Venous thrombosis and thromboembolism is common in children with acute osteomyelitis

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Crary et al in this issue of The Journal describe a retrospective case series over 18 months of occurrence of deep vein thrombosis (DVT) in children hospitalized for acute osteomyelitis in Dallas, Texas. The study population was limited to those with proximal extremity, pelvic or vertebral osteomyelitis (who possibly are at higher risk for DVT, or were more likely to have imaging for diagnosis of infection that included major veins, or both). Although only one patient was clinically suspected to have DVT, DVT was found by imaging in 10 of 35 (29%) study patients included because of site of osteomyelitis, or 10 of 52 (19%) patients who had the diagnosis of acute osteomyelitis at any site at the institution. Compared with study patients without DVT, those with DVT had excessive morbidity, such as disseminated infection in lung, brain or heart compatible with thromboembolism, and prolonged course of illness and hospitalization. Most patients did not have underlying thrombophilic disorders.

Eight of 10 cases were caused by methicillin-resistant Staphylococcus aureus (MRSA). Although association of DVT with MRSA was not statistically significant in this study, multiple other reports in the medical literature suggest that Panton-Valentine leukocidin (PVL) is the major virulence factor associated with the global epidemic strains of community-associated (CA)-MRSA. Recently, transfer of PVL and its attendant virulence to CA-MSSA strains has been documented in some locales. Infection with CA-MRSA mainly causes recurrent furunculosis but necrotizing pneumonia, complicated osteomyelitis and thromboembolic disease are well recognized to be “epidemic” concurrently.

With all of the limitations of a retrospective study, Crary et al have done a service to alert pediatricians that we frequently miss the diagnosis of DVT as well as septic thromboembolism and possibly miss the opportunity to enhance management by use of anticoagulant therapy.