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Luís Carlos Costa1, José Pedro Vieira2, Delfim Tavares3, Catarina Gouveia1

1Pediatric Infectology
2Neuropediatric Service, 
3Orthopedic Surgery Service
Hospital Dona Estefânia, Centro Hospitalar Lisboa Central, EPE

- 65 Congreso de la AEP Póster com defesa

Background: Osteomyelitis is the inflammatory process of the bone, mostly resulting from microorganism invasion. Isolation of the etiological organism remains the diagnostic gold standard, being the only way to establish a definitive microbiologic diagnosis. Blood cultures should also be obtained, as an organism is isolated in approximately half cases. In children, bone infection is primarily haematogenous in origin and acute in nature. It may also result from contiguous-focus and direct inoculation, as in trauma. Staphylococcus aureus is the most common etiologic organism in all age groups (70-90%). In rare cases, the infectious agent is a coccus from the Streptococcus anginosus group.
Case presentation: A 12-year-old boy, with a suspected history of left acute otitis twenty days before hospitalization, presented with a two week story of left temporal headaches irradiating to left cervical area and movement limitation, with progressive aggravation. Due to the onset of fever and clinical deterioration, he sought for medical attention. Blood analysis showed neutrofilic leucocitosis and elevation of CRP. Cervical CT revealed inflammatory alterations, initially interpreted as sternocleido mastoid pyomyositis. Intravenous antibiotic treatment was started with clindamicine and flucloxacillin. At day 2, neurological manifestations were observed (mild dysphagia and asymmetry of palate and tongue) and cervical MRI was performed, revealing an osteomyelitis process involving the cranial base up to C6, with epidural abscess and adenoflemon. Flucloxacillin was changed to ceftriaxone. On aetiological investigation SGB, HIV, tuberculosis, Bartonella and Brucella infections were excluded. Hemoculture was positive for Streptococcus intermedius. After 4 weeks of intravenous antibiotic treatment, with clinical and imagiological improvement, the patient was discharged and completed 4 more weeks of oral antibiotic with amoxicillin/clavulanate.
Discussion: Streptococcus anginosus group is a subgroup of viridians streptococci constituted by three species (S. anginosus, S. intermedius, and S. Constellatus) recognized as normal flora of the human oral cavity and gastrointestinal tract, capable of forming abscesses and cause systemic infections. Osteomyelitis due to the Streptococcus anginosus group is uncommonly reported and it can be an aggressive pathogen for pediatric populations. Due to the virulence of these agents, it is very important an aggressive clinical management for a better outcome.

Key words: osteomyelitis, Streptococcus anginosus, abscess