Extensive multifocal emphysematous osteomyelitis in a post-splenectomy thalassemia major patient with pneumococcal sepsis: A fatal case with imaging correlation

Emphysematous osteomyelitis is a rare, life-threatening infection characterized by intraosseous gas formation. It is most commonly caused by anerobic or enterobacteriaceae organisms and is rarely reported in patients with hemoglobinopathies. Prompt recognition of its characteristic imaging features, particularly on computed tomography (CT), is essential for early diagnosis and management. A 23-year-old post-splenectomy male presented with a 1-month history of progressive fever, severe pelvic and lower limb pain, and inability to ambulate. On admission, he was in septic shock with leukocytosis, markedly elevated inflammatory markers, and multiorgan dysfunction. Contrast-enhanced CT demonstrated extensive multifocal intraosseous gas in a permeative distribution involving the sacrum, bilateral iliac bones, acetabula, proximal femora, and right foot, with associated intramuscular and soft-tissue abscesses, hepatic abscesses, and septic pulmonary emboli. Magnetic resonance imaging showed diffuse marrow edema, cortical destruction, surrounding soft-tissue edema, and multiple rim-enhancing intramuscular collections, confirming extensive osteomyelitis and pyomyositis. The presence of intraosseous gas on CT, in the absence of recent trauma or surgery, strongly suggested emphysematous osteomyelitis. Blood, pus, and bone culture grew Streptococcus pneumoniae . Despite prompt surgical debridement and culture-directed intravenous antibiotics, the patient deteriorated rapidly and died from multiorgan failure within 10 days. This case highlights the fulminant course of pneumococcal emphysematous osteomyelitis in a post-splenectomy patient. CT identification of intraosseous gas in the absence of trauma or surgery is highly suggestive of emphysematous osteomyelitis and may facilitate early diagnosis, enabling timely multidisciplinary management in this life-threatening condition.