In acute haematogenous multifocal osteomyelitis, infectious foci occur in several bones simultaneously due to haematogenous bacterial spread.

Acute haematogenous multifocal osteomyelitis should be distinguished from chronic recurrent multifocal osteomyelitis (CRMO).

We reviewed the medical records of three male adolescents of 15 years (range 13–16 years) with acute multifocal haematogenous osteomyelitis. All patients were athletes (soccer player, water polo player, practicing rowing).

The mean duration of painful symptoms before seeking medical attention was 3 days. Osteomyelitis was confirmed by magnetic resonance imaging (MRI) and bone three phase scintigraphy. The lesions were at level of spine plus left femur in the first case, bilateral tibia and lumbosacral column in the second one, right foot plus left femur were interested in the third case. Two of the patients exhibited a spinal osteomyelitis, which is described as a common spinal affection in athletes.

Blood cultures (in all patients) and culture of abscess drainage (in one case) were positive for Staphylococcus aureus (MSSA). Inflammatory indices were increased in all patients (mean values: WBC 15.130/mmc, CRP 19 mg/dl, and ESR 63,6 mm/h).

Intravenous antibiotic therapy was prescribed for 19 days (range 13–33 days), followed by oral antibiotic therapy for a median of 18 days. After a median of 11 days, all patients clinically improved with resolution of fever and reduction of pain. Patients were discharged with oral antibiotic therapy after a median of 22 days hospitalization, and underwent a 16 months follow up. No patient reported sequelae.

Differential diagnosis among multifocal acute osteomyelitis, septic arthritis, CRMO, juvenile idiopathic arthritis and/or reactive arthritis may be difficult.

Previous studies reported that athletes are more at risk for osteomyelitis, but, to our knowledge, no case series of acute haematogenous multifocal infectious have been reported in competitive athletes. Staphylococcal outbreaks have been reported in sport players, as position, artificial grass abrasion, and body shaving are the main portal of bacterial entry.

In conclusion, a diagnosis of acute multifocal osteomyelitis must be considered in a patient with fever and pain of several bones. A prompt hospitalization and an appropriate therapy reduce the morbidities and can help to avoid surgery.

Among the extra pulmonary forms of tuberculosis (TB), the osteoarticular localization has been detached in 1–2% of cases. In 30% of these children either a pulmonary and extra-pulmonary localization was found. The diagnosis of skeletal TB is often insidious due to variable signs and symptoms.

The medical records of children admitted to our center between 2006 and 2013 due to skeletal TB were evaluated. All patient underwent TB skin test, IGRA test, chest X-ray and focused imaging tests. In the complicated forms of osteoarthritis the infected material drained spontaneously or surgically was analyzed for Mycobacterium Tuberculosis (MT) detection and culture. In patients with pulmonary localization gastric aspirates or sputum analysis was performed.

Nine patients met the inclusion criteria. The median age at diagnosis was 7 (range 2–13) years. All patients presented with local osteoarticular symptoms and 4 of them had fever. In five cases there was a preceding history of minor trauma. Three patients had a case of TB in the family. Four patients had a spinal localization, three hips and two ankles. ERS and CRP values were altered in 7 and 4 patients respectively. All patient underwent radiography, bone three phase scintigraphy and a MRI. The diagnosis of tuberculosis was confirmed by histopathological examination of bone biopsy in 6 (66%) cases. The skin test and the IGRA test were positive in all patients. The chest X-ray showed a pulmonary localization in 3 cases that had positive gastric aspirate or sputum. All patients were treated with isoniazid, rifampicin pyrazinamide and ethambutol. In 3 patients Linezolid or Ciprofloxacin was also associated. The follow-up had an average value of 34 months. Sequelae were reported in 7 patients (limping in 5 cases, severe kyphosis in 2 cases).

Owing to its low incidence in developed countries, the diagnosis ot TB is often delayed for months to years. Additionally, we highly recommend taking a biopsy of the site of suspected infection because an early diagnosis is the key to successful treatment.