tissue. The most commonly employed therapy for isolated bone disease is amphotericin alone or combined with surgical debridement. The new azoles may have a role in future therapy.

Abstract: Sternal wound infection with atypical mycobacteria following open heart surgery is a rare occurrence. Previous reports have described infection byMycobacterium fortuitum, an acid-fast bacillus and member of a larger family of rapidly growing mycobacteria. The source and mode of transmission have not been identified. Surgical debridement and the combination of aminoglycosides and quinolones have been shown to be effective methods of treatment. More recently, clarithromycin has been shown to be the drug of choice against rapidly growing mycobacteria. We describe a 49-year-old woman who underwent infundibular stenosis repair and in whomM fortuitumsternal osteomyelitis developed. Total sternectomy, muscle flap reconstruction, and antibiotic treatment successfully eradicated the infection. Arch Surg. 1996;131:1344-1346