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Comment & Response
June 15, 2020

Clinical Uncertainty

Author Affiliations
  • 1Orthopaedics, Harcourt Building, Harcourt House, Sheffield, United Kingdom
  • 2Salford Hosptial, Manchester, United Kingdom
  • 3Queen Elizabeth Hospital, Harlow, United Kingdom
JAMA Intern Med. Published online June 15, 2020. doi:10.1001/jamainternmed.2020.1692

To the Editor Russek et al1 provide a valuable framework for managing and effectively communicating clinical uncertainty. However, uncertainty can only be allowed to persist once life-threatening and serious conditions are excluded. In the present case there remains a possibility that the patient is experiencing osteomyelitis of the distal tibia, with the unicameral bone cyst actually representing an intraosseous abscess, also known as a Brodie abscess.2,3 This occurs when the body attempts to control an infection by encapsulating the infective osseous epicenter within inert tissue, such as fibrous connective tissue and, ultimately, sclerotic bone.2,3 A number of factors point to this diagnosis. First, the symptoms were sufficiently severe to impair ambulation. Blood cultures isolated a pathogen unlikely to be a contaminant. Further bacteraemia occurred some time after resolution of the enteric symptoms. This rules out a single enteric source and suggests a secondary septic source, namely, an osteomyelitic nidus. The tibia is the most common location for the Brodie abscess to occur, accounting for almost 50% of cases.2 Indeed, Brodie’s original 3 cases all occurred in the tibia.4 Epidemiologically, the condition is seen most commonly in young men. Typically, in subactue osteomyelitis, with Brodie abscess formation, the inflammatory indices are not elevated in more than 50% of cases.2 Further, more than 80% of patients are afebrile.2

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