Journal of the Royal Society of Medicine Volume 83 July 1990 for glial fibrillary protein was negative in the secondary deposits. Discussion Malignant mesothelioma is recognized to follow exposure to asbestos' which for this patient had occurred for 24 years. The morphological appearance of the tumour at biopsy and necropsy was consistent with malignant pleural mesothelioma3. Few nec-opsy studies have been performed on patients who have died of malignant pleural mesothelioma. Metastases frommalignant pleural mesothelioma may involve the underlying lung, hilar lymph nodes, bone, liver, kidney and adrenals. Cerebral metastases have only been reported infrequently and have not manifest at the clinical presentation. Five separate necropsy series44 noted four cases of cerebral metastases in a total of 132 autopsies of patients with mesothelioma. The Australian Mesothelioma Surveillance Program has full necropsy data on 207 cases and cerebral metastases were noted in nine instances (personal communication). Clinical series reporting the pattern of spread ofdisease are also uncommon. Harrison0 reported one case of sarcomatous malignant mesothelioma metastatic to brain and other sites, and commented on the predeliction of this histological type for haematological spread. Brenner and colleagues"0 reviewed 123 cases of malignant mesothelioma and reported that while no patients had cerebral metastatic disease at presentation, seven patients developed this complication during the course of their disease. Schwechheimer and Butzengeiger11 reported one case of multiple cerebral metastases arising from a malignant pleural mesothelioma in a patient with widespread metastatic disease. These authors searched the literature and
Osteomyelitis of the talus in childhood due to Haemophilus influenzae
J Wootton FRCS D Jones FRCS A Howard MRCPath Gwynedd District General Hospital, Bangor, Gwyndd LL57 2PW Keywords: osteomyelitis; talus; Haemophilus influenzae
Haemophilus influenzae is an infrequent cause of osteomyelitis with a reported incidence of 5-12%1,2. It usually causes an acute infection similar to staphylococcal osteomyelitis but may also be responsible for sub-acute infection36. Acute infection of the talus is seldom described6, and sub-acute infection of the talus is even more uncommon. The probable association of two such infections with Haemophilus influenzae prompted this report7.
Case reports Case 1 A 2-year-old boy was admitted on the 21 December 1984 with a 4-day history of a cold and a 24-hour history of a right limp. On examination there was a low grade fever and signs of irritability in the right hip with full movements albeit with discomfort at their extremes. The white cell count was normal and the erythocyte sedimentation rate 37 mm/h. The following day his temperature was 38°C and he was generally unwell. Blood cultures were negative. He was treated by intravenous erythromycin and flucloxacillin.
467
found 12 other cases of intra-cranial metastases from mesothelioma. This review suggests that metastatic spread of malignant mesothelioma to the brain is more common than generally recognized. References 1 Wagner JC, Sleggp CA, Marcand P. Diffuse pleural mesothelioma and asbeos exposure in the North Western Cape Province. Br J.Ind Med 1960;17:260-71 2 SelikoffIJ, Curg J, Hammond EC. Relation between exposure to asbestos and mesothelioma. N Engi J Med 1965;272:560-5 3 Enzinger FM, Weiss SW. Soft tissue tumours. St Louis: Mosby,
1983:550-79 4 Whitwell F- Rawcliffe RM. Diffuse malignant pleural mesothelioma and asbestos exposure. Thorax 1971;26:6-22 5 Roberts GIL Distant vism:eal me in pleural m io . Br J Dis Chest 1976;70:246-50 6 Griffiths MH, Riddell RJ, Xipell JM. Malignant mesothelioma: A review of 35 cases with diagnis and prognosis. Pathology 1980;12:591-603 7 Vogelzang NJ, Schultz SM, Iannucci AM, Kennedy BJ. Malignant mesothelioma. Cancer 1984;53:377-83 8 Adams VI, Unni KK. Diffuse malignant mesothelioma of pleura: Diagnostic criteria based on an autopsy study. Am J Clin Pathol 1984;82:15-23 9 Harrison RN. Sarcomatous pleural mesothelioma and cerebral metastases: case report and a review of eight cases. Eur JRespir Dis 1984;65:185-8 10 Brenner J, Sordillo PP, Magill GB, Golbey RB. Malignant mesothelioma of the pleura. Review of 12 patients. Cancer 1982;49:2431-5 11 Schwechheimer K, Butzengeiger M. Brain metastases and malignant fibrous mesothelioma. Case report and review ofthe literature. Acta Neuropathol (Berl) 1983;60:301-4
(Accepted 15 August 1989)
Within 48 h he was apyrexial and hip movements were full and comfortable. He was allowed home on oral antibiotics. Two weeks later he was limping again but well and not in pain. X-rays showed a defect in the capital epiphysis suggesting Perthes-type changes (Figure 1). Antibiotics were continued. The limp became worse and clinically it was difficult to be certain whether the hip was the culprit because he had now developed swelling and warmth in the right ankle. X-rays suggested a lytic area in the medial side of the talus. A week later it was obvious (Figure 1). The erythrocyte sedimentation rate was 48 mm/h. Because of the clinical uncertainty as to which joint was at fault both were explored. The hip was entered through a lateral approach. There were no signs of inflammation. The femoral head was slightly flattened and thought to be compatible with a Perthes-like disorder. A core biopsy was taken and the wound closed. The ankle was explored tbrough a postero-medial incision. There was thin turbid fluid in this joint. A core oftalus was removed. This allowed access to a cavity with release of yellow pus and fibrin. Aftr ettage the wound was closed. Histology of the hip specimen showed a central area of cystic degeneration with cavities lined with proliferating benign fibrous tissue. Bacteriological exaination was negative. The ankle specimen dmonstrated histological features of an abscess. Bacteriological mination showed Gram negative coccobacilli and Haemophilus influenzae type b ide was demonsrated by counter immuno poly electrophoresis. Culture was unsuccessful. The child was rested in a spica cast for 2 weeks and given ampicillin for 6 weeks. He made a rapid and full clinical recovery. X-rays of the ankle and hip taken 3% years
0141-0768/90/ 070487-02/S02.00/0 @ 1990 The Royal Society of Medicine
468
Journal of the Royal Society of Medicine Volume 83 July 1990
*~X}BaNe=i:~63;.l|*~ ~ ._I . ,: . . '
..
:
.0.
... s~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~......
...
..
Figure 1. Left, case 1: radiograph ofleft hip showing a defect in fernoral head. Right, case 1: radiogaph of left anlgk revealing a Iytic lesion in the talus
postoperatively show that the ankle had healed, albeit with slight broadening of the body of the talus. Radiologically the hip showed healing with mild general enlargement of the head compared with the left but no sign of distortion or damage to the growth plate. Case 2 A 14-month-old boy was referred with a 6-day history of a limp. There was mild swelling and reddening ofthe outer side of the right ankle. X-rays were normal. A diagnosis of cellulitis was made and he was treated with erythromycin 125 mg 6-hourly. The swelling and redness initially subsided but his limp continued. Three weeks later the ankle was again swollen and he had developed an equinus deformity. Further X-rays showed an erosion on the lateral side ofthe body ofthe talus (Figure 2). The ankle was explored through an anterolateral approach. The joint contained thin purulent fluid. The anterolateral aspect of the talus was found to have a small sinus which was enlarged to allow access to the abscess. Yellow pus was released and curettage performed. Gram negative coccobacilli were shown on staining. Morphology was ,ennRbiatnt with haemophilus but culture was unsuccessful.
3t| ji~ ~. i .
He was treated with amoxycillin 125 mg 6-hourly for 6 weeks and made a full recovery. When last seen 3 years postoperatively there was no clinical abnormality and X-rays showed the defect to have healed. Discussion Both cases were difficult to diagnose. Preoperative blood tests were unhelpful. Morey and Paterson8 in a series of 135 cases of osteomyelitis, showed that only 26%9 had a raised white cell count. In case 1 the cause ofthe hip lesion remains unclear. Haemophilus should always be considered in childhood bone and joint infection, but may pose diagnostic problems. Its fastidious nature can make isolation difflcult. Culture is likely to be unsuccessful in patients who have had antibiotic treatment before exploration. The importance of antigen detection, by methods such as counter immunoelectrophoresis to confirm diagnosis, is stressed. Of further significance are reports of strains resistant to ampicillin, cefamandole, and even chloramphenicol9'10. We believe these children represent the first reported cases of osteomyelitis of the talus due to Haemophilus influenzae. Treatment was by exploration, curettage and antibiotics.
References 1 Schwartz RH, Ring CM. Acute haematogenous osteomyelitis secondary to haemophilus influenzae. J Paediatric Orthop 1981;1:385-9 2 Dich VA, Nelson JD, Haltalin KC. Osteomyelitis in infants and children. Am J Dis Child 1975;129:1273-8 3 Skevis XA. Primary sub-acute osteomyelitis of the talus. JBone Joint Surg 1984;66-B 4 Phemister DB. Chronic fibrous osteomyelitis 1929. Am Surg
1929,90:756-64 5 Iurlanday LE, Quinn 0, Sills E. Haemophilus influenzae as a cause of Brodie's abscess in an infant. Johns Hopkins Med J
1979;144:15-17 6 Trueta J, Morgan JD. Late results in the treatment of 100 cases of actie haemategenous steitis in childhood. A review of 212 cases. -J Bone Joint Surg 1954;34-B:608-622 7 James T. Acute Osteomyelitis in infancy and early cildhood.
Br J Surg 1953;41:87-91 8 Morey F, Peterson JA. Haematogenous pyogenic osteomyeitis
in childr. Orthop Clin N Am 1975;6:935-51 9 Bergeron MG, Claveau S, Simard P. Limited in vitro activity of mandole against 100 beta lactamase+non beta lactamase
producing Haemophilus influenzae strains. Comparison of moattclam, chloramphenicol, anmpicillin. Antimicrob Agent Chemother 1981;19:101-5 10 Markham RE, Insel RA, Pets itF. Cefamandole failure in ampicillin hasmophilus b pneumonia. South Med J 1981; 74:147-9
Figure2. Case2: radograph of left ankle showing eroson on lateral aspect of the body of the talu
(Accepted 15 Augst 1989)
Osteomyelitis of the talus in childhood due to Haemophilus influenzae
J Wootton FRCS D Jones FRCS A Howard MRCPath Gwynedd District General Hospital, Bangor, Gwyndd LL57 2PW Keywords: osteomyelitis; talus; Haemophilus influenzae
Haemophilus influenzae is an infrequent cause of osteomyelitis with a reported incidence of 5-12%1,2. It usually causes an acute infection similar to staphylococcal osteomyelitis but may also be responsible for sub-acute infection36. Acute infection of the talus is seldom described6, and sub-acute infection of the talus is even more uncommon. The probable association of two such infections with Haemophilus influenzae prompted this report7.
Case reports Case 1 A 2-year-old boy was admitted on the 21 December 1984 with a 4-day history of a cold and a 24-hour history of a right limp. On examination there was a low grade fever and signs of irritability in the right hip with full movements albeit with discomfort at their extremes. The white cell count was normal and the erythocyte sedimentation rate 37 mm/h. The following day his temperature was 38°C and he was generally unwell. Blood cultures were negative. He was treated by intravenous erythromycin and flucloxacillin.
467
found 12 other cases of intra-cranial metastases from mesothelioma. This review suggests that metastatic spread of malignant mesothelioma to the brain is more common than generally recognized. References 1 Wagner JC, Sleggp CA, Marcand P. Diffuse pleural mesothelioma and asbeos exposure in the North Western Cape Province. Br J.Ind Med 1960;17:260-71 2 SelikoffIJ, Curg J, Hammond EC. Relation between exposure to asbestos and mesothelioma. N Engi J Med 1965;272:560-5 3 Enzinger FM, Weiss SW. Soft tissue tumours. St Louis: Mosby,
1983:550-79 4 Whitwell F- Rawcliffe RM. Diffuse malignant pleural mesothelioma and asbestos exposure. Thorax 1971;26:6-22 5 Roberts GIL Distant vism:eal me in pleural m io . Br J Dis Chest 1976;70:246-50 6 Griffiths MH, Riddell RJ, Xipell JM. Malignant mesothelioma: A review of 35 cases with diagnis and prognosis. Pathology 1980;12:591-603 7 Vogelzang NJ, Schultz SM, Iannucci AM, Kennedy BJ. Malignant mesothelioma. Cancer 1984;53:377-83 8 Adams VI, Unni KK. Diffuse malignant mesothelioma of pleura: Diagnostic criteria based on an autopsy study. Am J Clin Pathol 1984;82:15-23 9 Harrison RN. Sarcomatous pleural mesothelioma and cerebral metastases: case report and a review of eight cases. Eur JRespir Dis 1984;65:185-8 10 Brenner J, Sordillo PP, Magill GB, Golbey RB. Malignant mesothelioma of the pleura. Review of 12 patients. Cancer 1982;49:2431-5 11 Schwechheimer K, Butzengeiger M. Brain metastases and malignant fibrous mesothelioma. Case report and review ofthe literature. Acta Neuropathol (Berl) 1983;60:301-4
(Accepted 15 August 1989)
Within 48 h he was apyrexial and hip movements were full and comfortable. He was allowed home on oral antibiotics. Two weeks later he was limping again but well and not in pain. X-rays showed a defect in the capital epiphysis suggesting Perthes-type changes (Figure 1). Antibiotics were continued. The limp became worse and clinically it was difficult to be certain whether the hip was the culprit because he had now developed swelling and warmth in the right ankle. X-rays suggested a lytic area in the medial side of the talus. A week later it was obvious (Figure 1). The erythrocyte sedimentation rate was 48 mm/h. Because of the clinical uncertainty as to which joint was at fault both were explored. The hip was entered through a lateral approach. There were no signs of inflammation. The femoral head was slightly flattened and thought to be compatible with a Perthes-like disorder. A core biopsy was taken and the wound closed. The ankle was explored tbrough a postero-medial incision. There was thin turbid fluid in this joint. A core oftalus was removed. This allowed access to a cavity with release of yellow pus and fibrin. Aftr ettage the wound was closed. Histology of the hip specimen showed a central area of cystic degeneration with cavities lined with proliferating benign fibrous tissue. Bacteriological exaination was negative. The ankle specimen dmonstrated histological features of an abscess. Bacteriological mination showed Gram negative coccobacilli and Haemophilus influenzae type b ide was demonsrated by counter immuno poly electrophoresis. Culture was unsuccessful. The child was rested in a spica cast for 2 weeks and given ampicillin for 6 weeks. He made a rapid and full clinical recovery. X-rays of the ankle and hip taken 3% years
0141-0768/90/ 070487-02/S02.00/0 @ 1990 The Royal Society of Medicine
468
Journal of the Royal Society of Medicine Volume 83 July 1990
*~X}BaNe=i:~63;.l|*~ ~ ._I . ,: . . '
..
:
.0.
... s~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~......
...
..
Figure 1. Left, case 1: radiograph ofleft hip showing a defect in fernoral head. Right, case 1: radiogaph of left anlgk revealing a Iytic lesion in the talus
postoperatively show that the ankle had healed, albeit with slight broadening of the body of the talus. Radiologically the hip showed healing with mild general enlargement of the head compared with the left but no sign of distortion or damage to the growth plate. Case 2 A 14-month-old boy was referred with a 6-day history of a limp. There was mild swelling and reddening ofthe outer side of the right ankle. X-rays were normal. A diagnosis of cellulitis was made and he was treated with erythromycin 125 mg 6-hourly. The swelling and redness initially subsided but his limp continued. Three weeks later the ankle was again swollen and he had developed an equinus deformity. Further X-rays showed an erosion on the lateral side ofthe body ofthe talus (Figure 2). The ankle was explored through an anterolateral approach. The joint contained thin purulent fluid. The anterolateral aspect of the talus was found to have a small sinus which was enlarged to allow access to the abscess. Yellow pus was released and curettage performed. Gram negative coccobacilli were shown on staining. Morphology was ,ennRbiatnt with haemophilus but culture was unsuccessful.
3t| ji~ ~. i .
He was treated with amoxycillin 125 mg 6-hourly for 6 weeks and made a full recovery. When last seen 3 years postoperatively there was no clinical abnormality and X-rays showed the defect to have healed. Discussion Both cases were difficult to diagnose. Preoperative blood tests were unhelpful. Morey and Paterson8 in a series of 135 cases of osteomyelitis, showed that only 26%9 had a raised white cell count. In case 1 the cause ofthe hip lesion remains unclear. Haemophilus should always be considered in childhood bone and joint infection, but may pose diagnostic problems. Its fastidious nature can make isolation difflcult. Culture is likely to be unsuccessful in patients who have had antibiotic treatment before exploration. The importance of antigen detection, by methods such as counter immunoelectrophoresis to confirm diagnosis, is stressed. Of further significance are reports of strains resistant to ampicillin, cefamandole, and even chloramphenicol9'10. We believe these children represent the first reported cases of osteomyelitis of the talus due to Haemophilus influenzae. Treatment was by exploration, curettage and antibiotics.
References 1 Schwartz RH, Ring CM. Acute haematogenous osteomyelitis secondary to haemophilus influenzae. J Paediatric Orthop 1981;1:385-9 2 Dich VA, Nelson JD, Haltalin KC. Osteomyelitis in infants and children. Am J Dis Child 1975;129:1273-8 3 Skevis XA. Primary sub-acute osteomyelitis of the talus. JBone Joint Surg 1984;66-B 4 Phemister DB. Chronic fibrous osteomyelitis 1929. Am Surg
1929,90:756-64 5 Iurlanday LE, Quinn 0, Sills E. Haemophilus influenzae as a cause of Brodie's abscess in an infant. Johns Hopkins Med J
1979;144:15-17 6 Trueta J, Morgan JD. Late results in the treatment of 100 cases of actie haemategenous steitis in childhood. A review of 212 cases. -J Bone Joint Surg 1954;34-B:608-622 7 James T. Acute Osteomyelitis in infancy and early cildhood.
Br J Surg 1953;41:87-91 8 Morey F, Peterson JA. Haematogenous pyogenic osteomyeitis
in childr. Orthop Clin N Am 1975;6:935-51 9 Bergeron MG, Claveau S, Simard P. Limited in vitro activity of mandole against 100 beta lactamase+non beta lactamase
producing Haemophilus influenzae strains. Comparison of moattclam, chloramphenicol, anmpicillin. Antimicrob Agent Chemother 1981;19:101-5 10 Markham RE, Insel RA, Pets itF. Cefamandole failure in ampicillin hasmophilus b pneumonia. South Med J 1981; 74:147-9
Figure2. Case2: radograph of left ankle showing eroson on lateral aspect of the body of the talu
(Accepted 15 Augst 1989)
