Multiple bone lesions caused by Avian-Battey mycobacteria. Report of a case.

A boy aged fourteen years presented in May 1963 with a left axillary abscess. This had developed seven weeks before, four days after his left hand had been bitten by a pet rabbit, which was kept in an enclosure with hens. The abscess was incised but the pus was not cultared. In December 1963 he was seen by a paediatrician because the abscess was still draining, and there was a complaint of backache. It was noted that he had been given B.C.G. at school in December 1962 because of a negative Mantoux test. Radiographs of the lumbar spine showed no abnormality. After a period of rest in bed the abscess healed, the backache settled, and he appeared to be in good health. In April 1965 he returned with a stiff, painful back. On admission, radiographs showed destructive changes affecting the third and fourth lumbar vertebrae (Fig. 1) and the right sacro-iliac joint. He was given streptomycin and sodium aminosalicylate and nursed on a plaster bed. In July, through a left lateral approach a large abscess was evacuated, necrotic bone excised, and an iliac bone graft inserted. Culture yielded Mycobacterium tuberculosis partially sensitive to streptomycin, viomycin and cycloserine, but resistant to sodium aminosalicylate and isoniazid. In April 1966 he went home wearing a posterior spinal support and remained well until December 1966 when he developed swellings of the scalp, lower jaw at its angle, and right clavicle. Radiographs showed lesions in all these sites (Figs. 2 to 4). Treatment was by a further course of streptomycin, and surgical excision. Four months later the lesions had all healed. During 1968 he was apparently in good health, but in January 1969 cold abscesses developed in the right iliac fossa and in the left lumbar region. After starting streptomycin and pyrazinamide therapy, the lumbar spine was explored, affected bone removed and a cancellous bone graft inserted from the second to the fourth lumbar vertebrae. After operation the blood uric acid rose to 12 milligrams per cent, presumably from the pyrazinamide; treatment with alka-butazolidine and allopurinol was given. The organism now isolated by Dr J. B. Selkon of the Public Health Laboratory, Newcastle upon Tyne, was found to be an Avian type of Mycobacterium. Dr J. Marks of the Tuberculosis Reference Library identified the strain as Battey Serotype IV, which was confirmed by Dr W. B. Schaefer of Denver, Colorado, U.S.A. Sensitivity was now limited to cycloserine, and partially to clofazimine (Lamprene). He was receiving cycloserine, ethionamide and rifampicin (Rimactane), and was apparently well until October 1969 when a cold abscess developed in the right groin. A radiograph (Fig. 5) showed a lesion of the right pubic bone, which was curetted. Histological section (Figs. 6 and 7) showed typical tuberculous granulation tissue. In April 1970 he had an acute respiratory infection and an abscess appeared on the right chest wall. Initially haemophilus influenzae was grown from the sputum, but a little later it grew the acid-fast organism. Radiographs showed lung involvement and lesions of the bodies of the sixth, seventh and eighth thoracic vertebrae. It was noticed incidentally that the right clavicular lesion had healed. Treatment was by clofazimine (Lamprene), to which the organism was partially sensitive, and blood transfusions. By December 1970 the sputum was negative but the bone lesion had not improved. In February 1971 costo-transversectomy was done, necrotic bone removed and an iliac graft inserted. After the previous operations the patient’s general condition had quickly improved, but this time recovery was slow and the wound did not heal completely. The organism was now resistant to cycloserine, which was stopped. There was partial sensitivity to gentamycin, which was given in 80-milligram doses daily.