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Sternal Fracture Caused by Streptococcus pyogenes Abscess.

FIGURE. Sagittal chest computed tomography showing (A) sternal collection and osteomyelitis and (B) sternal fracture. Color online-figure is available at http://www.jclinrheum.com. A 57-year-old woman presented to the emergency department (ED) with 2 weeks of chest pain and spiking fever. She had a history of a lung adenocarcinoma, which was surgically resected and had received 1 cycle of chemotherapy. As a complication, she developed a hospital-acquired pneumonia due to an unidentified pathogen that required admission to the intensive care unit. There was no evidence of persistent infection on the successive controls. After that, she presented to the ED with 2 weeks of ongoing chest pain and 24 hours of high fever. Although the chest x-ray film showed no radiological signs of infection, given her medical history she was started on antibiotics and admitted. Because of lack of clinical improvement, a computed tomography of the chest was done revealing a sternal fracture with osteomyelitis and an underlying collection (Fig.). Bone gammagraphy showed no evidence of metastatic disease. The sternal collection was eventually drained, and the cultures were positive for Streptococcus pyogenes that was also isolated on the blood cultures previously drawn in the ED. The patient was then switched to intravenous penicillin G as guided by antibiogram, with subsequent negative blood cultures and significant clinical improvement. She was on 8 weeks of oral clindamycin after discharge. One month after completing the antibiotic treatment, a biopsy of the sternum showed no evidence of malignancy or inflammatory cells, and cultures were negative. One year after her admission, she was asymptomatic with no evidence of persistent infection. Pathological fractures are usually precipitated by a systemic (osteoporosis) or localized disease (osteomyelitis, tumors) that weakens the bone, leading to bone fragility and fracture after an innocuous or inexistent trauma. In adults, osteomyelitis occurs mainly in the mandible due to contiguous spread, but if the dissemination is hematogenous, vertebrae, sternoclavicular joint, sacroiliac joint, and pelvis are usually affected. If this is the case, most of the infections are caused by Staphylococcus aureus, coagulase-negative staphylococci, and gram-negative bacilli. Likewise, B-hemolytic group B streptococcus, diphtheroid bacillus, and Enterococcus faecalis have all been reported in calcaneus fractures in adults. Staphylococcus aureus, group B β-hemolytic streptococcus, S. pyogenes, and Streptococcus pneumoniae are the most frequent pathogens in the pediatric population. Bone fractures resulting from osteomyelitis are a rare entity, and there is significant scarcity of scientific literature on this matter. Although Janssen et al described a spontaneous fracture whose cultures were positive for the Streptococcus anginosus group, the bone involved was the femur, and metastasis could