Patient 90/1951 was initially transferred from the Newcastle Royal Victoria Infirmary (RVI), having been treated for a lesion on the left os-calcis (heel bone). The pus taken from the lesion was tested and returned positive for tubercle bacilli, tuberculosis infection. The patient was admitted to Stannington in June 1951. Later, in July 1951, a cold abscess formed in the right cuboid. According to the patient’s medical notes both sinus lesions were healed by January 1952, following a course of dihydrostreptomycin which, as a result of the healing, was discontinued.
In March 1952, radiographic imaging revealed the patient had developed tuberculosis osteomyelitis.
Osteomyelitis is an infection of the bone marrow, whereby the bone undergoes inflammatory destruction to create lesions. These lesions, or sinuses, can allow pus formation and ultimately new bone begins to form in repair. Osteomyelitis is caused by non-specific bacterial infection and as such is not a specific indicator of tuberculosis. In cases of tuberculosis, osteomyelitis is likely to be caused by haematogenous spread, also known as miliary tuberculosis.
Patient 90/1951, shown below, developed tuberculosis osteomyelitis affecting the tibiae. The radiograph shows the left leg, both laterally (left) and anteroposteriorly (right). Extensive bone destruction can be seen, as well as swelling with some new bone growth to the proximal tibia. The patient notes indicate that the patient was admitted to the RVI for an operation to incise the abscesses on their left leg in August 1952.
This is but one example of osteomyelitis in connection with tuberculosis. Further examples are evident within the patient files and will be discussed as the project continues.
For those of you who find the radiographic images of interest, more can be seen on our Flickr stream at https://www.flickr.com/photos/99322319@N07/sets/72157648833066476/
Sources:
C. Roberts & K. Manchester, The Archaeology of Disease Third Edition (New York: Cornell University Press, 2005)
Can this happen bilaterally? I’m thinking of a skeleton I’ve seen, with very similar lesions in both ulnae.
For this patient tuberculous osteomyelitis developed in both tibiae. Although, in this instance, it has occurred bilaterally, we could not say categorically that this would always be the case.
The nonunion of epiphyses indicates that the individual ?sex, was juvenile.
There are multiple tibial intramedullary lytic lesions. The proximal lesion has erosion of the endocortical surface anteriorly, with possible extension through the cortical bone. There is extension of the distal lesion anteriorly through the metaphyseal cortex. There is no perilesional sclerosis. There is enlargement of the proximal half of the tibia with evidence of subperiosteal new bone formation (involucrum). A linear radiolucent zone may indicate the margin of sequestrum. There is evidence of considerable soft tissue swelling of the posterolateral zone of the lower leg. There appears to be an effusion into the infrapatellar bursa.
Is there any reference to microbiology of the drained abscess contents?
Where is the primary tuberculous focus?
My opinion is that the tibial osteomyelitic lesions are due to haematogenous spread from a primary soft tissue focus. A differential diagnosis may be haematogenous pyogenic osteomyelitis, intercurrent with tuberculosis.
Many thanks for the observations you have made from the radiographic image.
Prior to admittance to the RVI in 1952 a bacteriological report of ‘Pus organisms’, was carried out following the discovery of a soft tissue lesion on the left shin. This tested with Direct Film as showing ‘A number of gram-positive cocci present. Tubercle bacilli NOT seen’ and the culture noted ‘A scanty growth of staphylococus aureus, coagulase positive’. Two days later the patient was admitted to the RVI for incision of abscesses to the left leg. They were prescribed penicillin and streptomycin and transferred back to Stannington following the operation. The penicillin was discontinued after approximately one month but further tuberculous medication was continued for some months. Unfortunately there are no microbiology reports of the incised abscesses from the RVI.
The initial tuberculous infection was noted in the form of a lesion in the left os-calcis, tubercle bacilli having been cultured from the pus. A cold abscess was then located on the right cuboid. Both sinuses were treated with dihydrostreptomycin and were considered healed by Januray 1952. Diagnosis of tuberculous osteomyelitis was made in March 1952.
Hopefully this information answers the questions you had but please feel free to contact us with any further queries.
The word tibiae initially used infers that the pathological lesions were in both right and left tibiae. However, only the left tibial Xray Is shown, and the RVI report only applies to the left tibia. I note, of course, that the right cuboid was infected. Please could you clarify whether it was unilateral in respect of the tibia. Interesting to note that Staph aureus was isolated from a soft tissue lesion in the left lower leg. I suspect that this was not a source for direct spread of pathogen to the tibial medulla. I believe that this was haematogenous. All the osseous lesions were, I think, due to haematogenous spread of M.tb from a distant soft tissue primary focus, identified or not.
Hi Keith, yes this particular patient did have lesions in both the left and right tibiae. There are also radiographs for the right tibia but this patient has a particularly large number of radiographs and as it isn’t possible to display them all we selected one and focused on some of the problems occurring with the left tibia in this post. If you need any more information please feel free to ask.