tuberculosis Archives - Page 5 of 6 - Northumberland Archives

Osteomyelitis Part 2: Dactylitis

30/03/2015 by Stannington Sanatorium Project

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 4^th 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 4^th toe left foot, discharging sinus at base,

right hand hard swelling of 5^th 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.

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.

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.

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.

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 4^th 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.

Harris Lines of Arrested Growth

20/02/201516/02/2015 by Stannington Sanatorium Project

The poor living conditions that many of the children at Stannington Sanatorium came from, outlined in our last post, can often leave physical markers on the skeleton, namely Harris Lines.

Harris Lines are an indication of periods of arrested growth whilst the body is still growing during childhood and can be displayed as opaque, transverse lines on long bones. These can be identified through radiographic imaging or physically on skeletal remains.

The appearance of these lines is considered to show periods in an individual’s childhood when the body comes under stress, which is usually attributed to malnutrition or significant childhood disease. In order for the individual to acquire Harris Lines, they have to have recovered from the period of stress, prolonged malnutrition or disease would not result in their appearance.

Numerous patients from Stannington Sanatorium demonstrate Harris Lines in their radiographs. One such example is seen above, patient 148/1948. Thi image was taken in November 1948, approximately 10 months after initial diagnosis of tuberculosis was made. On this patient Harris Lines are identifiable on both proximal and, to a greater degree, distal tibiae, as a brighter, opaque line close to the epiphysis.

This individual was admitted to the sanatorium aged 2 with a Primary Complex, primary infection in the mid zone of the right lung. Their medical history indicates that their father had been diagnosed with pulmonary tuberculosis and subsequently died. The family, consisting of mother, father and two children were living in one room for the majority of the individual’s life, only moving to a two roomed house around the time of their admission to Stannington and on admittance to the sanatorium the child was described in the medical notes as being ‘thin’ and ‘ pale’.

Social conditions such as these would have attributed to the premise of the child undergoing one or more periods of stress during growth and alongside the description of the individual being ‘thin’, malnutrition is possible. A poor appetite or anorexia is often noted in the medical notes of patients as being symptomatic of tuberculosis, again suggesting possible malnutrition. However, the effects of the tuberculosis infection alone would have put the body under due stress and may, therefore, have contributed to the presence of Harris Lines. Both malnutrition and acute tuberculous infection are potential causes of the Harris Lines, alone and in conjunction with one another, and demonstrate the secondary effects that disease and social conditions can have on an individual’s body.

This patient was removed against medical advice approximately one month after admittance, only to be re-admitted seven months later with tuberculosis of the cervical vertebrae. They were eventually discharged in December 1950, two years later, but continued to be seen as an out-patient. No further treatment was required at Stannington Sanatorium.

For more radiographic images, view the ‘Radiographs from Stannington’ on Flickr https://www.flickr.com/photos/99322319@N07/sets/72157648833066476/

Sources

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

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

06/02/2015 by Stannington Sanatorium Project

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)

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