Osteitis Tuberculosa Multiplex Cystica

Abstract

THERE are two types of tuberculosis of the bones. The first and most common is the one occurring in the region of the metaphysis, where there is usually only one bone and joint involved. The dissemination is hematogenous and the predilection for the metaphyseal region according to the work of Lexer is to be found in the peculiar vascular structure in this region in the growing long bones. Schulze, working with experimental animals, injected dye in Ringer's solution in the femoral artery which lodged in the end-arteries in the metaphysis with a resulting circumscribed ischemia. He suggests that tubercle bacilli could produce a similar embolus with resulting caseation. The process extends, infiltrating the epiphysis and destroying it, ultimately involving the joint; it may become arrested at any stage of its development, be surrounded by fibrous tissue, and present a fibrous cystic appearance which remains unchanged over a long period. The second and rarer form of tuberculosis of the bones is that one involving the diaphysis, this form usually being multiple. The dissemination is probably hematogenous. Fibrosis frequently predominates, surrounding the caseations and resulting in a cyst which remains comparatively quiescent and unchanged over a rather long period. This type was probably first described by Kreibish, in 1904, which, in appearance, closely corresponded to cases later reported by Jüngling, in 1920. Reider, in 1910, published an article on the combination of chronic osteomyelitis with lupus pernio. German dermatologists had long known that the so-called tuberculides of the skin (lupus pernio and Boeck's sarcoid) were not infrequently associated with chronic bone changes in the hands and feet. Jüngling, in 1920, made the most lucid and comprehensive observations of these cystic changes of bone to which he applied the name “osteitis tuberculosa multiplex cystica.” In 1924, Fleischner investigated the dermatologic literature and found a great number of cases with bone changes in the hands and feet. There is comparatively little in the American literature regarding the bone changes associated with tuberculous lesions of the skin. Doub and Menagy, in 1929, reviewed the scanty literature and presented two cases with bone lesions occurring in sarcoid in adults. Jüngling, in 1928, reviewed the literature and reported 46 cases to which he added nine of his own. Practically all of these have involved the phalanges, metacarpals, and metatarsals, but rarely the larger long bones. Van Alstyne and Gowen reported a multiple cystic type of tuberculosis occurring in the long bones in an adult. Schwenkter, in 1931, reported on a multiple cystic tuberculosis of the bone in an infant one year of age. We are reporting two cases because of the paucity of the cases in the literature. There is only one case occurring in an infant recorded in American literature. One of our cases is of especial interest because of the widespread distribution of the lesions.