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Old 08-16-2008, 07:46 AM   #1
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MSSA Experience - What Lies Ahead?

I am so grateful you all have shared information regarding Staph infecctions! I am a firm believer that knowledge is power, and I value being an informed patient. I just wish I would have been armed with this when I was first diagnosed with MSSA two years ago!

I realize some of you have already read my story, so I apologize. However, there are some new folks who seem to have a very good grasp on how MSSA works, so I am posting my story along with some new thoughts.

Maybe you can provide a little insight and possibly answer a question or two.

Two years ago (almost to the day) I had an external fixator placed to fuse my right ankle. Four weeks later, I had a dramatic increase in my pain level. I went to the emergency room 3 times before they determined my ankle/leg was infected where a battery had been placed for a bone growth stimulator. I have never been in so much pain!

I was hospitalized and more tests were run. They took a culture and learned it was MSSA and following a CT scan, they found it had reached the bone. They put me on daptomycin.

Eight weeks later, my drs assumed it was safe to go off the antibiotics. It was rough because I was very afraid that the infection would return. I was surprised to learn there was no test at the end of treatment to determine whether the infection was gone or not. Due to the amount of time I had spent in excruciating pain (1 week solid pain level of 10 with NO relief) and 3 trips to the ER before I was diagnosed or before anyone could help me, I lost faith in the medical industry. I certainly did not trust that the infection was gone or that it wouldn't return.

As it turned out, the infection did not return and I was able to recover from my fusion without further incidences. Now, fast forward 14 months when my ortho performs a bunionectomy to correct my great toe on the same foot/ankle. He inserted two pins that protruded from the end of my toe to correct my very crooked toe. I was nervous to say the least. Not because I doubted his ability, but due to the difficulties I went through in my prior recovery.

Approximately 2 weeks post op I noticed my toe turning more and more red and the swelling increased while the drainage was nasty. I called the dr and he started me on an oral antibiotic. I had to call again 3 days later to say there was no improvement. He directed me to the ER where his residents examined me and determined I needed to start on Vanco and be admitted for observation.

Five days later I was discharged with another picc line and vanco. The symptoms had drastically improved. Because there was nothing to biopsy or culture, the drs assumed it was a case of cellulitis. I was concerned there was a chance it was osteomyelitis, but they assured me it was not in the bone because the pin sites did not look infected. They could not do an MRI because the metal pins were still in my toe. I proceeded with 4 weeks of Vanco.

At the end of those 4 weeks, I was taken off the Vanco - again there is no test done to ensure the infection is gone. I was happy and relieved to put that chapter of my life behind me and get on with the healing process.

However, two weeks later the pain in my great toe was a 10 and the other symptoms returned. I went immediately to my ID Dr. He determined we stopped the antibiotics too soon and either the infection was in the joint or in the bone. He coordinated efforts with my ortho - both of them wanted an MRI, but until the results were back I would start back on the Vanco.

It took 2 weeks for the results of the MRI. My ortho was not satisfied with the initial reading of the MRI because it mentioned "probable osteomyelitis" which he believed was actually residual evidence of the metal that had been in my toe (the pins had been removed during my hospital stay). Finally, his "colleague" read it and determined the same - it was osteomyelitis.
After another 2 weeks of Vanco I was taken off and it was assumed it was gone.

Now, I have this constant fear in the back of my mind that it will return again in one way, shape or form or another. Why did I have osteomyelitis twice? Why did it take so long to diagnose? Why did my ortho not believe the first reading - it was almost like he didn't want to admit the initial diagnosis or treatment was correct. Did he not want to admit he made a mistake?

I am afraid to have any other procedures done. I have had 7 surgeries total on my foot/ankle in the past 8 years. I still have issues with it, and I am afraid there will be something else we need to do that will put me back in the same spot. What if I had something like dental work done? Would the infection come back in another area?

 
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Old 08-18-2008, 09:16 AM   #2
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Re: MSSA Experience - What Lies Ahead?

Whoa, you've had a pretty rough go! I'm glad you're feeling somewhat better now, but I can imagine the concern you must have in the back of your mind.

First, I want to mention something: there are three or four different ways things can be diagnosed in clinical medicine.

Clinically - this expression means the diagnosis is based on the doctor taking a history from and doing a physical exam on the patient.

Radiologically - the diagnosis is based on the way something looks from an imaging test (i.e. pneumonia diagnosed by Chest x-ray)

Laboratory - the diagnosis is based on chemical/microbiological tests on body specimens (e.g. a urinary tract infection based on a urine culture)

Pathologically - the diagnosis is based on microscopic examination of tissue and/or cells (e.g. diagnosing a cancer from a nodule biopsy).

Osteomyelitis is generally a CLINICAL diagnosis that can be reinforced (but does not necessarily need) imaging and/or lab testing. So you have to use the clinical evidence to come to your conclusion. If a patient has diabetes and a huge ulcer in the foot where the bone is exposed, well, you don't need an MRI or x-ray to prove that the bone is infected. In your case, it's a little more difficult because (I'm assuming) you don't have diabetes, and depending on how long after the procedure the symptoms happened it could be a deep bone infection, or it could have just been superficial. If the symptoms of infection happen severely and immediately after the placement of pins (i.e. within a week) it often means an MSSA infection which you have to assume as osteomyelitis and treat as such (i.e. with at least 6 weeks of antibiotics). The problem is, because there is foreign material in the bone, it often doesn't heal properly unless the appliance(s) are removed and parts of the dead/infected bone are cleaned out. If the osteomyelitis is early, you can sometimes get lucky, though, and clear it with antibiotics alone.

On to your questions:

Why did I have osteomyelitis twice?
***In short, probably bad luck, but also because you were twice given metal appliances deep in to your bones which always carry a small risk of getting infected.

Why did it take so long to diagnose?
******It didn't take long to diagnose...the doctors took a very acceptable approach to your diagnosis. Because you can't exactly go and do bone biopsies on everyone who shows up with signs of infection post orthopedic procedures--this happens quite commonly--doctors often follow the "therapeutic trial" approach. Here, they treat you for presumed cellulitis (which they did) and then if it doesn't work treat as osteomyelitis. The beauty about that is that the treatment for the two are pretty much the same, except osteomyelitis treatment is longer in duration. Also, if you are right with the first treatment, you don't have to put the patient through a painful bone biopsy +/- pin extraction.

You keep mentioning "there is no test to see if the infection is gone". That isn't totally true. The doctors can follow certain blood tests (i.e. your white count and ESR) and also the most important thing--how you're doing clinically. If after an appropriate course of antibiotics, the toe looks better, the clinical evidence is enough to assume cure and watch the patient. If the infection were to return, you could try another 6 weeks of Abx, and if THAT didn't work, then they would have to consider removing the pins.


Why did my ortho not believe the first reading - it was almost like he didn't want to admit the initial diagnosis or treatment was correct. Did he not want to admit he made a mistake?
****No, it's not that he thought he was wrong, it's because the MRI probably didn't show DEFINITE evidence of osteo which often happens. These tests are not specific and exact which is why clinical accumen is what is required for the diagnosis and following of the symptoms/treatment.

 
Old 08-24-2008, 04:23 PM   #3
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Re: MSSA Experience - What Lies Ahead?

cgranulomatis,

First, I would like to thank you for taking the time to explain these issues to me. I have a much better understanding of how my dr arrived at his diagnosis. I now feel empowered about this portion of my medical treatment.

Second, I am sure you can imagine, I have a fear that if I ever have another procedure where the placing of metal is involved, I will have another infection.

Third, I also have a fear the osteomyelitis in my toe or in my leg/ankle will return. I have heard it can come back a year or even more later. What is the likelihood of this happening? Is there anything I can do to prevent that from happening?

Again, thank you for taking the time to provide information on this topic.

Step

 
Old 10-25-2008, 06:18 PM   #4
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Re: MSSA Experience - What Lies Ahead?

This post has been editted to protect the privacy of the poster.

Last edited by sptidwell; 07-20-2009 at 04:15 PM. Reason: privacy issues

 
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