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radiographs

Osteomyelitis Part 2: Dactylitis

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Continuing on from our last post on osteomyelitis affecting the lower leg bones, see post dating 06/02/2015, here we are going to review a case of tuberculous osteomyelitis of the short tubular bones in the hands and feet; the metacarpals, metatarsals and phalanges,  commonly known as tuberculous dactylitis or ‘spina ventosa’(meaning short or small bone inflated with air). This is a particularly uncommon manifestation of tuberculosis primarily affecting children, and it is rare in anyone over the age of six.

Dactylitis affects the hands more often than the feet and can affect multiple bones at one time. It is caused by the haematogenous spread of tubercular bacteria which settles in the bone marrow of the short bones prior to the epiphyseal centre becoming established. This leads to thickening of the periosteum (outer membrane of the bone) with osteomyelitis, but rarely involves the joint.

 

Patient 90/27

This patient was a 16 year old male, admitted to Stannington Sanatorium in September 1940 with tuberculosis of the bones and joints, stage II. In this instance tuberculous dactylitis was diagnosed affecting the left foot and right hand, alongside queried primary infection in the lungs and concerns over the right elbow.

The patient’s medical history states that seven months prior to his admission the patient’s left ankle became swollen and started discharging; his 4th left toe became swollen and started discharging and 1 year prior to admission his right hand was hurt and it too became swollen.

Initial observations made by admitting doctors read as follows:

‘Left foot sinus over lateral malleolus,

swelling over 4th toe left foot, discharging sinus at  base,

right hand hard swelling of 5th metacarpal’

 

Diagnosis of dactylitis is made based on radiographic findings; however, it is often observable physically due to painless inflammation of the soft tissue surrounding the affected bone. As noted above sinuses may also form, which may discharge, as a result of infection. Although we have no photographic images of patient 90/27, we do have a photograph of another patient (for whom we have no radiographs) also diagnosed with tuberculous dactylitis showing the effects this infection had on the surrounding soft tissue, note the presence of a discharging sinus at the base of the first finger on the left hand, Figure 1.

FIGURE 1: HOSP-STAN-07-01-01-361_06
FIGURE 1: HOSP-STAN-07-01-01-361_06

 

The first x-ray report for patient 90/27 was in October 1940 and confirmed that the phalange of the fourth toe of the left foot was expanded but without any signs of a cavity; the fibula showed signed of decalcification; fibrosis was detected in the lungs, possibly the primary source of the tubercular infection, and the fifth metacarpal of the right hand was badly affected, Figure 2.

 

FIGURE 2: HOSP-STAN-07-01-02-641_07
FIGURE 2: HOSP-STAN-07-01-02-641_07

Once established, the tuberculous infection quickly involves the entire marrow space and the tuberculous granulation tissue expands the bone cortex following necrosis of the bone tissue. As a result the bone expands taking on a spindle form and appears much like an inflated balloon. This is well demonstrated in Figure 2, with the balloon like inflammation in the distal metacarpal. It is common to see new bone formation, or periostitis, as a result of the infection. Soft Tissue swelling can also be seen surrounded the affected metacarpal in Figure 2.

 

FIGURE 3: HOSP-STAN-07-01-02-641_11
FIGURE 3: HOSP-STAN-07-01-02-641_11

Throughout the patient’s notes, specific areas of infection are focussed upon. In April 1941 the x-ray report notes look at the fourth toe of the left foot, Figure 3. Here the proximal phalanx is noticeably expanded and the notes state that the cavity looks as though it has been filled in with granular tissue. By February 1942 the disease has taken over the whole of the phalanx and a cavity is noted in the distal end of the bone.

There is nothing within the patient notes about any specific treatment this patient was receiving for his condition. Given the nature of the infection and the continuous references to ulcers and sinuses that were discharging it is likely these would have been drained regularly as part of the general sanatorium treatment, alongside rest and fresh air. There is one side note within the notes that questions excision of toe, however this is not pursued anywhere else.

FIGURE 4: HOSP-STAN-07-01-02-641_05
FIGURE 4: HOSP-STAN-07-01-02-641_05

 

With tuberculous dactylitis, it is possible to achieve almost complete recovery. New bone formation around the affected bone is noted, but soft tissue swelling abates and deformity is rare, Figure 4. In April 1942 this patient’s notes read:

‘Nil active in lungs.

Foot: cavity in bone of 4th phalanx filled up. Quiescent.

Hand: metacarpal improving’

 

This patient was later discharged in May 1942 as ‘improved.’

 

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

Bhaskar, Khongla, T and Bareh, J (2013). Tuberculous dactylitis (spina ventosa) with concomitant ipsilateral axillary scrofuloderma in an immunocompetent child: A rare presentation of skeletal tuberculosis. Advanced Biomedical Research 2:29

Mishra Gyanshankar, P, Dhamgaye, T.M.  and Fuladi Amol, B (2009). Spina VentosaDischarging Tubercle Bacilli – A Case Report. Indian Journal of Tuberculosis 56: 100-103

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

The Stannington Radiographs

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The radiographs make up a significant part of the Stannington collection with a total of 14,674 separate images relating to 2220 different patients covering roughly a 20 year period from 1936 to c.1955. When the records were recovered in the 1980s the vast majority of the radiographs were copied on to microfiche and the originals destroyed as they were unstable. However, we still have 326 original radiographs within the collection. Over the course of the project all the microfiche images and the originals will be digitised and made publicly accessible. We also hope to preserve the remaining original radiographs as examples of how x-ray images at the time were produced. The problem here lies with the unstable nature of the film and its natural degradation.

 

All the radiographs were produced on cellulose acetate film, known as safety film as it replaced the earlier nitrate film that was highly flammable and potentially self-combustible, a problem for many film archives today. Over time the cellulose acetate film naturally breaks down, the early stages of this are recognisable by the strong smell of vinegar coming off the film as the process gives off acetic acid and because of this is known as vinegar syndrome. Eventually as the base of the film and the top layer pull away from one another the film will begin to buckle and crack and bubbles can form under the surface.

IMG_0904
Figure 1
IMG_0905
Figure 2

This process is already evident in several of the radiographs we hold (figures 1 & 2) and unfortunately there isn’t anything that can be done to reverse or halt the process. By storing the films in a closely monitored temperature and humidity controlled environment we hope to delay the process in most of the radiographs for as long as possible.

 

IMG_0903
Figure 4
IMG_0902
Figure 3

 

 

 

 

 

 

 

 

The x-rays were originally stored in ordinary brown envelopes and there could be as many as 15 in each envelope. (Figure 3)  To help preserve them we have instead transferred each x-ray into an individual acid free sleeve. (Figure 4)  By storing them individually we are able to minimise any accumulation of acetic acid that is produced in the degradation process.  Thanks to advice from conservators at Durham County Record Office and their assistance in sourcing the new x-ray envelopes, all the original films are now safely stored in their own envelopes in our photogrpahic strong room.

 

This degradation is evident in some of the microfiche as well as the original films had obviously started to buckle already at the time they were transferred to microfiche in the 1980s. Consequently some of the images are obscured by a crackling effect. Nevertheless the vast majority of the 14,674 images remain easily readable and the digitisation process will mean that they remain clearly accessible for future use.

 

[See our Flickr stream for examples of some of the radiographs https://www.flickr.com/photos/99322319@N07/sets/72157648833066476/]

Osteomyelitis Part 1 – A Case Study of Patient 90/1951.

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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.

HOSP-STAN-07-01-02-2011-33
HOSP-STAN-07-01-02-2011-33

 

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)

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