radiograph

Miliary TB

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Miliary spread is a pathological process involving the widespread dissemination of the tubercle bacilli but the manifestations of this can vary widely depending on factors such as the speed of the spread and the individual’s ability to inhibit further multiplication of the organisms in other areas of the body.  Miliary tuberculosis is recognised clinically in patients where there is radiographic evidence of tuberculous lesions of the same age distributed evenly throughout all areas of the lung.  This process is most likely to occur soon after the initial infection and is also more common in children under 5 than it is in older children.

 

It is not uncommon to see miliary tuberculosis develop further into tuberculous meningitis.  Whilst on the whole the death rate in Stannington was relatively low, in the pre-antibiotic era (pre-1947) it is noticeable that a significant number of fatalities are as a result of either miliary TB or TB meningitis.  The introduction of effective drug therapies altered this situation greatly and the prospects for these patients after this point improved significantly.

 

Patient 3/1947 was a 12 year old boy from Lemington-on-Tyne who was admitted to Stannington in January 1947 diagnosed with miliary tuberculosis.  A report on x-ray films taken in December 1946 prior to his admission describes extensive mottled shadowing across both lungs with hilar shadows much enlarged.  The Northumberland County medical officer of health that refers the boy to Stannington gives the following report:

‘States no cough.  Mother says he thinks he gets a bit short of breath at times, and that he has definitely lost weight.  On examination, slight cyanotic tinge; afebrile, pulse 108.  General condition satisfactory (amazing in view of films).  Little made out in chest apart from slight impairment of the air entry at both bases.  Mass of glands at right side of neck.’

 

Figure 1 is a chest x-ray taken the day after his admission and the report on it simply reads, ‘extensive bilateral miliary spread’.  The extensive mottled ‘snowstorm’ effect is indicative of miliary TB.  Strict bed rest is ordered and at this point he also has an enlarged gland at the angle of the jaw on the right side for which UV light treatment is prescribed.  Over the coming months the abscess on the jaw is described as discharging freely with brownish pus aspirated from it in June 1947.

Figure 1 - HOSP/STAN/7/1/2/1371_84
Figure 1 – HOSP/STAN/7/1/2/1371_84
09 Jan 1947
Figure 2 - HOSP/STAN/7/1/2/1371_05
Figure 2 – HOSP/STAN/7/1/2/1371_05
17 Sept 1947

 

 

 

 

 

 

 

 

 

 

 

 

 

In September 1947 the patient’s doctor suggests that he would be a suitable candidate for streptomycin treatment, which had only recently been introduced at this point.  However, having discussed the case further it was decided that he was not suitable as at this point in time streptomycin was being used for very early cases only and patient 3/1947 by now had a long history of TB and was doing very well without it.  Figure 2, is an x-ray taken around the time streptomycin treatment was being discussed and the report reads, ‘X-ray shows a little improvement.  Each individual lesion is smaller.’

 

Two months later in November 1947 his condition deteriorates a little and he begins to lose weight and so is again put forward for streptomycin ‘if any available.’  Whilst the attending doctor continues to push for streptomycin over the coming months it is not until November 1948 that the patient receives any.  There are continuing disputes as to whether he is a suitable candidate.  During this time his general condition fluctuates with periods of weight gain and weight loss and x-rays from April and June 1948 show some improvements, figures 3 and 4 respectively.

Figure 3 - HOSP/STAN/7/1/2/1371_09
Figure 3 – HOSP/STAN/7/1/2/1371_09
13 April 1948
‘Amazing improvement since last x-ray 3 months ago. The military lesions now appear to be resolving: the apices are almost clear. There is now a more homogenous opacity in the left lower lobe.’
Figure 4 - HOSP/STAN/7/1/2/1371_10
Figure 4 – HOSP/STAN/7/1/2/1371_10
04 June 1948
‘still some mottling at the bases, the apices are clear. The more homogenous density at the L base is getting smaller. Azygos lobe on right side.’

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ultimately the catalyst leading to the decision being made for streptomycin treatment to be commenced appears to be the fact that in June 1948 a swelling over the lower dorsal spine is identified and it is apparent that the tuberculous infection has spread further.  It is clear from radiographic evidence in 1948 that there are three spinal lesions: one in the 5th and 6th dorsal vertebrae causing some kyphosis; another affecting the 1st and 3rd lumbar vertebrae causing some deformity; and a final one in the inferior and anterior part of the body of the 5th lumbar vertebrae with some destruction.

 

All streptomycin treatment is discontinued by May 1949 when significant improvements in his chest are seen and treatment of the spinal lesions is continued with braces and plaster casts.  He is eventually discharged in July 1950 wearing a spinal brace and continues to be seen by the out-patients’ service until April 1954 when an abscess in the left iliac fossa leads to him being considered for admission to the Queen Elizabeth Hospital.

Figure 5 - HOSP/STAN/7/1/2/1371_18
Figure 5 – HOSP/STAN/7/1/2/1371_18
Spinal X-ray, 17 Jan 1950, calcifications in the lungs also evident.
Figure 6 - HOSP/STAN/7/1/2/1371_85
Figure 6 – HOSP/STAN/7/1/2/1371_85
Spinal X-ray, 10 July 1950, 4 days before discharge
Figure 7 - HOSP/STAN/7/1/2/1371_14 Chest X-ray, 17 Feb 1950, also showing calcifications in neck glands.
Figure 7 – HOSP/STAN/7/1/2/1371_14
Chest X-ray, 17 Feb 1950, also showing calcifications in neck glands.

 

 

 

 

 

 

 

 

 

 

 

Sources:

MILLER, F. J. W, SEAL, R. M. E, and TAYLOR, M. D. (1963) Tuberculosis in Children, J & A Churchill Ltd.

Patient 133/1959 – A Case of Fibrocystic Disease

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The radiographs held within the Stannington Sanatorium Collection date between 1936 and 1953 and are specific to the period when the sanatorium was used as a hospital for tuberculous children. However, through the process of listing the patient files for Stannington, which continue up until 1966, well into its use as a general children’s hospital, we have uncovered a set of radiographs for one other patient, a 6 year old boy who was admitted to Stannington on 15th June 1959: Patient 133/1959.

Patient 133/1959 was diagnosed with Fibrocystic Disease of the Pancreas, a generalised hereditary condition amongst children which, despite its name, can affect not only the pancreas but also the liver, lungs and sweat glands and was considered to be the most common cause of chronic non-tuberculous lung disease in children during the 1950s.

This patient was admitted to Stannington with widespread cystic change in both lungs, retarded growth and signs of chronically infected bronchiectasis. His medical notes also refer to ‘finger clubbing’, which involves changes to the areas of soft tissue under and surrounding the finger nails but may also involve the nails themselves. At this stage in his treatment the patient was prescribed penicillin, monitored for changes in weight and subjected to postural drainage.

By September 1959, the boy’s medical notes read:

‘No gain in weight and very little sputum but he has many loud râles in both sides of chest and a loose cough.’

 

At this time it is also noted that he has been prescribed pancreatin, a drug to help treat the symptoms of cystic fibrosis and to aid with digestion of fat, starch and protein. His lack of weight gain was considered to be associated with problems in the colon and as such his stools were also monitored regularly.

Little change is seen in the notes for the following year, weight gain is still elusive and the patient is often referred to as being small, with râles in the chest and having shortness of breath. However, in October 1960 the severity of this patient’s condition becomes clear as the attending physician writes:

‘Very poor appetite and very difficult.

I do not understand how this problem can be solved.’

However, from May 1961, this boy began to show slow improvements especially within regards to the colon and weight gain is evident with a total gain of 8lbs since admittance. Râles are still noted in the left side of the chest, see lung x-ray in Figure 1.

HOSP-STAN-07-01-02-2243-02
Figure 1 – HOSP-STAN-07-01-02-2243-02

In addition to his medical problems this boy also had learning difficulties according to notes from the hospital school teacher stating he was:

‘very much retarded and would need more individual help and attention ….

He is slow to complete written assignments but makes a good effort. His reading and arithmetic are well below average for his age but he has made satisfactory progress in both within his limited ability.’

As a result the doctors approached the subject of finding this boy a long term residential school for handicapped children to be transferred to following his discharge.

Patient 133/1959, remained in Stannington until 1962, where he continued to make improvements regarding his weight and height and the râles in his chest diminished significantly. In March 1962, he contracted German measles and then later chicken pox in June 1962. Despite these short term illnesses, this patient was discharged home in August 1962, having secured a place at the Windlestone Hall residential school near Ferryhill, County Durham, to begin in September 1962.

 

Sources:

di Sant’agnese, Paul. A (1955). The Pulmonary Manifestations of Fibrocystic Disease of the Pancreas. Chest. 27(6):654-667

Medline Plus (2015). Clubbing of the Fingers and Toes. http://www.nlm.nih.gov/medlineplus/ency/article/003282.htm

Patient (2015). Pancreatin. http://patient.info/medicine/pancreatin

Pott’s Disease (Tuberculosis of the Spine)

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The spine is the most frequent site of skeletal involvement in tuberculosis of the bones and joints. Commonly known as Pott’s Disease, after Sir Percival Pott who first described the condition in 1779, tuberculous osteomyelitis of the spine affects between 25 and 60% of all individuals suffering from skeletal tuberculosis. It is most commonly seen in children and young adults, predominantly affecting the thoracic and upper lumbar regions of the spine, although evidence of cervical involvement also exists. Spinal lesions begin in the cartilage between the vertebrae or in one or more vertebral bodies, this leads to a narrowing of the joint space, noticeable in radiological examination. Paravertebral abscesses can also occur when diseased tissue in the vicinity of the affected vertebrae forms a mass and pus collects. With the expansion of this abscess there can be a loss of blood supply to the vertebral body resulting in a loss of integrity causing the vertebral column to collapse creating an angulation or ‘kyphosis’ to the spine. The collapsed vertebrae form a wedge, known as a ‘Gibbus deformity’, which can lead to compression of the spinal cord resulting in paraplegia, as well as functional problems with the pulmonary system.

There are numerous cases of spinal tuberculosis in the records from Stannington, all varying in their severity and final outcome. Below are two examples of the different types of spinal tuberculosis and the methods used to treat it.

 

Case Study 1 – Dorsal (Thoracic) Spine

Patient 17/1949, a 4 year old boy, was transferred to Stannington Sanatorium from the Royal Victoria Infirmary (RVI) in January 1949. His medical history had included a bout of pertussis, whooping cough, complicated by pneumonia followed a year later by lethargy and a swollen knee. In April 1947 he was admitted to Earl’s House Sanatorium with a primary tuberculous complex in the left upper zone of his chest and TB of the left upper tibial epiphysis and upper dorsal (thoracic) spine.


Paraplegia developed in September 1948 and he was transferred to the RVI that December showing signs of wasting and obvious kyphosis in the upper dorsal spine with paraplegia evident and total incontinence. His notes state that his head and thorax were encased in plaster cast, as was the left leg, to immobilise the affected areas. The incontinence was dealt with by applying a tube. Tuberculosis of the spine was relatively advanced, with the 3rd and 4th dorsal vertebrae having collapsed resulting in a noticeable kyphosis, seen in Figure 1.

FIGURE 1: HOSP-STAN-07-01-02-1662-22
FIGURE 1: HOSP-STAN-07-01-02-1662-22

On admission to Stannington it is recorded that the radiographs showed a high dorsal lesion. The plaster cast encasing the head and thorax was removed and the patient was fixed to a short plaster boat with head piece, see left image in Figure 4.

FIGURE 4: HOSP-STAN-07-01-02-1662-24
FIGURE 3: HOSP-STAN-07-01-02-1662-24
FIGURE 2: HOSP-STAN-07-01-02-1662-16
FIGURE 2: HOSP-STAN-07-01-02-1662-16

 

 

 

 

 

 

 

 

 

 

 

 

Radiographic images show further kyphosis, Figure 2, and the collapse of the vertebral bodies. Porosity is evident in the vertebral bodies in the upper dorsal region, identifiable by their translucent nature in Figure 3, giving rise to the extent of the infection.

In November 1949, the patient was fitted for a plastic splint. This was to fit

‘from the hips up the trunk extending over the neck to the occiput, reinforced with metal where necessary’.

The spinal lesion was considered quiescent by April 1952, all evidence of paraplegia having cleared up. However, he was to be fitted with a splint with a shaped head piece to immobilise the spine as much as possible. This patient was discharged in March 1953 and his brace discarded entirely in May 1953. He continued to be seen as an outpatient until February 1959.

HOSP-STAN-09-01-01
Figure 4:  HOSP-STAN-09-01-01

 

Case Study 2 – Cervical Vertebrae

Patient 148/1948, a 3 year old girl, was initially admitted in January 1948 (Patient Number 8/1948) with a Primary Tuberculous Complex of the right mid-zone.

Preliminary medical reports described this girl as having had an enlarged right hilar shadow, a shadow of the hilar lymph nodes, and ‘shotty,’ swollen, glands with an impetigious lesion on the scalp. However, her initial stay at Stannington was short as she was removed against medical advice by her mother 28 days after admittance, only to be re-admitted seven months later with TB of the cervical spine.

Following an examination by the surgeon, Mr Stanger, on re-admission a comprehensive outline of her condition was given:

‘The lower surface of the 2nd c.v (cervical vertebrae) is involved; the body of the 3rd c.v is completely destroyed and the upper surface of the 4th is probably eroded.

This child should have every bone in her body x-rayed.’

The destruction of the vertebral bodies can be seen in the radiographs in Figures 5 and 6. Figure 5 shows the collapse of the vertebrae inwards creating a wedged shape in the neck. Figure 6, taken through the open mouth of the patient in order to gain a clear veiw of the vertebral bodies of the cervical vertebrae in the neck, shows a loss in denisty and clearly defined outer edges of the vertebral bodies due to collapse.

FIGURE 4: HOSP-STAN-07-01-02-1625-14
FIGURE 5: HOSP-STAN-07-01-02-1625-14
FIGURE 6: HOSP-STAN-07-01-02-1625-43
FIGURE 6: HOSP-STAN-07-01-02-1625-43

 

 

 

 

 

 

 

 

 

 

 

 

It is likely the request for all bones in her body to be x-rayed came from the suspicion that other areas of the skeleton had been affected by the disease. The request was carried out with the x-ray report card indicating that anteroposterior (AP) and lateral radiographs, where possible, were taken of the chest, spine, legs and hips. The patient was immobilised on a Bradford frame, a rectangular metal frame with canvas straps to hold the individual in a prone or supine position, seen in the right hand image of Figure 4.

Between September and December 1948 the patient is noted to have developed a number of additional symptoms, including vomiting sputum; patchy erythema (a scarlet rash) on her chest; purulent nasopharyngeal discharge (discharging pus from the nose); aural discharge; an inflamed throat and enlarged cervical glands.

By July 1949, these symptoms had largely been addressed and the patient was showing improvement. Immobilisation was considered satisfactory as a form of treatment and a moulded plastic splint was to be prepared for the patient, to consist of

‘a jacket taken from the hips and extending upwards to embrace the head and the occipital region to the chin.’

This was later described as being reinforced with steel both vertically and transversely.

 

One year later, further examination by Mr Stanger noted that the disease had involved the 2nd, 3rd and 4th cervical vertebrae; the bodies of the 2nd and 3rd were showing signs of fusion and bone regeneration. It is at this point in July 1950, two years after first being admitted, that the child was allowed to ‘get up’.

 

This patient was discharged in December 1950, as being clinically and radiologically inactive and able to dispense with the splint. She continued to be seen as an outpatient at Stannington until 1956. Her last out-patient report stating that there was no deformity and no limitation of movement. Sound fusion was noted between both the vertebral bodies and posterior articulation of the 2nd, 3rd and 4th cervical vertebrae.

 

Further radiographic images can be seen on the Stannington Sanatorium ‘Radiographs from Stannington’ Flickr stream https://www.flickr.com/photos/99322319@N07/sets/72157648833066476/

 

Sources

Miller, F.J.W, Seal, R.M.E and Taylor, M.D (1963). Tuberculosis in Children. J & A Churchill Ltd.

Roberts, C and Buikstra, J (2003). The Bioarchaeology of Tuberculosis: A Global View on Reemerging Disease. Univesity Press of Florida.

Roberts, C and Manchester, K (2006). Archaeology of Disease (3rd Edition). Cornell University Press.

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