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Case: A 38-year-old woman presented to our clinic with right knee pain and difficulty ambulating. After cultures were obtained, a cryptococcal infection of the patella was identified. Subsequent workup revealed previously undiagnosed HIV/AIDS and a disseminated cryptococcal infection., Conclusion: Over a 20-month course, the patient was treated with fluconazole and antiretroviral therapy with very limited medication compliance. The disseminated infection caused cutaneous, hepatic, and cerebral complications. Eventually, compliance improved, and a final procedure to obtain post-treatment cultures and apply antifungal bone matrix was completed. The patient cleared the infection and will likely require lifetime antifungal treatment., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C424)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Osteomyelitis is a rare infection that is considered to be a children’s disease. Diagnosis is frequently delayed because it is an uncommon pathology and is presented in various ways. After its diagnosis and treatment, the result is favourable in children. We present a clinical case that shows difficulties in its diagnosis. A high index of suspicion should be addressed for early recognition.

Linezolid is an effective antibiotic against most gram-positive bacteria including drug-resistant strains such as methicillin-resistant Staphylococcus aureus. Although linezolid therapy is known to result in thrombocytopenia, dosage adjustment or therapeutic drug monitoring of linezolid is not generally necessary. In this report, however, we describe the case of a 79-year-old woman with recurrent methicillin-resistant S. aureus osteomyelitis that was successfully treated via surgery and combination therapy using linezolid and rifampicin under therapeutic drug monitoring for maintaining an appropriate serum linezolid concentration. The patient underwent surgery for the removal of the artificial left knee joint and placement of vancomycin-impregnated bone cement beads against methicillin-resistant S. aureus after total left knee implant arthroplasty for osteoarthritis. We also initiated linezolid administration at a conventional dose of 600 mg/h at 12-h intervals, but reduced it to 300 mg/h at 12-h intervals on day 9 because of a decrease in platelet count and an increase in serum linezolid trough concentration. However, when the infection exacerbated, we again increased the linezolid dose to 600 mg/h at 12-h intervals and performed combination therapy with rifampicin, considering their synergistic effects and the control of serum linezolid trough concentration via drug interaction. Methicillin-resistant S. aureus infection improved without reducing the dose of or discontinuing linezolid. The findings in the present case suggest that therapeutic drug monitoring could be useful for ensuring the therapeutic efficacy and safety of combination therapy even in patients with osteomyelitis who require long-term antibiotic administration., (Copyright © 2015 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Tuberculosis of patella is a rare occurrence with incidence of less than 0.15% in the literature. Owing to its rarity the diagnosis is usually missed. Here we present a case of tuberculosis of the patella, being treated as chronic synovitis elsewhere. An 11-year-old boy presented to us with chronic knee swelling and a draining sinus of 5 months duration. He was being treated with broad spectrum antibiotics and incision and drainage. Standard X-rays revealed a lytic area with surrounding coke such as sequestrum in patella. MRI was suggestive of osteomyelitis of the patella with soft tissue oedema. Diagnosis was confirmed on biopsy. The patient was managed by curettage and excision of the sinus tract along with antitubercular treatment. The patient responded well to antitubercular therapy and gained excellent functional range of movement. In today's era of potent antituberculous drugs and decreasing tuberculosis incidence the rare and unusual locations of tuberculosis such as patella should be borne in mind while dealing with chronic lesions of the knee especially in tubercular endemic areas. A timely diagnosis helps in regaining good range of motion and a satisfactory outcome.

A 51-year-old man with a history of stage IV angioimmunoblastic T-cell lymphoma was diagnosed with osteomyelitis of the patella. Legionella anisa was identified by 16S rRNA gene sequencing and culture. The patient had pneumonia 2 months prior to this osteomyelitis episode. L. anisa was retrospectively detected in his lung tissue by 16S rRNA gene sequencing and was considered the source of the L. anisa that caused his patella osteomyelitis.

Osteomyelitis is an uncommon infection that is considered to be a childhood disease. Diagnosis is frequently delayed, as it is a very rare condition and also because of its variable presentation. After an accurate diagnosis and treatment, the outcome is favorable in children. We present one case without recent previous infection, antecedent trauma, or penetrating injury, illustrating the difficulties in diagnosis. Nontraumatic osteomyelitis of the patella should be regarded as a rare hematogenous infection. A high index of suspicion should be addressed for early recognition. Study design is level of evidence: level IV.

An enigmatic feature of Lyme disease is the slow resolution of musculoskeletal symptoms that can continue after treatment, with some patients developing an inflammatory arthritis that becomes refractory to antibiotic therapy. Using intravital microscopy and the mouse model of Lyme borreliosis, we observed that Borrelia burgdorferi antigens, but not infectious spirochetes, can remain adjacent to cartilage for extended periods after antibiotic treatment. B. burgdorferi was not recovered by culture or xenodiagnosis with ticks after antibiotic treatment of WT mice and all but one of the immunodeficient mice with heightened pathogen burden due to impaired TLR responsiveness. Amorphous GFP+ deposits were visualized by intravital microscopy in the entheses of antibiotic-treated mice infected with GFP-expressing spirochetes and on the ear cartilage surface in sites where immunofluorescence staining detected spirochete antigens. Naive mice were not infected by tissue transplants from antibiotic-treated mice even though transplants contained spirochete DNA. Tissue homogenates from antibiotic-treated mice induced IgG reactive with B. burgdorferi antigens after immunization of naive mice and stimulated TNF-α production from macrophages in vitro. This is the first direct demonstration that inflammatory B. burgdorferi components can persist near cartilaginous tissue after treatment for Lyme disease. We propose that these deposits could contribute to the development of antibiotic-refractory Lyme arthritis.

A 4-year-old, spayed female, mixed-breed dog was presented for evaluation of chronic left hind-limb lameness. Lytic lesions were observed in the left patella on radiographs of the stifle. A biopsy of the patella led to a histopathological diagnosis of blastomycosis. Surgical debridement followed by a 90-day course of itraconazole and physical rehabilitation resolved the clinical signs and stopped the progression of radiographic lesions. Blastomycosis should be considered as a differential diagnosis for stifle joint lameness with lytic lesions in the patella.

Osteomyelitis of the patella is rare; it essentially occurs in child age. The diagnosis is difficult because of its variable presentation; it should always be considered in patients with persistent peripatellar pain and swelling. This paper reports one case of haematogenous osteomyelitis of the patella not associated with septic knee arthritis. The identification of the organism was performed by the injection-aspiration fluid technique. Treatment is identical to the treatment of osteomyelitis at other locations. The literature is also reviewed and discussed.

Peripatellar lesions causing knee pain include cellulitis, bursitis, synovitis, septic arthritis and patellar osteomyelitis. We present here two cases of patellar osteomyelitis which were misdiagnosed as prepatellar bursitis. Operative treatment was required for these lesions. Patellar osteomyelitis should always be considered when treating a peripatellar lesion, although it is very rare condition.

The gastrocnemius muscle is versatile in flap repair of defects from anterior knee to lower leg. We describe a case of extensor reconstruction using an extended medial gastrocnemius myocutaneous flap. A medial gastrocnemius flap was raised distal to its musculotendinous insertion. At its point of rotation, it was anchored to the anterior periosteum of the tibia, hence obliterating dead space and recreating the extensor mechanism of the knee. The patient had no flap loss and was able to ambulate independently. He showed no extensor lag. Our flap is unique in that it is the only medial gastrocnemius flap that has shown no extensor lag as well as complete flexion of the knee following a disrupted entire quadriceps mechanism. It is also the first myocutaneous gastrocnemius flap that has been described for this purpose.

A rare case of tuberculosis of the patella is presented. Diagnostic features include an osteolytic lesion in the patella with flaky sequestrum, associated with typical clinical features. Treatment should be urgent and should include a regimen of surgical debridement along with four antitubercular drugs. Once the joint is involved, the end results become less satisfactory.

Tuberculosis in an isolated localization in the patella is rarely reported. Five cases were found in the literature. Two new cases together with the radiographic work-up to be performed in case of a "painful" knee are presented. Histology of the curetage specimen is required to reach certain diagnosis and develop an adapted management strategy to protect the functional future of the knee.