Diaphyseal osteomyelitis of femur with suspected ewing sarcoma in 8 years old children: a case report

Panji Sananta, Hidayat Rizal


Metaphyseal osteomyelitis in children due to direct bone trauma or vascular insufficiency is a frequent problem in orthopaedic surgery. In contrast, diaphyseal osteomyelitis represents a rare entity that almost exclusively affects child with bony infarct in sickle cell anemia. Differentiating neoplasm from musculoskeletal infection can sometimes be very challenging. In particular, Ewing sarcoma can masquerade as osteomyelitis with the presenting symptoms of fever, localized bone pain, and elevated inflammatory markers common to both entities, although osteomyelitis is a totally different type of disease. In this article, we report the case of chronic osteomyelitis of the femur in an immunocompetent and otherwise healthy 8 years old boy with minor inflammation signs and misleading clinical features. The X-ray showed onion skin periosteal reaction. We evacuated about 200 cc of abscess. Biopsy report revealed polimononuclear, mononuclear, and necrotic inflammatory cells. The patient was treated with antibiotic for two weeks and discharged with improved general condition. Six months follow-up shows clinical and radiological improvement. The diagnosis had to be confirmed by surgery which allowed the initiation of a targeted therapy. A case of diaphyseal osteomyelitis of a femur, lacking predisposing factors or trauma, is unique in children and never been reported previously.


Ewing sarcoma, Onion skin, Osteomyelitis, Periosteal reaction

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Tountas AA, Kwok JM. Acute hematogenous diaphyseal osteomyelitis in childhood. Canadian Medical Association J. 1985 Jun 1;132(11):1287.

Patzakis MJ, Zalavras CG. Chronic posttraumatic osteomyelitis and infected nonunion of the tibia: current management concepts. JAAOS. 2005 Oct 1;13(6):417-27.

McCarville MB. The child with bone pain: malignancies and mimickers. Cancer Imaging. 2009(9):S115-21.

Frank G, Mahoney HM, Eppes SC. Musculoskeletal infections in children. Pediatr Clin North Am. 2005;52(4):1083-106.

Gutierrez K. Bone and joint infections in children. Pediatric Clinics. 2005 Jun 1;52(3):779-94.

Yeo A, Ramachandran M. Acute haematogenous osteomyelitis in children. BMJ. 2014 Jan 20;348(315):g66.

Abdi R, Taheri MMH. A case report of ewing's sarcoma of tibial epiphysis with retrobulbar mass. J Surg and Trauma. 2015;3(1-2):23-5.

Peltola H, Pääkkönen M. Acute osteomyelitis in children. N Engl J Med. 2014;370(4):352-60.

Kremers HM, Nwojo ME, Ransom JE, Wood-Wentz CM, Melton III LJ, Huddleston III PM. Trends in the epidemiology of osteomyelitis. a population-based study, 1969 to 2009. J Bone Joint Surg Am. 2015;97:837-45.

Sferopoulos NK. Ewing’s sarcoma of the pubis in a child misdiagnosed as osteomyelitis: a case report. Res Rev Ortho. 2017:1(2):4-8.

Forsberg JA, Kyle Potter MAJB, Cierny III G, Webb L. Diagnosis and management of chronic infection. J Am Acad Orthop Surg. 2009:8-19.

Henninger B, Glodny B, Rudisch A, Trieb T, Loizides A, Putzer D, Judmaier W, Schocke MF. Ewing sarcoma versus osteomyelitis: differential diagnosis with magnetic resonance imaging. Skeletal Radiol. 2013(42):1097-104.

Nesbit ME Jr, Gehan EA, Burgert EO Jr, Vietti TJ, Cangir A, Tefft M, et al. Multimodal therapy for the management of primary, non metastatic Ewing's sarcoma of bone: a long-term follow-up of the First Intergroup study. J Clin Oncol. 1990;8(10):1664-74.

Widhe B, Widhe T. Initial symptoms and features in osteosarcoma and Ewing sarcoma. J Bone Joint Surg Am. 2000;82(5):667-74.

Heck Jr RK. Malignant tumors of bone. In: Terry Canale S, Beaty JH. Campbell’s operative orthopedics. 11th ed. Philadelphia: Mosby;2008:901-38.

Varunjikar MD, Jayan BE. Osteomyelitis of femur mimicking ewings sarcoma-a case report. Sch J Med Case Rep. 2014;2(2):118-21.

Tow BPB, Tan MH. Delayed diagnosis of Ewing’s sarcoma of the right humerus initially treated as chronic osteomyelitis: A case report. J Orthop Surg. 2005:13(1):88-92.

Metcalfea JE, Grimer RJ. Ewing’s sarcoma of the foot masquerading as osteomyelitis. Euro Foot Ankle Soc. 2004(10):29-33.

McCarville MB, Chen JY, Coleman JL, Li Y, Li X, Adderson EE, et al. Distinguishing osteomyelitis from ewing sarcoma on radiography and MRI. AJR Am J Roentgenol 2015;205(3):640-51.

Funk SS, Copley LAB. Acute hematogenous osteomyelitis in children pathogenesis, diagnosis, and treatment. Orthop Clin N Am. 2017;48:199-208.

Shimose S, Sugita T, Kubo T, Matsuo T, Nobuto H, Ochi M: Differential diagnosis between osteomyelitis and bone tumors. Acta Radiol. 2008(49):928-33.

Huang PY, Wu PK, Chen CF, Lee FT, Wu HT, Liu CL, et al. Osteomyelitis of the femur mimicking bone tumors: a review of 10 cases. World J Surg Oncol. 2013(11):283-91.

Lyall HA, Constant CR, Wraight EP. Case report: ewing's sarcoma in distal tibial metaphysis mimicking osteomyelitis. Clin Radiol. 1993(48):140-42.

Cottias P, Tomeno B, Anract P, Vinh TS, Forest M. Subacute osteomyelitis presenting as a bone tumour. A review of 21 cases. Int Ortho. 1997(21):243-8.

Dich VQ, Nelson JD, Haltalin KC. Osteomyelitis in infants and children: a review of 163 cases. Am J Dis Child. 1975;(129):1273-8.