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Special Feature
October 2000

Radiological Case of the Month

Arch Pediatr Adolesc Med. 2000;154(10):1060. doi:
Denouncement and Discussion: Multiple-Bone Tuberculosis and Dactylitis

Figure 1. Radiographs of the lower legs show multiple cystic lesions in the proximal and distal ends of the tibias with periosteal reaction. A pathologic fracture is present in the distal right tibia (A and C).

Figure 2. Dactylitis of the metacarpals in the right hand and cystic spina ventosa lesions.

The patient's erythrocyte sedimentation rate was 130 mm/h (Westergren method), and the Mantoux tuberculin skin test was positive with an induration of 30 mm. Results from complete blood cell count confirmed a severe hypochromic, microcytic anemia (hemoglobin, 70 g/L). The child's rapid plasma reagin titer for syphilis was 1:512; the mother's, 1:64. Findings from human immunodeficiency virus serology were negative. A chest radiograph was unremarkable, and a single orbital lytic lesion was noticed on a lateral radiograph of the skull. Surgical drainage of the soft tissues of the right hand yielded thick pus and granulomatous tissue. Mycobacterium tuberculosis (TB) susceptible to isoniazid and rifampin was obtained from tissue culture. The child was treated for congenital syphilis with penicillin G procaine intramuscularly daily for 10 days and for TB with isoniazid, rifampin, and pyrazinamide for 12 months. Clinical and radiological responses after 5 months were remarkable.

Tuberculosis and congenital syphilis cause bone lesions in infants and young children but are rarely reported in the same child.1,2 Dactylitis is present but rare in both diseases.24 Although the combination of dactylitis and multiple cystic lesions is typical of multiple bone TB, the clinical feature of condylomata lata and the severe periosteal reaction in the long bones lead to the suspicion of congenital syphilis.

A literature search produced no recent cases of both TB and syphilis in an infant, but Komins1 in 1952 described 3 cases of multiple cystic lesions with confirmed TB and congenital syphilis and traced another 6 patients from the literature. Findings from biopsy and in 1 case autopsy revealed no evidence of congenital syphilis as the cause for bone disease, and it was concluded that congenital syphilis does not contribute to the development of multiple cystic TB except perhaps by altering the immune response of the body. Although Cremin et al2 found no cases of congenital syphilis among their patients with multiple-bone TB, they found it possible to distinguish these lesions from congenital syphilis because bone involvement in the latter usually is seen before age 9 months. Syphilitic dactylitis can occur up to age 2 years.5 Periosteal reaction is said to be uncommon in osteoarticular TB,6 but smooth, layered, periosteal reaction is common and can be extensive in the long bones overlying the multiple cystic TB lesions.7

Multiple-bone TB is a disease of young children and is the result of hematogenous spreading from a lung focus that has healed by the time the bone TB is observed.7 The multiple bone–type TB occurs in tubular and flat bones. Classic spina ventosa dactylitis rarely occurs in the hands and feet and sometimes breaks through the cortex to form a cold abscess. In larger bones recent lesions cause bone expansion and periosteal layering. Older lesions have a cystic appearance as described by Komins.1 Sclerosis is common.7 The orbit is a site for skull involvement. Both congenital syphilis and TB are often preventable by timely evaluation and preventative measures. Screening children in contact with adult pulmonary TB and giving directly observed chemoprophylaxis could have prevented this case.

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Article Information

Accepted for publication January 7, 1999.

Reprints: H. Simon Schaaf, MBChB, DCM(SA), MMed(PAED), Department of Pediatrics and Child Health, University of Stellenbosch, PO Box 19063, Tygerberg 7505, Republic of South Africa (e-mail: hss@maties.sun.ac.za).

References
1.
Komins  C Multiple cystic tuberculosis: a review and revised nomenclature. Br J Radiol. 1952;251- 8Article
2.
Cremin  BJFisher  RMLevinsohn  MW Multiple bone tuberculosis in the young. Br J Radiol. 1970;43638- 645Article
3.
Rasool  MNGovender  SNaidoo  KS Cystic tuberculosis of bone in children. J Bone Joint Surg Br. 1994;76113- 117
4.
Sachdev  MBery  KChawla  S Osseous manifestations in congenital syphilis: a study of 55 cases. Clin Radiol. 1982;33319- 323Article
5.
Dennie  CCPakula  SF Congenital syphilis of bones and joints. Congenital Syphilis. Philadelphia, Pa Lea and Febriger1940;187- 270
6.
Vallejo  JGOng  LTStarke  JR Tuberculous osteomyelitis of the long bones in children. Pediatr Infect Dis J. 1995;14542- 546Article
7.
Goldblatt  MCremin  BJ Osteo-articular tuberculosis: its presentation in coloured races. Clin Radiol. 1978;29669- 677Article
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