Lyme disease progresses through three distinct clinical phases: early localized, early disseminated, and late disseminated. Lyme arthritis is characterized by attacks of joint swelling lasting for weeks to months, potentially causing permanent joint damage in late disseminated disease. Our case focuses on a 63-year-old, obese, type 2 diabetic, wheelchair-bound, Caucasian male with severe bilateral knee pain. Our patient had previously undergone bilateral knee arthroscopies for meniscal tears and also had knee injections performed previously without the desired level of pain alleviation. He indicated a recent cough that was treated with erythromycin and noted his knees felt better during the course of the antibiotic. The patient recreationally enjoyed hunting and mentioned that his dog had Lyme Disease. Laboratory confirmation of Lyme disease prompted our patient to be treated with doxycycline. Upon completion of doxycycline therapy, our patient noted significant improvement in his knee pain. The improvement was significant enough that the patient canceled a planned bilateral knee replacement with his orthopedic surgeon, and no longer required the use of a wheelchair as he was able to return to ambulating independently. The patient's quality of life improved significantly, and he could also return to work. Lyme disease should be a consideration in the differential diagnosis of patients in areas endemic to the disease, and patients who tend to have outdoor lifestyles.
Osteomyelitis is by definition any infection of the bone. It can have a hematogenous or non-hematogenous mechanism of infection, but comorbidities such as cardiovascular disease, diabetes mellitus, and the presence of orthopedic hardware can increase the risk of osteomyelitis. Our case focuses on a 64-year-old Caucasian female with multiple comorbidities who presented with a fractured right patella that was not healing four months after the occurrence of the fracture. The patient reported cramping, fasciculations, and severe pain that was worsening. She also reported that she received nine X-rays from different orthopedists before receiving an MRI, ordered by internal medicine. The MRI showed a small knee effusion with mild generalized edema of the nearby subcutaneous tissues and evidence of nonunion of the fracture as evidenced by fracture fragments of the right patella. The MRI additionally showed increased signal in the bone fragments of the right patella, as well as the anterior and posterior superior rims of the right tibial plateau, concerning for potential osteomyelitis. Referral to infectious disease confirmed the diagnosis of patellar osteomyelitis, a rather rare diagnosis. The patient was promptly started on cefdinir and doxycycline, and within days of starting antibiotic therapy, her right knee pain was reduced to zero. Surgical debridement was not necessary, and the patient was able to resume her daily activities with the pain resolved. The possibility of patients only having to undergo antibiotic treatment for patellar osteomyelitis improves their chances of a full recovery and reduces the risks associated with undergoing surgical debridement.
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