Mycobacterium ulcerans Osteomyelitis: A Closer Look at the X-Ray Films

N Engl J Med 1996; 335:1771-1772December 5, 1996

Article

To the Editor:

I have been a reader of the Journal for many years and learn a great deal from it. From the Brief Report on Mycobacterium ulcerans osteomyelitis by Hofer et al. (April 8, 1993, issue),1 I learned for the first time about this new strain of M. ulcerans. However, I believe there are a few errors and omissions in the interpretation of the x-ray films in their Figure 1Figure 1Radiograph Showing Destructive Lesions Suggestive of Chronic Osteomyelitis. (reprinted on page 1771).

Panel A is described as showing “the left femur with sequestra.” In addition, the epiphysis of this tibia is clearly being destroyed. The fact that it is so white indicates that the bone is dying or dead. There are many small radiolucent areas or fissures that split the upper cortex into small pieces. Further evidence of destruction is given by the crescent-shaped layer of new bone about 3 to 4 mm thick that covers this nonviable epiphysis like a crown.

Panel C is described as showing “an area of osteolysis . . . in the right radius.” The authors are wrong. The diseased bone is the ulna, not the radius. Probably the authors noted that this bone is quite large, which makes it look like the radius, but that is due to the enlargement of the shaft of the ulna due to extreme, chronic proliferation of the periosteum.

Panel D is described as showing “the moth-eaten appearance of the first and second phalanges of the right thumb.” Again, the authors got the anatomy wrong. The arrows in the panel point to the first metacarpus and the proximal phalanx, not the first and second phalanges.

Although this article deals chiefly with the biologic identification of species of mycobacteria, one should still be careful and correct in describing the basic anatomical and radiologic findings.2

Lian Bi Hu, M.D.
Petroleum Control Department of Sichuan Province, Chengdu 610212, China

2 References

1
Hofer M, Hirschel B, Kirschner P, et al. Disseminated osteomyelitis from Mycobacterium ulcerans after a snakebite. N Engl J Med 1993;328:1007-1009
Full Text | Web of Science | Medline

2
The value of simple radiographsAJR Am J Roentgenol 1982;139:196-197
Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Dr. Hu is correct. Panel A does show lesions in addition to those described in the legend, as does Panel B. However, given the limited space available, the point was not to describe all the lesions present, but rather to describe a few typical ones. In Panel C the lesion is indeed in the ulna and not in the radius, as the legend states. And in Panel D the arrows point to the first metacarpus and proximal phalanx and not to the first and second phalanges, as the legend says.

We thank Dr. Hu for pointing out these errors to us. We are not radiologists, but we can vouch for the exactitude of our microbiologic data. We should have checked more carefully on the descriptions of the radiographs.

Michael Hofer, M.D.
National Jewish Center for Immunology and Respiratory Medicine, Denver, CO 80206

Bernard Hirschel, M.D.
Hôpital Universitaire, C-1211 Geneva 14, Switzerland