Working Diagnosis:
Sternomanubrial osteomyelitis and methicillin sensitive Staphylococcus aureus bacteremia due to hematogenous seeding from an infected friction blister.

Treatment:
He was treated with intravenous nafcillin by PICC line for a total of 6 weeks.

Outcome:
He began a graduated exercise program three weeks after discharge and was able to successfully return back to competitive rowing without further complication.

Author's Comments:
Mechanical chest wall pain in rowers is common, and the differential is broad. Osteomyelitis should also be considered in the presence of infectious symptoms, as there are case reports of rowers experiencing bacteremia and hematogenous spread to bone from infected friction blisters.
Sternomanubrial osteomyelitis, as in this case, is rare. Injury to a native joint does not increase the risk of hematogenous spread to that area in the setting of bacteremia according to current literature. However, this patient's long-standing "popping" in this area certainly raises the question that this joint was perhaps more predisposed.

Editor's Comments:
Primary osteomyelitis of the sternomanubrium is a rare cause of chest pain with fever accounting for 0.3% of all cases of osteomyelitis. Risk factors for osteomyelitis include immunodeficiency, HIV infection, diabetes mellitus, local infection with hematogenous spread, and intravenous drug use. Secondary osteomyelitis of the sternomanbrium is more common and related to complications due to sternotomy, chest trauma, or subclavian catheterization. The locations most common for osteomyelitis related to hematogenous seeding include the tibia and the vertebrae. Blood cultures are helpful in identifying the causative organism in 50% of cases. This case demonstrates the importance of early recognition of osteomyelitis to begin effective intravenous treatment which can lead to early recovery and return to play.

References:
Gregory PL, Biswas AC, Batt ME. Musculoskeletal problems of the chest wall in athletes. Sports Med. 2002;32(4):235-50.

Matta RF, El Hajje MJ, Safadieh L, Salem G, Hmaimess G, Korkomaz R, Diab NA. Primary sternal osteomyelitis: a report of two cases with literature review. Pediatr Infect Dis J. 2010;29(10):976-8.

Garcia del Pozo E, Collazos J, Carton JA, Camporro D, Asensi V. Bacterial osteomylelitis: microbiological, clinical, therapeutic, and evolutive characteristics of 344 episodes. Rev Esp Quimioter. 2018;31(3):217-225

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