Multiple Cystic Tuberculosis of Bones: Its Roentgen Picture and Reparative Process as Seen in Serial Roentgenograms

Abstract

DURING the past four years I have had the opportunity of closely following the healing process, through roentgenograms, of widely disseminated cystic bone lesions of tuberculous origin in a young girl. A complete clinical report of this case has been given in another journal (1). The present communication concerns itself mainly with the roentgen picture. The present concept of multiple cystic bone tuberculosis, “osteitis tuberculosa multiple cystica,” is applied to a comparatively rare form of diaphysial bone tuberculosis, usually multiple, and of metastatic origin from a primary thoracic focus. It is insidious in onset, with few or no localizing signs such as pain, tenderness, or external evidence of inflammation. The lesions run a chronic benign course, consist of a circumscribed area of soft tuberculous granulation tissue and degenerated bone which tend to heal slowly. The roentgen picture is fairly characteristic and of distinct diagnostic importance. Two main roentgen types are described; the diffuse and the circumscribed (2, 3). The diffuse is the more acute initial stage. In it, the diaphysis cannot be differentiated into medulla and cortex. Here the cystic areas of decreased density are honeycombed with a web-like structure of increased density. The individual or several apertures in the web vary in size from that of a millet seed to that of a pea. The cystic areas may enlarge to include both medulla and cortex, increase the diameter of the involved bone, and cause destruction of a phalanx. The patient presented demonstrates the circumscribed type. In typical cases the roentgenogram shows round smooth or irregular punched-out like areas of decreased density, with a thin cortex and little or no surrounding sclerosis. There is usually no involvement of the periosteum, no cortical expansion, and no abscess or sequestrum formation. The roentgen picture of these circumscribed lytic tuberculous lesions is not only characteristic but, in the general absence of any localizing physical signs, the diagnosis of multiple cystic bone tuberculosis is contingent on roentgen bone examination in children who have tuberculous thoracic disease. Without roentgen bone examination, the far-flung lytic lesions in my little patient would not have been suspected or detected. In March, 1935, a six-year-old girl was admitted to the Pediatric Service, University Hospital, with an immediate history of kyphotic deformity of the spine which had not improved after three months' treatment in a cast. At the time of admission she was fairly well developed and nourished. Mid-thoracic kyphosis, protuberance of three vertebræ, and some local tenderness were the only positive signs. They justified a diagnosis of spinal tuberculosis which was confirmed by roentgen examination. Figure 1 shows the widely scattered lytic lesions in the bones related to the thorax.