Published online May 1, 2006
PEDIATRICS Vol. 117 No. 5 May 2006, pp. 1673-1679 (doi:10.1542/10.1542/peds.2005-2009)

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Venous Thrombosis Associated With Staphylococcal Osteomyelitis in Children

Blanca E. Gonzalez, MD^a,c, Jun Teruya, MD, DSc^a,b,c, Donald H. Mahoney, Jr, MD^a,c, Kristina G. Hulten, PhD^a,c, Rachael Edwards, BS^b,c, Linda B. Lamberth^a,c, Wendy A. Hammerman, RN^a,c, Edward O. Mason, Jr, PhD^a,c and Sheldon L. Kaplan, MD^a,c

^a Departments of Pediatrics
^b Pathology, Baylor College of Medicine, Houston, Texas
^c Texas Children's Hospital, Houston, Texas

BACKGROUND. Venous thrombosis (VT) in children with Staphylococcus aureus osteomyelitis occurs rarely. We describe clinical features of infections and molecular characterization of isolates of children at Texas Children's Hospital with S aureus osteomyelitis and VT.

METHODS. We reviewed records and imaging studies (chest radiographs, ultrasound, computed tomography, and MRI) of 9 patients at Texas Children's Hospital with acute S aureus osteomyelitis and new onset VT between August 1999 and December 2004. Isolates were fingerprinted by pulsed-field gel electrophoresis and tested for the presence of genes encoding selective virulence factors.

RESULTS. The mean age of the patients was 10.6 years. All 9 of the patients had osteomyelitis with sites of infection adjacent to the VT. The femoral and popliteal veins were most commonly affected. Two patients had VTs develop on the same side in which a central line had been in place. Four patients had chest radiographs consistent with septic emboli; inferior vena cava filters were placed in 3. Evaluation for hypercoagulable state revealed 3 patients with lupus anticoagulant, 1 with anticardiolipin IgG antibody, and 5 with no defect. Most laboratory abnormalities had resolved at follow-up. Seven patients had infections caused by methicillin-resistant S aureus belonging to the same clonal group (USA300); all were community acquired. Seven isolates carried the Panton-Valentine leukocidin (luk-S-PV and luk-F-PV) genes.

CONCLUSIONS. The predominant community-acquired, methicillin-resistant S aureus clone in Houston, Texas, (USA300) may have a unique propensity to cause VT in association with osteomyelitis. Management of the venous thrombosis in this setting may be complicated by the rapid evolution of septic emboli.

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Key Words: venous thrombosis • Staphylococcus aureus • osteomyelitis

Abbreviations: VT—venous thrombosis • CA—community acquired • MRSA—methicillin-resistant Staphylococcus aureus • TCH—Texas Children's Hospital • PFGE—pulsed-field gel electrophoresis • MSSA—methicillin-susceptible Staphylococcus aureus • LMWH—low molecular weight heparin • IVC—inferior cava filter • PVL—Panton-Valentine leukocidin

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Accepted Oct 19, 2005.

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