Asthimajjavidradhi (osteomylitis)

as per ayurvedic kayachikitsa syllaus

1. 1 ASTHIMAJJA VIDRADHI ( OSTEOMYLITIS ) Class Notes – KC (Paper 2, Part B/2) Prof Sriram Chandra Mishra Kayachikitsa Department VYDS Ayurved Mahavidyalaya , Khurja

2. 2 The concept of Asthimajja Vidradhi descried in Sushrut Samhita Nidana sthana 9/34-38 & Chikitsasthana 16/39-43 Asthimajja Vidradhi is tridoshaja ( Vidradhi 6 types - Vataja , Pittaja , Kaphaja , Tridoshaja , Kshataja , Raktaja ). Asthimajja Vidradhi can be correlated with Osteomyelitis . Brodie's abscess  is a sub-acute form of osteomyelitis , presenting as a collection of pus in bone, often with an insidious onset.

3. 3 Nidana & Samprapti of Vidradhi मिथ्याहार विहार से अत्यन्त कुपित हुए वातादि दोष प्रथम त्वचा, रक्त, मांस और मेदो धातु को दूषित करके अस्थि के अन्दर आश्रित होकर धीरे - धीरे भयंकर शोथ उत्पन्न करते हैं । जब यह शोथ महामूल (गम्भीर धातु आश्रित), रूजायुक्त, गोल या आयताकार हो जाता है, तब उसे विद्रधि कहते हैं । (Su. Ni. 9/4-5)

4. 4 Asthimajja Vidradhi सर्वविद्रधयो वातादिना यदास्थ्याश्रित्य जायन्ते, उपादानादनन्तरं तद्गतमज्जा च परिपच्यते तदा एतद् रूपमुक्तम् । ( Dalhana on Su. Ni. 9/34-38) सभी विद्रधियों में जब दोषों के कारण अस्थि का आश्रय लेकर मज्जा का परिपाक होने लगता है तो अस्थिमज्जा पाकादि लक्षण पाये जाते हैं।

5. 5 Symptoms of asthimajja Vidradhi अस्थिमज्जा पाक ( suppuration) जब वह पाक बाहर निकलने का द्वार ( route ) नहीं पाता है तो प्रभावित क्षेत्र में अग्नि की तरह दाह ( burning sensation) अस्थि तथा मज्जा की उष्मा ( heat) से अस्थि मज्जा का क्षय ( destruction) इस शल्य ( foreign body ) रूपी व्याधि से रोगी को चिरकाल ( for long time ) तक क्लेश ( agony / discomfort ) होता है । जब शस्त्रादि कर्म से अस्थि के भिन्न होने (टूटने) पर पूयादि को बाहर निकलने का द्वार ( outlet) मिल जाता है तो इस विद्रधि से मेद ( fat like) जैसा, स्निग्ध ( slimy), शुक्ल ( whitish), शीत ( cold) और गुरु ( heavy) स्राव ( discharge) निकलता है । यह सभी दोषों का प्रकोप और वेदनायुक्त ( painful ) होता है । (Su. Ni. 9/34-38)

6. 6 Management of Asthimajja Vidradhi Treatment principle of vidradhi विद्रधिं सर्वमेवामं शोफवत्समुपाचरेत् ।। प्रततं च हरेद्रक्तं पक्वे तु व्रणवत्क्रिया।। ( अ . ह्रि . चि १३ / १ ) Shamana ausadhi पंचतिक्तघृत गुग्गुलु , अमृतादि गुग्गुलु , त्रिफला गुग्गुलु, लाक्षादि गुग्गुलु संजीवनी वटी स्वर्ण भस्म , वंगभस्म , रसमाणिक्य जात्यादि घृत / जात्यादि तैल For asthi srava - Shatavari Guda , Dhatradi ghrita

7. 7 मज्जागत विद्रधि में पाक होने पर सफलता अनिश्चित रहती है अतः मज्जागत विद्रधि की चिकित्सा प्रत्याख्याय ( difficult to cure) समझ कर करनी चाहिए । (Su. Chi. 16/39-43) पक्व विद्रधि - विद्रधि ( suppurated abscess) चिकित्सा क्रियाविधि ( जैसे शोधन, रोपण, लेपन , बंधन आदि ) या अस्थि का भेदन (puncturing) अपक्व विद्रधि - स्नेहन , स्वेदन , रक्तमोक्षण , व्रण शोधन - तिक्त ( pungent) द्रव्यों के कषाय ( decoction) से व्रण को धोना ( wound cleansing), तिक्त द्रव्यों से सिद्ध घृत ( तिल्वक घृत या त्रिवृतादिगण क्वाथ सिद्ध घृत ) का उपयोग भेदनोपरान्त मज्जपरिस्राव न रूकने पर संशोधनीय ( cleansing) कषाय का उपयोग व्रणरोपण ( wound healing) के लिए प्रियंग्वादि तैलम् ( प्रियंगु, धाय के फूल, लोध्र, कायफल, तिनिश और सेन्धा नमक) का प्रयोग ।

8. Vyavasthapatra ( Sub-acute Osteomyelitis / Brodie abscess , prescription depends upon severity ) Suvarna vasanta malati Rasa – 125 mg + Guduchi satva – 500 mg + Praval panchamrita – 62.5 mg + Rasamani k ya – 62.5 mg …………………………………….. 1 dose twice daily with honey Pachatiktaghrita guggulu – 1 tab Lakshadi guggulu – 1 tab …………………………………….. 1 dose twice daily with L.W. Water Kshara sutra packing Drainage and Dressing with Jatyadi Ghrita 8

9. Osteon – Bone Myelo - Marrow Itis  - Inflammation 9 Osteomyelitis (OM)

10. Definition Osteomyelitis (OM) is the Inflammation of the bone caused by an infecting organism , which may spread to the bone marrow, cortex, periosteum , and soft tissue surrounding the bone. 10

11. Classifications Traditional classifications Suppuration (Pus formation) Acute suppurative osteomyelitis Chronic suppurative osteomyelitis Primary (no preceding phase) Secondary (follows an acute phase) Non- suppurative / Sclerosis  (Increased density of bone) Diffuse sclerosing Focal sclerosing Proliferative periostitis Osteo-radionecrosis 11

12. Classifications Based on the duration Acute Osteomyelitis – Typically presents within two weeks after bone infection, characterized by inflammatory bone changes. Sub-acute Osteomyelitis – (Less virulent - more immune) Brodie abscess  is a subacute osteomyelitis , which may persist for years before progressing to a chronic, frank osteomyelitis . Chronic Osteomyelitis – Typically presents six or more weeks after bone infection and is characterised by the presence of bone destruction and formation of sequestra Classifications according to Route, duration and anatomical location Duration - Acute, Subacute or Chronic Route of infection - Hematogenous or Exogenous Host response - Pyogenic or Granulomatous Area of the skeleton - OM of Jaws / OM of Long Bones/ OM of Vertebral column 12

13. Classifications according to anatomic stage and the host health status ( Cierny and Mader scheme provides guidance in patient management) Stage 1: Disease confined to the medullary of the bone Stage 2: Superficial disease  Stage 3: Localized spread  Stage 4:  Diffuse disease  13

14. Etiology Healthy intact bone is resistant to infection. The bone becomes susceptible to disease with exposure of a large inoculum of infecting organism to the bone sites to which microorganisms can bind. Route of entry (via) Bone can get infected via The bloodstream ( The hematogenous route of infection through bacteremic seeding of bone from a distant source of infection ) From local areas of infection - Contiguous spread from surrounding tissue and joints (cellulites) Penetrating trauma ( Direct inoculation of bone from trauma or surgery like joint replacements or internal fixation of fractures or secondary periapical periodontitis in teeth etc.) 14

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16. Causative organisms Bacteria (Most often) Staphylococcus aureus , Enterobacter  species, Streptococcus species, Haemophilus influenzae , Mycobacteria . Salmonella species Fungi (Rare but mixed with Bacteria) Candida species, Aspergillus spp , Cryptococcus spp , Histoplasma spp , Blastomyces spp , Coccidioides spp 16

17.  The most common Bacterial pathogens in osteomyelitis depend on the patient's age Age group Most common organisms Newborns (≤ 4 months) S. Aureus ,  Enterobacter  Species, and  Group A  and  B   Streptococcus  Species Children (aged 4 mo to 4 y) S. Aureus , Group A  Streptococcus  Species, Haemophilus Influenzae and  Enterobacter  Species Children, Adolescents ( aged 4 y to adult) S. Aureus  (80%), Group A  Streptococcus  Species, H. Influenzae and  Enterobacter  Species Adult S. Aureus  and occasionally  Enterobacter Or Streptococcus Species Sickle cell anemia patients Salmonella   species, S. aureus is still most likely Vertebral osteomyelitis Staphylococci (50%), and Tuberculosis (50%). S. aureus is the most common causative organism in all patients Age group 17

18. Pathogenesis Bone is infected  Leukocytes  enter the infected area  Attempt to engulf  the infectious organisms  Release enzymes that lyses the bone ( tissue necrosis, breakdown of bone )  Pus formation  Pus spreads into the bone's blood vessels  Impairing blood flow  Sequestra formed (form the basis of a chronic infection)  The body will try to create new bone (called an involucrum) around the area of necrosis 18

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21. Clinical features Sometimes mild or absent (neonates) Fever and chills Malaise (General discomfort, uneasiness) Local swelling, redness and warmth The limb is held still ( pseudo paralysis ) May pus formation Bone pain (vertebral Osteomyelitis - Severe back pain especially at night) Because of the particulars of their blood supply, the tibia (mostly), femur,  humerus , vertebra, the maxilla, and the  mandibular bodies  are especially susceptible to osteomyelitis .  21

22. In infants The infection can spread to a joint cause  arthritis . In children The long bones are usually affected. Large  subperiosteal  abscesses   can form because the  periosteum  is loosely attached to the surface of the bone. In adults The vertebrae and the pelvis  are most commonly affected. 22

23. Investigations CBC ( Leukocytosis , ↑ ESR ,  ↑ CRP ) Radiological (shows lytic   center with a ring of sclerosis) Plain X-Ray ( takes 10 to 21 days for an osseous lesion to become visible - soft tissue swelling, osteopenia , osteolysis , bony destruction, and nonspecific periosteal reaction) CT Scan (more sensitive than plain radiograph for assessing cortical and trabecular integrity, periosteal reaction, intraosseous and soft tissue gas, the extent of a sinus tract, and is superior to MRI in detecting necrotic bone fragments) MRI (can detect early bone infection within 3 to 5 days of disease onset) Radionuclide scanning - Injection of certain radioactive elements into the bloodstream, followed by a series of x-ray pictures Bone biopsy (either open or percutaneously - identify the causative pathogen) Blood cultures (may be positive, especially in hematogenous osteomyelitis involving the vertebrae, clavicle, or pubis)  23

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27. Complications Chronic osteomyelitis Bone death ( osteonecrosis and sequestrum formation) Septic arthritis Growth disturbance (mainly in children- when epiphyseal plate is involved ) Pathological fracture Deep vein thrombosis in the region near the infected bone Septicemia & Metastatic abscesses Skin cancer (The open sore that is draining pus, the surrounding skin is at higher risk of developing squamous cell cancer) 27

28. MANAGEMENT Hematogenous osteomyelitis is primarily monomicrobial Contiguous spread osteomyelitis or direct inoculation osteomyelitis is usually polymicrobial or monomicrobial . The recommended duration of treatment for osteomyelitis in adults is 4 to 6 weeks of parenteral antibiotic therapy to achieve acceptable cure rates with a decreased risk of recurrence.[ Antibiotic therapy Antifungal therapy (Mixed therapy) Surgical treatment Nutritional therapy (Enough caloric, protein, vitamin etc) Immobilization 28

29. Antibiotic therapy ( broad-spectrum empiric antibiotic regimen against both gram-positive and negative organisms ) Vancomycin (15 mg/kg intravenously [IV] every 12 hours) plus A third generation cephalosporin (e.g., ceftriaxone 2 gm IV daily) or A beta- lactam / beta- lactamase inhibitor combination (e.g., piperacillin / tazobactam 3.375 IV every 8 hours)  Once sensitivity data becomes available, then the antibiotic therapy should be narrowed for targeted coverage of the susceptible organisms. Beta- lactam antibiotics – Penicillin derivatives ( penams ),  Cephalosporins ( cephems ),  monobactams ,  carbapenems  and  carbacephems Beta- lactamase inhibitor combination (Block the activity of beta- lactamase enzymes, preventing the degradation of beta- lactam antibiotics) -   ampicillin-sulbactam , amoxicillin- clavulanate , ticarcillin-clavulanate , and piperacillin-tazobactam . 29

30. Pathogen-Specific Antibiotic Therapy for Osteomyelitis in Adults Staphylococcus aureus   penicillin-sensitive Treatment of choice is Penicillin G 4 million units every 6 hours Alternative regimens - First-generation cephalosporin e.g., cefazolin 2 g IV every 8 hours, Clindamycin 900 mg IV every 8 hours, Vancomycin 15 mg/kg IV every 12 hours, Oxacillin or Nafcillin 2 g IV every 4 hours Staphylococcus aureus  penicillin-resistant Treatment of choice is Nafcillin 2 gm IV every 4 hours Alternative therapies are cefazolin , clindamycin or vancomycin (doses as above) Staphylococcus aureus   methicillin -resistant Treatment of choice is vancomycin IV An alternative regimen is linezolid 600 mg IV every 12 hours. Streptococci (group A, B, Beta hemolytic, Streptococcus  pneumoniae ) Treatment of choice is penicillin G 4 million units every 6 hours Alternative regimens include ceftriaxone 2 gm IV daily, clindamycin IV, vancomycin IV, cefazolin IV (doses as above) 30

31. Cont. Pathogen-Specific Antibiotic Therapy for Osteomyelitis in Adults Enterobacteriaceae   quinolone sensitive Treatment of choice is ciprofloxacin 400 mg IV twice per day (bid) or 750 mg orally (PO) bid, levofloxacin 500 to 750 mg PO or IV daily Alternative regimens include ceftriaxone 2g IV daily, cefepime 2 gm IV every 12 hours, ceftazidime 2 gm IV every 8 hours Enterobacteriaceae ,  quinolone -resistant (Escherichia coli) Treatment of choice is piperacillin / tazobactam 3.375 g IV every 8 hours, Ticarcillin / clavulanate 3.1 gm IV every 4 hours An alternative regimen is ceftriaxone 2 g IV daily Pseudomonas aeruginosa Treatment of choice is cefepime 2 gm IV every 12 hours, ceftazidime 2 gm IV every 8 hours Alternative regimens include meropenem 1 gm IV every 8 hours, Imipenem 500 mg IV every 6 hours, ciprofloxacin 400 mg IV every 12 hours or 750 mg PO daily 31

32. Cont. Pathogen-Specific Antibiotic Therapy for Osteomyelitis in Adults Enterococci Treatment of choice is penicillin G 4 million units every 6 hours Alternatively vancomycin 15 mg/kg every 12 hours, daptomycin 6 mg/kg IV daily, linezolid 600 mg IV or PO every 12 hours Anaerobes Treatment of choice is clindamycin 900 mg IV every 8 hours, ticarcillin / clavulanate 3.1 gm IV every 4 hours Alternatively, metronidazole 500 mg IV every 8 hours (for gram-negative anaerobes 32

33. Antifungal therapy - Oral azoles currently represent the most appropriate long-term treatments for osteo-articular fungal infections. Antifungal (Pathogen-Specific) Therapy for Osteomyelitis in Adults Candida spp Fluconazole 400mg for 6-12 months for OM 6 weeks for septic arthritis Liposomal Amphotericin B (L - AMB ) for 2 weeks followed by fluconazole for 6-12 months Echinocandins or AMB for 6 weeks followed by fluconazole Aspergillus spp Voriconazole iv or oral Liposomal AMB Capsofungin Posaconazole Itraconazole 33

34. Cryptococcus No meningoencephalitis : Fluconazole 400mg /d for - 12 months Meningoencephalitis : AMB + Flucytosine Liposomal AMB Histoplasma Mild : Itraconazole 200mg tid for 3days then 200mg bd for 6-12 weeks. Moderate to severe : Liposomal AMB for 1-2 weeks followed by Itraconazole Blastomyces dermatitidis AMB 0.7- 1mg /kg/d for 1-2 weeks then Itraconazole 200mg tid for 3 d and 200mg bd for 12 months Liposomal AMB for 1-2 weeks then Itraconazole Only Itraconazole for mild to moderate disease Coccidiodes spp Fluconazole Itraconazole Ketoconazole AMB 34

35. Surgical treatment Debridement includes removal of sinus tracts, necrotic bone and soft tissue, placement of antibiotic or antifungal beads. 35

36. THANK YOU 36