Arch Dis Child: first published as 10.1136/adc.28.137.19 on 1 February 1953. Downloaded from TYPHOID OSTEITIS IN INFANCY BY HARRIS JACKSON, I. KESSEL, S. N. JAVETT and P. KUSHLICK From the Departments of Paediatries and Radiology, University of the Witwatersrand. and the Transvaal Memorial Hospital for Children, Johannesburg, South Africa (RECEIVED FOR PUBLICATION JULY 21, 1952) In 1835 Maisonneuve first recognized osteomyelitis for 17 days before admission. Four days after the onset as a complication of typhoid and since then this bone he developed a macular skin eruption suggestive of a lesion, although well known, has been reported only 'rose' rash. For six days he was treated with sulpha- occasionally. Murphy (1916) collected 164 cases of diazine and penicillin, when the pyrexia subsided. After typhoid periostitis and osteitis occurring in 18,840 another six days it was noticed that the infant resented any interference with the left shoulder, apparently due cases of typhoid infection reported by 15 authors, to pain. Four days later the right shoulder became an incidence of 0 82% of bone involvement. Veal affected and he was admitted to hospital. In the four (1939) also found osteitis in less than 1 % of typhoid days before admission he again became pyrexial. infections. The pregnancy and labour were normal and the parents In discussing the age incidence Murphy (1916) and one sibling were healthy. The birth weight was reported six cases (0*9 %) of typhoid periostitis 7 lb. 6 oz. and there had been no illness before the present Protected by copyright. occurring in the age-group 1 to 10 years in a total one. He had been vaccinated two months, and immu- of 68 cases at all ages. By comparison, in a series nized against pertussis one month before admission. of 411 cases of septic osteomyelitis at all ages he On examination he appeared a well nourished infant found 108 in the weighing 19 lb. 10 oz. The temperature was 101 F., pulse (26%) first decade. Winslow (1923) rate 124 per minute, respiration 26 per minute. Nothing found 101 proven cases in the literature and he added abnormal was detected in the cardiovascular, respiratory two of his own. Four of these occurred in the first or central nervous systems. The liver and spleen were not decade, the youngest being 2 years old. Of this series palpable. The child resented handling of both shoulders. 68 had one and 23 had two bones involved. Veal He would not move his arms and this refusal appeared to (1939) also recorded multiple bone involvement in be due to pain and not to muscular weakness. There were less than 5 % ofcases. Typhoid lesions tend to remain palpable lymph nodes in both axillae. localized in contrast to paratyphoid B infections INVESTGATIONs. A blood count gave: haemoglobin, which tend to spread through the length of the bone. 9 4 g. 00: colour index, 0 87: erythrocytes, 3,500,000 per c.mm.: leucocytes. 13,700 per c.mm. Webb-Johnson (1917) illustrated the extreme rarity (neutrophils, 5501, http://adc.bmj.com/ monocytes, 3500o, lymphocytes. 4100, eosinophils, of bone involvenent in paratyphoid B infections, 0 5 . The sedimentation rate was moderately increased. recording only two instances in a study of 1,038 The cerebrospinal fluid was normal. The Wassermann examples of this disease. reaction of both cerebrospinal fluid and blood was Tlhere may be a wide variation in the latent period negative. Blood culture in broth and bile grew no between the acute idlness and the subsequent bone bacteria. No pathogenic bacteria or animal parasites involvement. In Winslow's 101 cases the bone were isolated from the stool on repeated examination. manifestations occurred during the acute attack in The urine contained no albumin, sugar or acetone and nine, at an unspecified date during convalescence in S. typhi was not isolated from the urine. The Mantoux on September 29, 2021 by guest. 53, and months or years after convalescence in 20 reaction was negative. S. typhi was not isolated from a sternal marrow culture. The agglutination reaction for cases. The tibia appears to be the bone most com- S. typhi 0 antigen was positive at a titre of I in 800, with monly affected. Morse and Geiser (1950) reported a a trace at I in 1,600. This was obtained 17 days after case of typhoid osteomyelitis treated with chlor- admission to hospital. A further positive reaction to the amphenicol. same antigen in a titre of I in 400 was obtained a month Typhoid bone lesions are extremely rare in infancy later. Agglutination reactions for S. typhi H and Vi were and we wish to record two cases. negative, as were those for S. paratyphi A, B and C. and Brucella abortus and melitensis. The intracutaneous Case Reports Brucella skin test yielded a negative result. Case 1. W.R., a boy 6 months old, was admitted to RADIOLOGICAL EXAMINATION. Radiographs of both hospital on April 3, 1951. He had had a pyrexial illness shoulders taken three days before admission to hospital 19 Arch Dis Child: first published as 10.1136/adc.28.137.19 on 1 February 1953. Downloaded from 20 ARCHIVES OF DISEASE IN CHILDHOOD were normal. :imm lesions becane Two days after more sclerotic admission the and the epi- right shoulder _ _ - physes re- was still nor- _ ~~~~appeared in a mal, but on f ragmented the left the fashion sug- deltoid region gestmg ossi- was swollen, fication in with oedemaof multiple cen- the musculo- tres. On the subcutaneous right side the plane (Fig. 1), epiphysis of and there was the greater a narrow band t u b erosity of rarefaction appeared pre- in the meta- maturely. The physis of the subluxation on head of the the right dis- humerusparal- appeared but lel to the it persisted on epiphyseal FIG. IA F}G. IB the left side. There FIG. I._(Case 1. 5.4.51.) Radiographs taken o0 n April 4 showing right shoulder radiologically This infant line. normal; left shoulder with soft tissue swelling cif the deltoid region, oedema of the musculo- with was also swell- subcutaneous plane, enlargement of the axillar lymph nodes and a band of minimal (not presented ing of the reproducible) rarefaction in the metaphysis. an acute py- rexial illness lymph nodes Protected by copyright. a m the axilla. On the following day this area of associated with rose-rash suggesting an acute typhoid rarefaction was larger and more irregular (Fig. 2) and infection. It was soon followed by involvement of the there was a similar area in the head of the right humerus. left and then the right shoulder, causing pain and One week later the lesion in the right head was more immobilizatlon at these sites. The radiological examina- obvious (Fig. 3) and that in the left was a little larger and tion at first suggested an acute metaphyseal osteitis, but better defined. After a further week marginal sclerosis the subsequent course was unusually slow. The epiphyseal could be detected about the area of erosion on both sides changes were due to direct invasion or to avascular and there was bilateral minimal subluxation. At the end necrosis consequent upon the metaphyseal involvement of the sixth week these changes were well developed or to hyperaemia. The first was thought to be the more (Fig. 4). During the next month the area of sclerosis likely as avascular necrosis following infection usually gradually encroaced on the area of rarefaction, which leads to complete resorption or extrusion of the epiphysis on the right side developed a coarse trabeculation and reossification after hyperaemia is not multicentric. (Fig. 5), while the epiphyses of the head became smaller It cannot be determined without aspiration, which was and almost completely disappeared. Thereafter the not performed here, whether the joint was actually http://adc.bmj.com/ FIG. 2.-An increase in size and irregularity of the area of rarefac- tion is seen in the left metaphysis on April 6. The musculo-sub- cutaneous plane is now well defined. A similar but less marked area of rarefaction on the right side could on September 29, 2021 by guest. not be reproduced. FIG. 3.-The area of rarefaction in the right head is now (Apnrl 12) clearlv visible. FKG 2. FIG. 3. TYPHOID OSTEITIS IN INFANC Y 21 Arch Dis Child: first published as 10.1136/adc.28.137.19 on 1 February 1953. Downloaded from infected or not. The There was full move- initial blood count ment of the elbow and showed an anaemia wrist, and the other with a neutrophilia, limbs were normal. and the diagnosis of INVESTIGATIONS. A typhoid osteitis was blood count gave: determined by the haemoglobin, 9-9 g. initial illness and the ;t 0o; colour index. positive agglutination 092; erythrocytes. reactions to S. typhi 0 3,500,000 per c.mm.: antigen in titres of I leucocytes, 8,400 per in 1,600 and I in 800. ~~~~~~~c.mm. The red cells A diagnostic titre for showed anisocytosis. this antigen for trhe The sedimentation Witwatersrand area, rate was 60 mm. in where this case occur- one hour. The packed red, has been deter- cell volume was 300o. mined by Lewin (1938) The modified Ide test to be 1 in 200. and the Mantoux Tlhis child had two reaction were nega- courses of chloram- tive. The cerebro- phenicol therapy, in a spinal fluid was nor- dosage of 250 mg. mal. Agglutination every six hours first tests for S. tyrhi 0 for 13 days, and sub- showed a positive re- sequently for 11 days. -> action in a serum Protected by copyright.