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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Salmonella osteomyelitis</span> is a rare infection manifested mostly in patients with sickle cell disease&#46; Of all locations&#44; sternal osteomyelitis comprises only 0&#46;3&#37; of the cases&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> the majority being a complication secondary to sternotomy&#46; Primary sternal osteomyelitis is a rare syndrome&#44; with <span class="elsevierStyleItalic">Staphylococcus aureus</span> being the most frequent cause&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> We report the case of a primary sternal osteomyelitis caused by Salmonella&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 45 year-old male presented with a long-standing history of an osteo-cutaneous fistula over the sternal area&#46; His previous medical history included poorly controlled Diabetes Mellitus and hypertrigliceridemia&#46; His present illness started 16 months before his visit to our hospital&#44; when he developed a left pectoral muscle tear after lifting a heavy object&#46; He initially received conservative care with little improvement&#44; later presenting with fever&#44; pain and edema over retrosternal area&#46; An MRI demonstrated an isolated left major-pectoralis abscess near the left sternum border at the level of third intercostal space&#44; with no chondroesternal involvement&#46; A surgical drainage was performed&#44; obtaining purulent material that grew positive for <span class="elsevierStyleItalic">Salmonella enteritidis</span> with intermediate sensitivity for quinolones &#40;MIC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#41;&#46; Oral ciprofloxacin was prescribed for three months&#44; with clinical improvement&#46; Eight months later&#44; a lump formed over the sternal area&#44; fistulizing days later&#46; Culture grew positive for <span class="elsevierStyleItalic">S&#46; enteritidis</span> and antibiotic was restarted&#46; Patient remained with continuous discharge trough sternal fistula&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">After several months of unsatisfactory evolution&#44; he attended to our hospital for further investigation&#46; Physical examination was remarkable for an osteo-cutaneous fistula over the sternal area&#46; Culture of the sternal discharge grew positive for <span class="elsevierStyleItalic">S&#46; enteritidis</span>&#46; Full laboratory analysis showed a markedly elnacyevated glycosilated hemoglobin &#40;HbA1C<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>13&#46;02&#37;&#41;&#46; We performed a mediastinum-focused Tc 99<span class="elsevierStyleHsp" style=""></span>m bone gammagram that showed early and late radiotracer uptake at left edge of sternal handle&#46; A low dose PET&#47;CT scan confirmed the results and also showed a component of adjacent soft tissue activity in the posterior aspect of costal cartilage &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; A full body contrast enhanced CT scan showed no other areas of inflammation or infection&#46; An abdominal ultrasound showed no involvement of the biliary tract&#46; A transthoracic echocardiogram ruled out infective endocarditis&#46; Blood and stool cultures were negative&#46; Open surgical drainage was performed via partial sternotomy&#44; showing fibrous tissue&#44; bad quality bone and the presence of a granuloma fistulising to fourth and fifth intercostals space&#46; Granuloma resection and curettage were performed and a negative pressure wound therapy system was used during 7 days&#46; Antibiotic therapy with intravenous ceftriaxone 1<span class="elsevierStyleHsp" style=""></span>g b&#46;i&#46;d&#46; was administered for 14 days&#59; Trimethoprim 800<span class="elsevierStyleHsp" style=""></span>mg&#47;sulfamethoxazole 160<span class="elsevierStyleHsp" style=""></span>mg q&#46;d&#46; was then continued for six weeks&#46; C-reactive protein&#44; erythrocyte sedimentation rate and control cultures were negative after cessation of antibiotic therapy&#44; and the patient remained symptom free during his follow up&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Salmonella is estimated to cause 0&#46;45&#37; of osteomyelitis&#44; and is most commonly associated with sickle cell disease&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> The three most common strains of <span class="elsevierStyleItalic">Salmonella</span> causing osteomyelitis are <span class="elsevierStyleItalic">Salmonella typhimurium</span>&#44; <span class="elsevierStyleItalic">Salmonella typhi</span>&#44; and <span class="elsevierStyleItalic">S&#46; enteritidis</span>&#44; with <span class="elsevierStyleItalic">S&#46; typhi</span> being the only strain to be transmitted from human to human&#46; Typhoid osteomyelitis has a predilection for patients with comorbidities such as diabetes&#44; systemic lupus erythematosus&#44; lymphoma&#44; liver disease&#44; previous surgery and those at extremes of age&#46; The incidence of typhoid osteomyelitis in otherwise healthy individuals is much lower&#46; Given the extremely low incidence of the pathogen and the very unusual site of infection&#44; it is unsurprising that only two comparable case reports of <span class="elsevierStyleItalic">S&#46; osteomyelitis</span> in the sternum were found&#46; The first case reported a 71 year-old man with primary sternal osteomyelitis caused by <span class="elsevierStyleItalic">Salmonella hirschfeldii</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> treated successfully with surgical debridement and 6 weeks of high dose ampicillin&#46; The second case reported the case of 73-year-old man with Crohn&#39;s disease and a history of a sternotomie 15 years before&#44; who developed Salmonella sternoclavicular osteomyelitis subsequent to a <span class="elsevierStyleItalic">S&#46; enteritidis</span> sepsis&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In regard to our case&#44; we found no clinical risk factors for osteomyelitis other than diabetes mellitus&#46; The history of a left pectoral muscle tear may contribute to tissue friability and local factors predisposing to infection&#46; The isolated Salmonella strain showed intermediate resistance to quinolones&#58; this could explain the persistence of the infection after the first course of ciprofloxacin&#46; The patient denied recent history of gastroenteritis&#44; abdominal pain&#44; thoracic trauma&#59; he also denied high risk sexual practices&#46; Nasal exudate&#44; stool culture and a liver and bladder ultrasound demonstrated no evidence of chronic colonization&#46; Therefore&#44; we diagnosed the case of a true primary osteomyelitis in the absence of secondary foci&#46; To our knowledge&#44; this is the third reported case of a primary osteomyelitis of the sternum&#46; A high clinical suspicion is needed to diagnose the disease&#46;</p></span>"
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