Diagnostic Radiology
Brodie Abscess: Reappraisal 1 William B. Miller, Jr., M.D., William A. Murphy, M.D., and Louis A. Gilula, M.D.
Upon review, 25 cases of Brodie abscess demonstrated a radiological spectrum not previously appreciated. One third of the lesions were diaphyseal in location, and 50 % had associated cortical thickening, while 40 % showed a stimulated periosteal reaction, and 20 % contained sequestra. The variable radiological appearance was underscored by the fact that the preoperative diagnosis was other than osteomyelitis in half the cases. A diverse nomenclature has proliferated to describe and catalogue bone abscess formation. Although the radiological spectrum is broad, the unanimity of clinical presentation, pathological findings, and response to surgical excision supports the concept of a single entity with variable expression. INDEX TERMS: Abscess. Bones, infection. (Skeletal system, osteomyelitis, 4 [0] .210) • (Skeletal system, Brodie's abscess, 4[0].213) Radiology 132:15-23, July 1979
1832 and later in 1845, Sir Benjamin Collins Brodie described the clinical aspects and surgical treatment of a chronic inflammatory process in the tibia associated with no known antecedent infection (1, 2). Subsequent reports chronicled the multiplicity of sites and described the radiographical appearance of such bone abscesses. They emphasized a characteristic metaphyseal location in long bones; a small, eccentric, lytic lesion with reactive sclerosis; and predominant occurrence in males with unfused epiphyseal plates. A diverse nomenclature proliferated to catalogue clinical, radiological, and bacteriological variants (3-9). The present study was undertaken to reappraise chronic bone abscesses, their radiological appearance, and nomenclature.
METHODS AND RESULTS
N
I
TABLE. I:
Patient WH JH BW MB HD MW LF MP DO WH PB AC PK PW LZ LL JW WA JD LS
Age (yr.)/ Sex 6F 6M 8M 9F 10 F 11 F 12 M 12 M 13 M 14 M 15 M 16 M 16 M 18 F 24M 36 F 39 M 46 M 54 M 61 F
* NR = no record; SA
Symptom Duration
Previous Infection
4wk. 4 wk. 5 wk. 3 mo. 6 mo. 2.5 yr. 15 mo. 6 mo. 3.5 mo. 3 mo. 3 mo. 6 wk. 1.5 yr. 1 yr. 3 yr. 6mo. 5 wk. 7 mo. 6mo. 4mo.
+
Case material consisted of all retrievable pathologically proved Brodie abscesses referred to the Mallinckrodt Institute of Radiology from 1937 to the present. In all, 25 cases were available for review. Completed records were obtained for 20 patients, and clinical follow-up ranged from five months to eight years. Clinical Findings: ( TABLE I) The patients ranged from 6 to 61 years in age. Half of them were between 6 and 15 years of age, and three quarters were less than 25. One third were female. The
CLINICAL FINDINGS (N = 20) Previous Trauma
+ + +
Aspirin Pain Relief*
+ + +
NR
+ NR
+ +
+
+ + + + +
+ +
+
NR NR
+ NR
+ +
+ = Staphylococcus aureus; NG = no growth; PM = Proteus mirabilus.
Preoperative Diagnosis
Culture Results*
Osteomyel itis Osteomyelitis Osteomyelitis Eosinophilic granuloma Sarcoma Sarcoma Osteomyelitis Osteoid osteoma Osteomyelitis Osteomyelitis Osteomyelitis Eosinophilic granuloma Osteoid osteoma Osteomyelitis Osteoid osteoma Osteomyelitis Enchondroma Osteomyel itis Metastasis Chondrosarcoma
NG SA SA SA SA NG SA NG SA NG SA NG NG SA NG SA SA PM SA NG
1 From the Mal Iinckrodt Institute of Radiology, Washington University School of Medicine, St.Louis, MO. Presented at the Sixty-fourth Scientific Assembly and Annual Meeting of the Radiological Society of North America, Chicago, 111., Nov. 26-Dec. 1, 1978. Received Dec. 5,1978; accepted and revision requested Feb. 28, 1979; received April 3. jr
15
WILLIAM B. MILLER, JR. AND OTHERS
16
METAPHYSEAL 15
DIAPHYSEAL 9 SESAMOID I
3
1
Fig. 1.
Skeleta l distrib ution of Brodie absces ses.
durat ion of symptomatology before diagnosis ranged from four weeks to three years , with an ave rage of seven mon ths. Eight abscesses were diagnosed with in three
TABLE II:
Patient WH JH BW MB HD MW LF MP DO WH PB AC PK PW LZ LL JW WA JD LS FO JC AK SA JH , T
Age 6 6
8 9 10 11 12 12 13 14 15 16 16 18 24 36 39 46 54 61 14 20 21 26
?
Bone ' T T F R F T T F T F T F F T P F MT T F F T F Fi Fi F
Diaphyseal vs. Metaphyseal ' M D M D D D M M M M M M M D D M D D M M M M D M
months of the historical onset of symptoms, and 14 of the 20 were diagnosed within six months. In only 4 patients were the abscesses diagnosed more than a year after onset of symptoms. The 3 patients under eight years of age presented with the short est duration of symptoms; each had experienced four to five weeks of local ized pain and limping. In all cases , the presenting complaint was recurrent pain , described as a persistent ache . Remissions and exacerbations were limited to those with a longer duration of symp toms . Twelve pat ients had focal tenderness over the abscess ; 3 had regional erythema of the affe cted limb , and 4 had mild swelling . Five patients, all of whom were less than 12 years old, had a limp. Only 5 patients recounted a situ at ion possibly related to previous infection. One had a soft-tissue staphylococcal abscess of the arm three weeks prior to the diagnosis of Brodie abscess in a femur. However, local pain in the femur antedated the arm abscess by several months. Two other patients had open fracture reduc tion on the same bone but at sites distant to their subsequent bone abscess. The fourth patient gave an unconfirmed history of prior " blood po isoning. " The last patient complained of inter mittent pain in his hip 10 years prior to diagnosis of Brodie abscess in the femu r. Radiographs which had been taken at the onset of his pain 10 years before showed a sclerot ic lesion with a small central radiolucency which was interpreted as an old , inacti ve infection, and no surgery was performed . The patient subsequently experienced only infrequent hip pain until six months prior to diagnosis, when
RADIOLOGICAL FINDINGS (N Epiphyseal Vio lation
July 1979
= 25)
Sequestr a Formation
React ive Bone Formation" Cancello us Periosteal Corti ca l 2+
+ + +
+
+
+
+
+
3+ + + + + 2+ + + + + + + 2+ + 2+ + 2+
ref er to a subjec tive sca le used to quantitate rea c tive bone formation. where 1
+ 2+ 3+
+ + +
2+ +
+
+
+
+ +
+ + + +
+ + 2+
+ +
+ 3+ +
= tib ia; F = femur; R = radius ; P = patella; MT = metatarsal; Fi = fibula ; M = metaphysea l; D = diaphyseal.
T Numbe rs
3+
= slig ht rea ction and 3 = marked reaction .
Vol. 132
17
BRODIE ABSCESS: REAPPRAISAL
Fig. 2. Metaphyseal Brodie abscess (15-year-old boy). Lobulated distal tibial lucent lesion with barely perceptible cancellous sclerosis and short metaphyseal sinus tracts (arrowheads) .
it became unrelenting. He was shown to have a spontaneous reactivation of a Brodie abscess that had been quiescent for 10 years . Preoperative fever was documented in only 4 patients and a leukocytosis in 5, all of whom were less than 15 years of age. A history of trauma was related by 8 patients, and although most seemed coincidental, 1 patient had a calcified hematoma adjacent to the abscess. She had had an automobile accident with blunt injury to that region, and had experienced considerable pain for six weeks between the accident and diagnosis. In 10 patients, a history of significant pain relief by aspirin was specified. Five patients reported no relief, and no record is available for the remaining 5. This aspect of the history did not help differentiate between Brodie abscess and osteoid osteoma. Antibiotics were administered preoperatively in 5 patients, and 14 received varying courses of antibiotics postoperatively. The only patient with postsurgical recurrence of an abscess received both preoperative and postoperative antibiotic therapy. All 20 patients had a biopsy specimen sent for culture. Of these, Staphylococcus aureus was demonstrated in 11. No bacterium could be recovered in 8, and one abscess grew Proteus mirabilis. Surgical procedures included curettement, sequestrectomy, and fenestration. In many operative reports, it was noted that intramedullary or intracortical pus spurted from the bone as though under
Diagnostic Radiology
Fig. 3. Diaphyseal Brodie abscess (36-year-old woman) . Well circumscribed lucent lesion completely filling the femoral medullary canal has surrounding dense endosteal sclerosis and cortical thickening.
pressure. Secondary closure was necessary in several of the younger patients, and skin grafting was required twice . Follow-up varied from five months to eight years after surgery. Two patients experienced continued pain , and 1 of these had a proved recurrence two years after the initial surgery. Five years after the second surgical procedure, the patient was entirely asymptomatic. The second patient experienced mild pain, but no clinical recurrence was documented during the 15 months before the patient was lost to follow-up.
Radiological Findings:
(TABLE
If)
Location: Twenty-five patients were evaluated (Fig. 1), and all but 1 of the abscesses were found in the legs, most commonly in the femur (11 patients) or tibia (9 patients). Fifteen lesions occurred in metaphyseal regions (Fig. 2), while 9 involved the diaphyses (Fig. 3). Five of the 9 diaphyseal abscesses were cortical rather than medullary (Fig. 4). Four abscesses were located in the femoral neck, 1 in the femoral head, and 2 in the intertrochanteric region. A metatarsal head and a patella were affected. Nearly all lesions were eccentric, except those large le-
18
WILLIAM
B.
MILLER, JR. AND OTHERS
July 1979
Fig. 5. Epiphyseal plate violation (8-year-old boy). Proximal femoral metaphyseal abscess crosses epiphyseal growth plate (arrows) to involve femoral capital epiphysis; very little bone reaction is present.
Fig. 4. Diaphyseal Brodie abscess with cortical predominance (9-year-old girl). Long eccentric lesion with focal cortical thinning (arrowheads) and endosteal sclerosis of the radius ; originally diagnosed as eosinophilic granuloma.
sions that filled or slightly expanded the affected metaphysis or diaphysis (Fig . 3). Three abscesses crossed an epiphyseal plate (Figs. 5 and 6). Of these, 1 patient had an eight-year follow-up after curettement, and no asymmetry in limb growth was recorded . Size and Shape: Abscess diameter ranged from 4 mm to 5 em. The larger lesions were generally found in the metaphyseal regions. Lucent tracks often extended through cancellous bone for distances up to 9 em (Fig. 6). The shape was variable, often of lobulated contour, but tending to be greater in length than width . In several cases, a small intraosseous sinus tract extended from the main body of the lesion and correctly suggested the inflammatory nature of the abnormality (Fig . 2). Four abscesses appeared multiloculated (Fig. 7). Five abscesses, of which 4 were diaphyseal, exhibited sequestration within the abscess cavity (Fig. 8). Bone Destruction: The predominant manifestation of abscess formation is a circumscribed focus of bone destruction surrounded by a variable amount of bone reaction. While some lesions were well marginated (Fig. 3), others were barely perceptible (Fig. 2). Although the spectrum
Fig. 6. Epiphyseal plate violation (12-year-01d boy). A 9-cm long, well marginated, proximal tibial metaphyseal abscess with moderate cancellous reaction crosses the growth plate to involve the tibial plateau epiphysis (arrows).
Vol. 132
BRODIE ABSCESS: REAPPRAISAL
19
Diagnostic Radiology
Fig. 7. Multiloculated Brodie abscess (13-year-old boy). Several connecting abscess cav ities in the distal tibia project with a multilocular appearance.
of margin sharpness was broad, all lesions were basically geographic in pattern. The exception to this rule was that cortically located lesions did show intracortical permeation early in their history. This appearance, seen only on close
Fig. 8. Diaphyseal cortical abscess with sequestrum (18-year-old girl). Endosteal and cortical thickening of the tibia.
Fig. 9. Brodie abscess in the femoral neck (12-year-old boy). Barely perceptible lucent lesion (black arrowheads) was confirmed by laminography; the medial cortex of the femoral heck was thickly buttressed with new bone formation (white arrowheads). The original diagnosis was osteoid osteoma.
inspection, caused confusion with permeative patterns. However, the overall appearance clarified the lesion as focal and geographic . Bone Reaction: Cancellous, periosteal, and cortical reactive bone formation were quantitated on a subjective scale of 1 to 3, from slight to marked reaction. The zone of transition between the abscess and surrounding bone ranged from nearly imperceptible blending with trabecular architecture (Fig. 9) to sharp demarcation surrounded by a variable degree of reactive cancellous sclerosis (Fig. 10). The least defined lesions were found in the femoral neck, and in 3 patients laminography helped confirm an abnormality. Twenty-one cases showed a degree of cancellous sclerosis. A spectrum of periosteal reaction ranging from immature (Fig. 11) to mature (Fig. 12) was encountered in 10 instances. The periostitis was seen with purely lytic lesions as well as with those surrounded by reactive sclerosis. Buttressing of the femoral calcar was present in the 4 femoral neck abscesses (Figs. 9 and 10). Cortical thickening of varying degree was noted in 13 patients (Figs. 8, 12, and 13).
20
WILLIAM
B.
MILLER, JR . AND
OTHERS
July 1979
Fig . 10. Brodie abscess in the femoral neck (16-year-old boy). Well defined abscess with moderate cancellous reaction and thickly buttressed femoral neck. The original diagnosis was eos inophilic granuloma.
Fig. 11. Thick , immature periosteal reaction (6-year-old girl) . Multiloculated abscess nearly fills the distal tibial metaphys is, crosses the epiphyseal plate (black arrowheads), and stimulates periosteal reaction (white arrowheads).
Other Radiographic Studies: In most instances, only standard radiographs were obtained before biopsy. A hip arthrogram in a patient with a femoral neck abscess demonstrated synovial hypertrophy. In another case, an arteriogram was performed for a lesion with a central lucent nidus, and no blush was demonstrated. FOllow-up radiographs were available for 6 pat ients, and all demonstrated healing of the previous surgical defect. Diagnosis: The preoperative diagnosis was osteomyelitis in only half the cases. Three patients were thought to have an osteoid osteoma (Figs. 9 and 12). The remaining misdiagnoses included eosinophilic granuloma (Figs. 4 and 10), chondrosarcoma (Fig. 13), osteogenic sarcoma (Fig. 14), possible metastasis (Fig. 15), Ewing sarcoma, and chondroma. Pathological Findings
Fig. 12. Thick, mature periosteal reaction (6-year-old boy). Long region of mature periosteal thickening of tibial cortex with lucent nidus (arrowheads) originally diagnosed as osteoid osteoma.
All surgical specimens were similar in that active granulation tissue lined the abscess cavities. Acute and chronic inflammatory cells consisting of leukocytes, lymphocytes, and plasma cells diffusely infiltrated this lining. A moderate fibroblastic response was present in most cases, and a fibrin layer separating bone from
BRODIE ABSCESS: REAPPRAISAL
Vol. 132
21
Diagnostic Radiology
14a
Fig. 13. Brodie abscess originally diagnosed as chondrosarcoma (61-year-old woman). III-defined lucent abscess cavity in the distal femoral metaphysis (arrowheads) with a mottled appearance of metadiaphyseal cancellous bone, endosteal and cortical thickening, and a focus of medullary calcification (arrow).
granulation tissue was common. Trabeculae within the inflammatory focus were enveloped by loose edematous fibrous tissue containing plasma cells and leukocytes. Several specimens showed foci of ischemic necrosis. DISCUSSION
The precise clinical and surgical description of bone abscess formation by Sir Benjamin Collins Brodie in 1832 and 1845, though unaided by radiography or bacteriology, rema ins accurate and pertinent (1, 2). He reported 8 patients with a disease of the tibia which was clinically characterized by local swelling and excessive pain, often with periodic exacerbation; the pain was often worse at night. Lengthy remissions were observed. The ages at consultation ranged from 13 to 34 years, but the age of clinical onset was always during the second decade of life. Duration of pain was up to 18 years. All but 1 of the patients were male, and there was no history of antecedent infec-
Fig. 14. Brodie abscess originally diagnosed as osteosarcoma (10-year-old girl). Thick periosteal new bone formation along medial cortex and an amorphous deposit of calcium (a, arrowheads and b) in the soft tissues adjacent to the destructive proximal femoral diaphyseal lesion .
tion . All lesions of the tibia , except the initial one which was treated by amputation, were treated by trephine osteotomy. Pus-filled cavities were drained, and the surrounding cortex and periosteum appeared thickened. All patients who survived surgery were cured; 1 patient, who had a recurrence 18 months after surgery, was cured by a second operation.
22
WILLIAM
B. MILLER, JR. AND OTHERS
July 1979
15a,b
Fig. 15. Recurrent Brodie abscess originally diagnosed as metastasis (54-year-old man) . a. July 1976-Unchanged from 3 years previously by radiography and from 10 years previously by history; dense cancellous sclerosis (arrows) surrounds a faint lucent medullary lesion (arrowhead). b. December 1976-The enlarged lucent lesion with well defined margins is a reactivated Brodie abscess which cultured Staphylococcus aureus .
Our series of bone abscesses is similar to Brodie's with respect to clinical presentation because of chronic pain, and with respect to uniform surgical cure by osteotomy. The episodic nature of the pain was less pronounced in the current group. The other differences in age, sex, and symptom duration are largely due to the advent of radiography and to social pressures for early diagnosis and therapy. Although Brodie did not know the precise etiology of his cases of bone abscess, almost all investigators since his time, including us, have reported Staphylococcus aureus as the predominant organism cultured (6, 9). The reason for the high proportion of sterile abscesses (approaching 50 %) in our study is still unknown, but may be due to an attenuated organism, a strong host response, or other unknown factors. Whether or not organisms are retrieved may depend on the duration of the lesion and preoperative antibiotic therapy. The radiologic diagnosis began in 1906 with Thomson's series (3) and was expanded by Brickner (4) in 1917 and Brailsford (6) in 1938. On the basis of these descriptions, Brodie abscess has been characterized as a small metaphyseal lesion with well defined margins, which is often tibial, and which occurs in young men prior to epiphyseal closure. In this series, only 5 (20%) abscesses were found in the classic tibial locations. Of the majority (60 %) which were found in metaphyseal locations, 4 were in the femoral
neck, a location not previously reported. Another was present in the patella (10). Our series is similar to previous series in that very few lesions were found in areas other than the legs, the reason for which is unknown. This series emphasizes the diversity of location within a bone and shows that diaphyseal location (36 %) is not as uncommon as previously recorded. The classic radiological descriptions of Brodie abscess describe sequestrum formation and violation of the epiphyseal plate as distinctly unusual (3-6). Sequestra were found in 5 (20 % ) of our cases and epiphyseal plate violation in 3 (12 %). The presence of sequestra in this series may be due to earlier diagnostic intervention. If we assume that a Brodie abscess has a natural history which includes a destructive phase prior to the containment phase, then we might expect to find sequestra if we examine cases earlier in the natural history. Brailsford (6) felt that the cartilaginous epiphyseal plate was an absolute barrier to a bone abscess. Kandel and Mankin (9) reported 3 examples of epiphyseal plate violation similar to those in this series. Although accelerated maturation resulting from hyperemia or epiphyseal closure due to injury might be expected, no discrepancy in leg length developed in our patients or those of Kandel and Mankin. Perhaps this favorable outcome is due to the small area involving the epiphyseal plate, coupled with effective surgical and antibiotic therapy.
23
BRODIE ABSCESS: REAPPRAISAL
Vol. 132
As a result of this study, we gained a new appreciation for the variable expression of bone reaction to a Brodie abscess. The amount and variability of cancellous, cortical, and periosteal bone formation is remarkable. Cancellous bone may vary from normal, with a nearly hidden zone of destruction, to dense medullary sclerosis completely surrounding a cavity. Some degree of cortical thickening is often present and may vary from buttressing of the femoral neck to diffuse addition of endosteal bone. Periosteal reaction includes lamellar, thick, and mature types. The atypical periosteal reactions provide the greatest diagnostic problems and have been misdiagnosed as Ewing sarcoma and osteosarcoma. Although the differential diagnosis of a Brodie abscess can be extensive (6, 10), it is more important to consider a bone abscess as a possibility when confronted with an atypical lesion, than to expand a differential diagnosis when a bone abscess is the prime consideration. Treatment has not changed since Brodie's original description nearly 150 years ago. An osteotomy with curettage is the treatment of choice, and antibiotic therapy is generally an adjunct and should be specific for any organisms cultured. Recent Soviet literature (11, 12) has stressed a complicated treatment protocol utilizing staphylococcal antitoxin, novacaine blockade, and local and systemic antibiotics in addition to surgical intervention. This approach does not seem to have any advantage over present surgical therapy. In recent years, a number of subcategories of bone abscess formation have been proposed. Although they are individualized by names, such as primary subacute pyogenic osteomyelitis (7), subacute haematogenous osteomyelitis (8), and pyogenic abscess of the long bones (9), they are all similar to Brodie abscess. In general, they present with gradually increasing chronic pain. When the abnormality is radiologically localized, surgery is uniformly curative. Certainly there is some clinical diversity, and we have demonstrated wide radiological variation. However, the uniformity of presentation, pathological findings, and the singular success of local surgery suggest the usefulness of considering these circumscribed inflammatory lesions of bone as a single entity. The eponymic term "Brodie abcess," serves this purpose well and provides appropriate recognition for the remarkable original description of this lesion. CONCLUSION
This study has demonstrated that the clinical and radi-
Diagnostic Radiology
ological presentations of Brodie abscess have changed during the past 50-75 years. Although the history of chronic, gradually worsening pain and the uniformly curative result of surgery are unaltered, the history of exacerbations and remissions is less impressive and the radiological appearance diverse. Depending upon when in the history of an abscess a radiograph is obtained, a more or less mature appearance is expected. In this series, the findings of sequestration and immature periosteal reaction support the theory that these lesions are being evaluated earlier in their clinical course. Furthermore, the findings in this study emphasize the spectrum of radiologic appearance of bone abscesses. Diaphyseal location is more common than previously appreciated. Violation of the epiphyseal plate occurs but apparently does not lead to discrepancy in leg length. Cancellous, cortical, and periosteal new bone formation is varied. When an atypical bone lesion is encountered in the legs, a Brodie abscess should be considered in the differential diagnosis. William A. Murphy, M.D. Mallinckrodt Institute of Radiology 510 South Kingshighway Boulevard St. Louis, Missouri 63110
REFERENCES 1. Brodie BC: An account of some cases of chronic abscess of the tibia. Medico-Chir Trans 17:239-249. 1832 2. Brodie BC: Lecture on abscess of the tibia. London Medical Gazette 36: 1399- 1403, 12 Dec 1845 3. Thomson A: Observations on the circumscribed abscess of bone (Brodie's abscess). Edinburgh Med J 19:297-309, 1906 4. Brickner WM: Chronic medullary abscess of the long bones; its clinical and rbntgenographic features; its treatment by simple trephining. Ann Surg 65:483-490, Apr 1917 5. Henderson MS, Simon HE: Brodie's abscess. Arch Surg 9: 504-515, Nov 1924 6. Brailsford JF: Brodie's abscess and its differential diagnosis. Br Med J 2:119-123, 16 Jul 1938 7. Harris NH, Kirkaldy-Willis WH: Primary subacute pyogenic osteomyelitis. J Bone Joint Surg [Br] 47:526-532. Aug 1965 8. King OM, Mayo KM: Subacute haematogenous osteomyelitis. J Bone Joing Surg [Br] 51:458-463, Aug 1969 9. Kandel SN, Mankin HJ: Pyogenic abscess of the long bones in children. Clin Orthop 96:108-117, Oct 1973 10; Miller WB, Murphy WA, Gilula LA, et al: Brodie's abscess of the patella. JAMA 238: 1179-1180, 12 Sep 1977 11. Nadzhmitdinov NN, Klevits VE: Bone abscesses. Vestn Khir 97:93- 94, Oct 1966 12. Sadykhov AG, Gamidov EM, Pauker AV: Brodie's abscess. Khirurgiya 6:63-67, Jun 1977
Brodie Abscess: Reappraisal 1 William B. Miller, Jr., M.D., William A. Murphy, M.D., and Louis A. Gilula, M.D.
Upon review, 25 cases of Brodie abscess demonstrated a radiological spectrum not previously appreciated. One third of the lesions were diaphyseal in location, and 50 % had associated cortical thickening, while 40 % showed a stimulated periosteal reaction, and 20 % contained sequestra. The variable radiological appearance was underscored by the fact that the preoperative diagnosis was other than osteomyelitis in half the cases. A diverse nomenclature has proliferated to describe and catalogue bone abscess formation. Although the radiological spectrum is broad, the unanimity of clinical presentation, pathological findings, and response to surgical excision supports the concept of a single entity with variable expression. INDEX TERMS: Abscess. Bones, infection. (Skeletal system, osteomyelitis, 4 [0] .210) • (Skeletal system, Brodie's abscess, 4[0].213) Radiology 132:15-23, July 1979
1832 and later in 1845, Sir Benjamin Collins Brodie described the clinical aspects and surgical treatment of a chronic inflammatory process in the tibia associated with no known antecedent infection (1, 2). Subsequent reports chronicled the multiplicity of sites and described the radiographical appearance of such bone abscesses. They emphasized a characteristic metaphyseal location in long bones; a small, eccentric, lytic lesion with reactive sclerosis; and predominant occurrence in males with unfused epiphyseal plates. A diverse nomenclature proliferated to catalogue clinical, radiological, and bacteriological variants (3-9). The present study was undertaken to reappraise chronic bone abscesses, their radiological appearance, and nomenclature.
METHODS AND RESULTS
N
I
TABLE. I:
Patient WH JH BW MB HD MW LF MP DO WH PB AC PK PW LZ LL JW WA JD LS
Age (yr.)/ Sex 6F 6M 8M 9F 10 F 11 F 12 M 12 M 13 M 14 M 15 M 16 M 16 M 18 F 24M 36 F 39 M 46 M 54 M 61 F
* NR = no record; SA
Symptom Duration
Previous Infection
4wk. 4 wk. 5 wk. 3 mo. 6 mo. 2.5 yr. 15 mo. 6 mo. 3.5 mo. 3 mo. 3 mo. 6 wk. 1.5 yr. 1 yr. 3 yr. 6mo. 5 wk. 7 mo. 6mo. 4mo.
+
Case material consisted of all retrievable pathologically proved Brodie abscesses referred to the Mallinckrodt Institute of Radiology from 1937 to the present. In all, 25 cases were available for review. Completed records were obtained for 20 patients, and clinical follow-up ranged from five months to eight years. Clinical Findings: ( TABLE I) The patients ranged from 6 to 61 years in age. Half of them were between 6 and 15 years of age, and three quarters were less than 25. One third were female. The
CLINICAL FINDINGS (N = 20) Previous Trauma
+ + +
Aspirin Pain Relief*
+ + +
NR
+ NR
+ +
+
+ + + + +
+ +
+
NR NR
+ NR
+ +
+ = Staphylococcus aureus; NG = no growth; PM = Proteus mirabilus.
Preoperative Diagnosis
Culture Results*
Osteomyel itis Osteomyelitis Osteomyelitis Eosinophilic granuloma Sarcoma Sarcoma Osteomyelitis Osteoid osteoma Osteomyelitis Osteomyelitis Osteomyelitis Eosinophilic granuloma Osteoid osteoma Osteomyelitis Osteoid osteoma Osteomyelitis Enchondroma Osteomyel itis Metastasis Chondrosarcoma
NG SA SA SA SA NG SA NG SA NG SA NG NG SA NG SA SA PM SA NG
1 From the Mal Iinckrodt Institute of Radiology, Washington University School of Medicine, St.Louis, MO. Presented at the Sixty-fourth Scientific Assembly and Annual Meeting of the Radiological Society of North America, Chicago, 111., Nov. 26-Dec. 1, 1978. Received Dec. 5,1978; accepted and revision requested Feb. 28, 1979; received April 3. jr
15
WILLIAM B. MILLER, JR. AND OTHERS
16
METAPHYSEAL 15
DIAPHYSEAL 9 SESAMOID I
3
1
Fig. 1.
Skeleta l distrib ution of Brodie absces ses.
durat ion of symptomatology before diagnosis ranged from four weeks to three years , with an ave rage of seven mon ths. Eight abscesses were diagnosed with in three
TABLE II:
Patient WH JH BW MB HD MW LF MP DO WH PB AC PK PW LZ LL JW WA JD LS FO JC AK SA JH , T
Age 6 6
8 9 10 11 12 12 13 14 15 16 16 18 24 36 39 46 54 61 14 20 21 26
?
Bone ' T T F R F T T F T F T F F T P F MT T F F T F Fi Fi F
Diaphyseal vs. Metaphyseal ' M D M D D D M M M M M M M D D M D D M M M M D M
months of the historical onset of symptoms, and 14 of the 20 were diagnosed within six months. In only 4 patients were the abscesses diagnosed more than a year after onset of symptoms. The 3 patients under eight years of age presented with the short est duration of symptoms; each had experienced four to five weeks of local ized pain and limping. In all cases , the presenting complaint was recurrent pain , described as a persistent ache . Remissions and exacerbations were limited to those with a longer duration of symp toms . Twelve pat ients had focal tenderness over the abscess ; 3 had regional erythema of the affe cted limb , and 4 had mild swelling . Five patients, all of whom were less than 12 years old, had a limp. Only 5 patients recounted a situ at ion possibly related to previous infection. One had a soft-tissue staphylococcal abscess of the arm three weeks prior to the diagnosis of Brodie abscess in a femur. However, local pain in the femur antedated the arm abscess by several months. Two other patients had open fracture reduc tion on the same bone but at sites distant to their subsequent bone abscess. The fourth patient gave an unconfirmed history of prior " blood po isoning. " The last patient complained of inter mittent pain in his hip 10 years prior to diagnosis of Brodie abscess in the femu r. Radiographs which had been taken at the onset of his pain 10 years before showed a sclerot ic lesion with a small central radiolucency which was interpreted as an old , inacti ve infection, and no surgery was performed . The patient subsequently experienced only infrequent hip pain until six months prior to diagnosis, when
RADIOLOGICAL FINDINGS (N Epiphyseal Vio lation
July 1979
= 25)
Sequestr a Formation
React ive Bone Formation" Cancello us Periosteal Corti ca l 2+
+ + +
+
+
+
+
+
3+ + + + + 2+ + + + + + + 2+ + 2+ + 2+
ref er to a subjec tive sca le used to quantitate rea c tive bone formation. where 1
+ 2+ 3+
+ + +
2+ +
+
+
+
+ +
+ + + +
+ + 2+
+ +
+ 3+ +
= tib ia; F = femur; R = radius ; P = patella; MT = metatarsal; Fi = fibula ; M = metaphysea l; D = diaphyseal.
T Numbe rs
3+
= slig ht rea ction and 3 = marked reaction .
Vol. 132
17
BRODIE ABSCESS: REAPPRAISAL
Fig. 2. Metaphyseal Brodie abscess (15-year-old boy). Lobulated distal tibial lucent lesion with barely perceptible cancellous sclerosis and short metaphyseal sinus tracts (arrowheads) .
it became unrelenting. He was shown to have a spontaneous reactivation of a Brodie abscess that had been quiescent for 10 years . Preoperative fever was documented in only 4 patients and a leukocytosis in 5, all of whom were less than 15 years of age. A history of trauma was related by 8 patients, and although most seemed coincidental, 1 patient had a calcified hematoma adjacent to the abscess. She had had an automobile accident with blunt injury to that region, and had experienced considerable pain for six weeks between the accident and diagnosis. In 10 patients, a history of significant pain relief by aspirin was specified. Five patients reported no relief, and no record is available for the remaining 5. This aspect of the history did not help differentiate between Brodie abscess and osteoid osteoma. Antibiotics were administered preoperatively in 5 patients, and 14 received varying courses of antibiotics postoperatively. The only patient with postsurgical recurrence of an abscess received both preoperative and postoperative antibiotic therapy. All 20 patients had a biopsy specimen sent for culture. Of these, Staphylococcus aureus was demonstrated in 11. No bacterium could be recovered in 8, and one abscess grew Proteus mirabilis. Surgical procedures included curettement, sequestrectomy, and fenestration. In many operative reports, it was noted that intramedullary or intracortical pus spurted from the bone as though under
Diagnostic Radiology
Fig. 3. Diaphyseal Brodie abscess (36-year-old woman) . Well circumscribed lucent lesion completely filling the femoral medullary canal has surrounding dense endosteal sclerosis and cortical thickening.
pressure. Secondary closure was necessary in several of the younger patients, and skin grafting was required twice . Follow-up varied from five months to eight years after surgery. Two patients experienced continued pain , and 1 of these had a proved recurrence two years after the initial surgery. Five years after the second surgical procedure, the patient was entirely asymptomatic. The second patient experienced mild pain, but no clinical recurrence was documented during the 15 months before the patient was lost to follow-up.
Radiological Findings:
(TABLE
If)
Location: Twenty-five patients were evaluated (Fig. 1), and all but 1 of the abscesses were found in the legs, most commonly in the femur (11 patients) or tibia (9 patients). Fifteen lesions occurred in metaphyseal regions (Fig. 2), while 9 involved the diaphyses (Fig. 3). Five of the 9 diaphyseal abscesses were cortical rather than medullary (Fig. 4). Four abscesses were located in the femoral neck, 1 in the femoral head, and 2 in the intertrochanteric region. A metatarsal head and a patella were affected. Nearly all lesions were eccentric, except those large le-
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Fig. 5. Epiphyseal plate violation (8-year-old boy). Proximal femoral metaphyseal abscess crosses epiphyseal growth plate (arrows) to involve femoral capital epiphysis; very little bone reaction is present.
Fig. 4. Diaphyseal Brodie abscess with cortical predominance (9-year-old girl). Long eccentric lesion with focal cortical thinning (arrowheads) and endosteal sclerosis of the radius ; originally diagnosed as eosinophilic granuloma.
sions that filled or slightly expanded the affected metaphysis or diaphysis (Fig . 3). Three abscesses crossed an epiphyseal plate (Figs. 5 and 6). Of these, 1 patient had an eight-year follow-up after curettement, and no asymmetry in limb growth was recorded . Size and Shape: Abscess diameter ranged from 4 mm to 5 em. The larger lesions were generally found in the metaphyseal regions. Lucent tracks often extended through cancellous bone for distances up to 9 em (Fig. 6). The shape was variable, often of lobulated contour, but tending to be greater in length than width . In several cases, a small intraosseous sinus tract extended from the main body of the lesion and correctly suggested the inflammatory nature of the abnormality (Fig . 2). Four abscesses appeared multiloculated (Fig. 7). Five abscesses, of which 4 were diaphyseal, exhibited sequestration within the abscess cavity (Fig. 8). Bone Destruction: The predominant manifestation of abscess formation is a circumscribed focus of bone destruction surrounded by a variable amount of bone reaction. While some lesions were well marginated (Fig. 3), others were barely perceptible (Fig. 2). Although the spectrum
Fig. 6. Epiphyseal plate violation (12-year-01d boy). A 9-cm long, well marginated, proximal tibial metaphyseal abscess with moderate cancellous reaction crosses the growth plate to involve the tibial plateau epiphysis (arrows).
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Diagnostic Radiology
Fig. 7. Multiloculated Brodie abscess (13-year-old boy). Several connecting abscess cav ities in the distal tibia project with a multilocular appearance.
of margin sharpness was broad, all lesions were basically geographic in pattern. The exception to this rule was that cortically located lesions did show intracortical permeation early in their history. This appearance, seen only on close
Fig. 8. Diaphyseal cortical abscess with sequestrum (18-year-old girl). Endosteal and cortical thickening of the tibia.
Fig. 9. Brodie abscess in the femoral neck (12-year-old boy). Barely perceptible lucent lesion (black arrowheads) was confirmed by laminography; the medial cortex of the femoral heck was thickly buttressed with new bone formation (white arrowheads). The original diagnosis was osteoid osteoma.
inspection, caused confusion with permeative patterns. However, the overall appearance clarified the lesion as focal and geographic . Bone Reaction: Cancellous, periosteal, and cortical reactive bone formation were quantitated on a subjective scale of 1 to 3, from slight to marked reaction. The zone of transition between the abscess and surrounding bone ranged from nearly imperceptible blending with trabecular architecture (Fig. 9) to sharp demarcation surrounded by a variable degree of reactive cancellous sclerosis (Fig. 10). The least defined lesions were found in the femoral neck, and in 3 patients laminography helped confirm an abnormality. Twenty-one cases showed a degree of cancellous sclerosis. A spectrum of periosteal reaction ranging from immature (Fig. 11) to mature (Fig. 12) was encountered in 10 instances. The periostitis was seen with purely lytic lesions as well as with those surrounded by reactive sclerosis. Buttressing of the femoral calcar was present in the 4 femoral neck abscesses (Figs. 9 and 10). Cortical thickening of varying degree was noted in 13 patients (Figs. 8, 12, and 13).
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Fig . 10. Brodie abscess in the femoral neck (16-year-old boy). Well defined abscess with moderate cancellous reaction and thickly buttressed femoral neck. The original diagnosis was eos inophilic granuloma.
Fig. 11. Thick , immature periosteal reaction (6-year-old girl) . Multiloculated abscess nearly fills the distal tibial metaphys is, crosses the epiphyseal plate (black arrowheads), and stimulates periosteal reaction (white arrowheads).
Other Radiographic Studies: In most instances, only standard radiographs were obtained before biopsy. A hip arthrogram in a patient with a femoral neck abscess demonstrated synovial hypertrophy. In another case, an arteriogram was performed for a lesion with a central lucent nidus, and no blush was demonstrated. FOllow-up radiographs were available for 6 pat ients, and all demonstrated healing of the previous surgical defect. Diagnosis: The preoperative diagnosis was osteomyelitis in only half the cases. Three patients were thought to have an osteoid osteoma (Figs. 9 and 12). The remaining misdiagnoses included eosinophilic granuloma (Figs. 4 and 10), chondrosarcoma (Fig. 13), osteogenic sarcoma (Fig. 14), possible metastasis (Fig. 15), Ewing sarcoma, and chondroma. Pathological Findings
Fig. 12. Thick, mature periosteal reaction (6-year-old boy). Long region of mature periosteal thickening of tibial cortex with lucent nidus (arrowheads) originally diagnosed as osteoid osteoma.
All surgical specimens were similar in that active granulation tissue lined the abscess cavities. Acute and chronic inflammatory cells consisting of leukocytes, lymphocytes, and plasma cells diffusely infiltrated this lining. A moderate fibroblastic response was present in most cases, and a fibrin layer separating bone from
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Diagnostic Radiology
14a
Fig. 13. Brodie abscess originally diagnosed as chondrosarcoma (61-year-old woman). III-defined lucent abscess cavity in the distal femoral metaphysis (arrowheads) with a mottled appearance of metadiaphyseal cancellous bone, endosteal and cortical thickening, and a focus of medullary calcification (arrow).
granulation tissue was common. Trabeculae within the inflammatory focus were enveloped by loose edematous fibrous tissue containing plasma cells and leukocytes. Several specimens showed foci of ischemic necrosis. DISCUSSION
The precise clinical and surgical description of bone abscess formation by Sir Benjamin Collins Brodie in 1832 and 1845, though unaided by radiography or bacteriology, rema ins accurate and pertinent (1, 2). He reported 8 patients with a disease of the tibia which was clinically characterized by local swelling and excessive pain, often with periodic exacerbation; the pain was often worse at night. Lengthy remissions were observed. The ages at consultation ranged from 13 to 34 years, but the age of clinical onset was always during the second decade of life. Duration of pain was up to 18 years. All but 1 of the patients were male, and there was no history of antecedent infec-
Fig. 14. Brodie abscess originally diagnosed as osteosarcoma (10-year-old girl). Thick periosteal new bone formation along medial cortex and an amorphous deposit of calcium (a, arrowheads and b) in the soft tissues adjacent to the destructive proximal femoral diaphyseal lesion .
tion . All lesions of the tibia , except the initial one which was treated by amputation, were treated by trephine osteotomy. Pus-filled cavities were drained, and the surrounding cortex and periosteum appeared thickened. All patients who survived surgery were cured; 1 patient, who had a recurrence 18 months after surgery, was cured by a second operation.
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15a,b
Fig. 15. Recurrent Brodie abscess originally diagnosed as metastasis (54-year-old man) . a. July 1976-Unchanged from 3 years previously by radiography and from 10 years previously by history; dense cancellous sclerosis (arrows) surrounds a faint lucent medullary lesion (arrowhead). b. December 1976-The enlarged lucent lesion with well defined margins is a reactivated Brodie abscess which cultured Staphylococcus aureus .
Our series of bone abscesses is similar to Brodie's with respect to clinical presentation because of chronic pain, and with respect to uniform surgical cure by osteotomy. The episodic nature of the pain was less pronounced in the current group. The other differences in age, sex, and symptom duration are largely due to the advent of radiography and to social pressures for early diagnosis and therapy. Although Brodie did not know the precise etiology of his cases of bone abscess, almost all investigators since his time, including us, have reported Staphylococcus aureus as the predominant organism cultured (6, 9). The reason for the high proportion of sterile abscesses (approaching 50 %) in our study is still unknown, but may be due to an attenuated organism, a strong host response, or other unknown factors. Whether or not organisms are retrieved may depend on the duration of the lesion and preoperative antibiotic therapy. The radiologic diagnosis began in 1906 with Thomson's series (3) and was expanded by Brickner (4) in 1917 and Brailsford (6) in 1938. On the basis of these descriptions, Brodie abscess has been characterized as a small metaphyseal lesion with well defined margins, which is often tibial, and which occurs in young men prior to epiphyseal closure. In this series, only 5 (20%) abscesses were found in the classic tibial locations. Of the majority (60 %) which were found in metaphyseal locations, 4 were in the femoral
neck, a location not previously reported. Another was present in the patella (10). Our series is similar to previous series in that very few lesions were found in areas other than the legs, the reason for which is unknown. This series emphasizes the diversity of location within a bone and shows that diaphyseal location (36 %) is not as uncommon as previously recorded. The classic radiological descriptions of Brodie abscess describe sequestrum formation and violation of the epiphyseal plate as distinctly unusual (3-6). Sequestra were found in 5 (20 % ) of our cases and epiphyseal plate violation in 3 (12 %). The presence of sequestra in this series may be due to earlier diagnostic intervention. If we assume that a Brodie abscess has a natural history which includes a destructive phase prior to the containment phase, then we might expect to find sequestra if we examine cases earlier in the natural history. Brailsford (6) felt that the cartilaginous epiphyseal plate was an absolute barrier to a bone abscess. Kandel and Mankin (9) reported 3 examples of epiphyseal plate violation similar to those in this series. Although accelerated maturation resulting from hyperemia or epiphyseal closure due to injury might be expected, no discrepancy in leg length developed in our patients or those of Kandel and Mankin. Perhaps this favorable outcome is due to the small area involving the epiphyseal plate, coupled with effective surgical and antibiotic therapy.
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As a result of this study, we gained a new appreciation for the variable expression of bone reaction to a Brodie abscess. The amount and variability of cancellous, cortical, and periosteal bone formation is remarkable. Cancellous bone may vary from normal, with a nearly hidden zone of destruction, to dense medullary sclerosis completely surrounding a cavity. Some degree of cortical thickening is often present and may vary from buttressing of the femoral neck to diffuse addition of endosteal bone. Periosteal reaction includes lamellar, thick, and mature types. The atypical periosteal reactions provide the greatest diagnostic problems and have been misdiagnosed as Ewing sarcoma and osteosarcoma. Although the differential diagnosis of a Brodie abscess can be extensive (6, 10), it is more important to consider a bone abscess as a possibility when confronted with an atypical lesion, than to expand a differential diagnosis when a bone abscess is the prime consideration. Treatment has not changed since Brodie's original description nearly 150 years ago. An osteotomy with curettage is the treatment of choice, and antibiotic therapy is generally an adjunct and should be specific for any organisms cultured. Recent Soviet literature (11, 12) has stressed a complicated treatment protocol utilizing staphylococcal antitoxin, novacaine blockade, and local and systemic antibiotics in addition to surgical intervention. This approach does not seem to have any advantage over present surgical therapy. In recent years, a number of subcategories of bone abscess formation have been proposed. Although they are individualized by names, such as primary subacute pyogenic osteomyelitis (7), subacute haematogenous osteomyelitis (8), and pyogenic abscess of the long bones (9), they are all similar to Brodie abscess. In general, they present with gradually increasing chronic pain. When the abnormality is radiologically localized, surgery is uniformly curative. Certainly there is some clinical diversity, and we have demonstrated wide radiological variation. However, the uniformity of presentation, pathological findings, and the singular success of local surgery suggest the usefulness of considering these circumscribed inflammatory lesions of bone as a single entity. The eponymic term "Brodie abcess," serves this purpose well and provides appropriate recognition for the remarkable original description of this lesion. CONCLUSION
This study has demonstrated that the clinical and radi-
Diagnostic Radiology
ological presentations of Brodie abscess have changed during the past 50-75 years. Although the history of chronic, gradually worsening pain and the uniformly curative result of surgery are unaltered, the history of exacerbations and remissions is less impressive and the radiological appearance diverse. Depending upon when in the history of an abscess a radiograph is obtained, a more or less mature appearance is expected. In this series, the findings of sequestration and immature periosteal reaction support the theory that these lesions are being evaluated earlier in their clinical course. Furthermore, the findings in this study emphasize the spectrum of radiologic appearance of bone abscesses. Diaphyseal location is more common than previously appreciated. Violation of the epiphyseal plate occurs but apparently does not lead to discrepancy in leg length. Cancellous, cortical, and periosteal new bone formation is varied. When an atypical bone lesion is encountered in the legs, a Brodie abscess should be considered in the differential diagnosis. William A. Murphy, M.D. Mallinckrodt Institute of Radiology 510 South Kingshighway Boulevard St. Louis, Missouri 63110
REFERENCES 1. Brodie BC: An account of some cases of chronic abscess of the tibia. Medico-Chir Trans 17:239-249. 1832 2. Brodie BC: Lecture on abscess of the tibia. London Medical Gazette 36: 1399- 1403, 12 Dec 1845 3. Thomson A: Observations on the circumscribed abscess of bone (Brodie's abscess). Edinburgh Med J 19:297-309, 1906 4. Brickner WM: Chronic medullary abscess of the long bones; its clinical and rbntgenographic features; its treatment by simple trephining. Ann Surg 65:483-490, Apr 1917 5. Henderson MS, Simon HE: Brodie's abscess. Arch Surg 9: 504-515, Nov 1924 6. Brailsford JF: Brodie's abscess and its differential diagnosis. Br Med J 2:119-123, 16 Jul 1938 7. Harris NH, Kirkaldy-Willis WH: Primary subacute pyogenic osteomyelitis. J Bone Joint Surg [Br] 47:526-532. Aug 1965 8. King OM, Mayo KM: Subacute haematogenous osteomyelitis. J Bone Joing Surg [Br] 51:458-463, Aug 1969 9. Kandel SN, Mankin HJ: Pyogenic abscess of the long bones in children. Clin Orthop 96:108-117, Oct 1973 10; Miller WB, Murphy WA, Gilula LA, et al: Brodie's abscess of the patella. JAMA 238: 1179-1180, 12 Sep 1977 11. Nadzhmitdinov NN, Klevits VE: Bone abscesses. Vestn Khir 97:93- 94, Oct 1966 12. Sadykhov AG, Gamidov EM, Pauker AV: Brodie's abscess. Khirurgiya 6:63-67, Jun 1977
