Clostridioides difficile osteomyelitis presenting as a Brodie's abscess of the tibia

Extraintestinal Clostridioides difficile (Clostridium difficile) infection rarely involves bone and can mimic malignancy. A man in his 70s with chronic kidney disease presented with a longstanding, painless, fluctuant anterior lower leg mass without systemic or gastrointestinal symptoms. Imaging showed a proximal tibial lytic lesion and aspiration of a superficial collection grew C. difficile Symptoms persisted despite 4 weeks of oral amoxicillin-clavulanate (875-125 mg every 12 hours) plus oral metronidazole (500 mg every 8 hours). MRI demonstrated chronic tibial osteomyelitis with cortical disruption and a contiguous intramedullary and soft tissue abscess consistent with a Brodie's abscess. He underwent excisional debridement with dead-space management and local vancomycin, followed by prolonged pathogen-directed antimicrobials. Two deep intraoperative cultures again yielded rare C. difficile with negative aerobic and blood cultures. He improved without amputation and remained stable at 9-month follow-up.