FAMILIAL OUTBREAK OF STAPHYLOCOCCAL INFECTION OF BONE AND JOINT
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727 preference for one or other treatment may be determined by this, as. much as by the small differences between the therapeutic effects. , We wish to thank Dr. E. Arnold Carmichael, of the National Hospital, Queen Square, for access to the cases treated and for invaluable advice and criticism ; Dr. Kurt Hartmann, of Zurich, for advice ; and Pharmaceutical Laboratories Geigy and Messrs. H. R. Napp Ltd. for supplying generous amounts of drugs. The investigation was undertaken on behalf of the Medical Research Council. REFERENCES Bickel, G., Dubois, J. P. (1947) Rev. méd. Suisse rom. 67, 708. Domenjoz, R. (1946) Schweiz. med. Wschr. 76, 1282. Grünthal, E. (1946) Ibid, p. 1286. Hartmann, K. (1946) Ibid, p. 1289. — (1947) Therap. Umschau, 3, part II. Heymans, C., De Vleeschhouwer, G. R. (1947) Arch. int. Pharma- codyn. 75, 307. FAMILIAL OUTBREAK OF STAPHYLOCOCCAL INFECTION OF BONE AND JOINT M. H. M. HARRISON M.B. Leeds LATE HOUSE-SURGEON, WINGFIELD-MORRIS ORTHOPÆDIC HOSPITAL, OXFORD STAPHYLOCOCCAL infections in a community are sufficiently commonplace to pass without comment, but this familial outbreak is reported because of two unusual features. First, in a family of seven children there were, besides multiple examples of cutaneous infections, three cases of acute infection of bone or of joint. Two children developed acute suppurative arthritis and the third an acute osteomyelitis, and all three patients were in hospital at one time. Secondly, the strain of the causal staphylococcus was found to be the same in each of these major lesions, and the same organism was also recovered from other members of the same family. The family of nine live under rather crowded conditions in an Oxfordshire village. The following is a summary of the family and their illnesses : Leslie.-Aged 1 year, had impetigo in January, 1947, which cleared under local penicillin therapy. Staphylococcus (mreus (phage type 29/31) was recovered from his nasal’ mucosa in April, 1947. Christopher.-Aged 3 years, had no known lesion. Erf2est.-Aged 4 years, had impetigo in December, 1946, which cleared under local penicillin therapy. He had a boil over a medial malleolus in March, 1947, and acute septic arthritis of the right knee in April, 1947. Staph. aureus (phage type 29/31) was recovered from the knee-joint and blood-culture. A staphylococcus recovered from his nasal mucosa was not typable. Brian.—Aged 7 years, had impetigo and boils on his heels in January, 1947, which cleared under local penicillin therapy. He had acute osteomyelitis of left pubis and right radius in April, 1947. Staph. aureus (phage type 29/31) was recovered from blood-culture: Eric.-Aged 11 years, had no known lesion. Mavis.—Aged 12 years, had suppurative arthritis of the right hip in February, 1947. Staphylococcus (phage type 29/31) was recovered from blood-culture and hip-joint, and phage type 47 from nasal mucosa and skin swabs. Beryl.-Aged 14, had no known lesion, but Staph. aureus (phage type 29/31) was recovered from her nasal mucosa. Mother.—Aged 34, had no known lesion. An untypable staphylococcus was recovered from skin swabs. Father.—Aged 37, had a chronic discharging ear, but no staphylococci were recovered from the discharge. TREATMENT AND RESULTS The three cases of bone and joint involvement were all under the care of Dr. J. Trueta in the Wingfield- Morris Orthopaedic Hospital, and were all treated by a similar method. (1) Penicillin was administered by a continuous intra- muscular drip delivering 400,000 units a day as the initial dose, decreasing to 200,000 units a day as progress became satisfactory. In addition, one of the children was given sulphadiazine 14 g. by mouth. (2) The affected part was immobilised. Ernest, with acute septic arthritis of the knee, was placed in a posterior portion of a split plaster hip spica. Brian, with acute osteomyelitis of the pubis and radius, was placed on a Robert Jones double abduction frame, and a plaster back slab was applied to the affected upper limb. Mavis, with acute septic arthritis of the hip, was placed on a Robert Jones double abduction frame. (3) When, on the child’s admission to hospital, pus was considered to be already present, the lesion was explored with a view to removing it. In ’Ernest’s case, diagnostic aspiration of the knee-joint having yielded pus, under. general anaesthesia and a tourniquet an arthrotomy was performed, the pus and fibrin were removed, and the joint was closed. On three subsequent occasions he underwent aspiration of the joint and instillation of penicillin. In Mavis’s case, 35 ml. of pus was removed by aspiration from the hip-joint and replaced with penicillin. (4) When on admission, however, the physical signs and response to treatment suggested that the lesion had not yet progressed to suppuration, conservative measures were found t7o be adequate. Thus Brian, who had the double bone lesion, recovered completely with penicillin treatment alone. The results were as follows. Nine months later Ernest’s knee was cool and dry, with a full range of active movement, and Brian had full function in his arm and pelvic joints with no residual tenderness. Mavis’s arthritis of the hip flared up again five weeks after admission. Eleven months later she has a good gait and function, but radiography suggests some reduction of the joint space in the affected hip, and there is half an inch of real shortening and restriction of full flexion of that joint. DISCUSSION In all cases a blood-culture was made before treatment was begun, and any pus recovered from the cases was sent for bacteriological examination. The organisms recovered from all these children were reported as Staph. aureus, and all were found to have the same cultural characteristics. A further attempt was made to establish their identity by bacteriophage typing 1 and they were all reported as phage type 29/31. About half of all pathogenic staphylococci cannot be phage typed at all, but of the remainder some fifty different strains can be differentiated by their reactions. The fact, therefore, that these five strains were all of the same phage type seems a reasonable indication that they had originated from a common source. Despite careful investigation of the home environment no direct source of the organism could be traced, but the close living conditions were almost certainly respon- sible for the multiplicity and persistence of the infection. Acute pyogenic infections of bone or joint, though by no means uncommon, are not an everyday occurrence, and the surprise which greeted the arrival in the ward of the second case from the same family grew almost to incredulity when the third child appeared. I have not been able to find any comparable published report. SUMMARY In a family of seven children described, there were, besides multiple examples of cutaneous infections, three cases of acute infection of bone or of joint. The infecting organism was a Staph. aureus, demonstrated by bacterio- phage typing to be the same in all three cases and the same as that recovered from the nasal mucosæ of two of the remaining four children of the family. I wish to thank Dr. J. Trueta and Mr. J. C. Scott for their kind permission to publish these cases; Dr. J. R. O’Brien for the bacteriological examinations; and Dr. V. D. Allison, of the Staphylococcal Reference Laboratory, Colindale, London, for bacteriophage typing all the organisms. 1. Wilson, G. S., Atkinson, J. D. Lancet, 1945, i, 647.
Transcript of FAMILIAL OUTBREAK OF STAPHYLOCOCCAL INFECTION OF BONE AND JOINT
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preference for one or other treatment may be determinedby this, as. much as by the small differences betweenthe therapeutic effects.
,
We wish to thank Dr. E. Arnold Carmichael, of the NationalHospital, Queen Square, for access to the cases treated andfor invaluable advice and criticism ; Dr. Kurt Hartmann,of Zurich, for advice ; and Pharmaceutical Laboratories
Geigy and Messrs. H. R. Napp Ltd. for supplying generousamounts of drugs. The investigation was undertaken onbehalf of the Medical Research Council.
REFERENCES
Bickel, G., Dubois, J. P. (1947) Rev. méd. Suisse rom. 67, 708.Domenjoz, R. (1946) Schweiz. med. Wschr. 76, 1282.Grünthal, E. (1946) Ibid, p. 1286.Hartmann, K. (1946) Ibid, p. 1289.
— (1947) Therap. Umschau, 3, part II.Heymans, C., De Vleeschhouwer, G. R. (1947) Arch. int. Pharma-
codyn. 75, 307.
FAMILIAL OUTBREAK OF
STAPHYLOCOCCAL INFECTION OF BONEAND JOINT
M. H. M. HARRISONM.B. Leeds
LATE HOUSE-SURGEON, WINGFIELD-MORRIS ORTHOPÆDIC
HOSPITAL, OXFORD
STAPHYLOCOCCAL infections in a community are
sufficiently commonplace to pass without comment, butthis familial outbreak is reported because of two unusualfeatures. First, in a family of seven children therewere, besides multiple examples of cutaneous infections,three cases of acute infection of bone or of joint. Twochildren developed acute suppurative arthritis and thethird an acute osteomyelitis, and all three patientswere in hospital at one time. Secondly, the strain ofthe causal staphylococcus was found to be the same ineach of these major lesions, and the same organism wasalso recovered from other members of the same family.The family of nine live under rather crowded conditions
in an Oxfordshire village. The following is a summaryof the family and their illnesses :Leslie.-Aged 1 year, had impetigo in January, 1947,
which cleared under local penicillin therapy. Staphylococcus(mreus (phage type 29/31) was recovered from his nasal’mucosa in April, 1947.Christopher.-Aged 3 years, had no known lesion.Erf2est.-Aged 4 years, had impetigo in December, 1946,
which cleared under local penicillin therapy. He had a boilover a medial malleolus in March, 1947, and acute septicarthritis of the right knee in April, 1947. Staph. aureus
(phage type 29/31) was recovered from the knee-joint andblood-culture. A staphylococcus recovered from his nasalmucosa was not typable.
Brian.—Aged 7 years, had impetigo and boils on his heelsin January, 1947, which cleared under local penicillin therapy.He had acute osteomyelitis of left pubis and right radiusin April, 1947. Staph. aureus (phage type 29/31) was
recovered from blood-culture:
Eric.-Aged 11 years, had no known lesion.Mavis.—Aged 12 years, had suppurative arthritis of the
right hip in February, 1947. Staphylococcus (phage type29/31) was recovered from blood-culture and hip-joint, andphage type 47 from nasal mucosa and skin swabs.Beryl.-Aged 14, had no known lesion, but Staph. aureus
(phage type 29/31) was recovered from her nasal mucosa.Mother.—Aged 34, had no known lesion. An untypable
staphylococcus was recovered from skin swabs.Father.—Aged 37, had a chronic discharging ear, but no
staphylococci were recovered from the discharge.
TREATMENT AND RESULTS
The three cases of bone and joint involvement wereall under the care of Dr. J. Trueta in the Wingfield-Morris Orthopaedic Hospital, and were all treated by asimilar method.
(1) Penicillin was administered by a continuous intra-muscular drip delivering 400,000 units a day as the initial
dose, decreasing to 200,000 units a day as progress becamesatisfactory. In addition, one of the children was givensulphadiazine 14 g. by mouth.
(2) The affected part was immobilised. Ernest, with acuteseptic arthritis of the knee, was placed in a posterior portion of asplit plaster hip spica. Brian, with acute osteomyelitis ofthe pubis and radius, was placed on a Robert Jones doubleabduction frame, and a plaster back slab was applied tothe affected upper limb. Mavis, with acute septic arthritisof the hip, was placed on a Robert Jones double abductionframe.
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(3) When, on the child’s admission to hospital, pus wasconsidered to be already present, the lesion was exploredwith a view to removing it. In ’Ernest’s case, diagnosticaspiration of the knee-joint having yielded pus, under. generalanaesthesia and a tourniquet an arthrotomy was performed,the pus and fibrin were removed, and the joint was closed.On three subsequent occasions he underwent aspiration ofthe joint and instillation of penicillin. In Mavis’s case,35 ml. of pus was removed by aspiration from the hip-jointand replaced with penicillin.
(4) When on admission, however, the physical signs andresponse to treatment suggested that the lesion had notyet progressed to suppuration, conservative measures werefound t7o be adequate. Thus Brian, who had the double bonelesion, recovered completely with penicillin treatment alone.The results were as follows. Nine months later Ernest’s
knee was cool and dry, with a full range of activemovement, and Brian had full function in his arm andpelvic joints with no residual tenderness. Mavis’sarthritis of the hip flared up again five weeks afteradmission. Eleven months later she has a good gaitand function, but radiography suggests some reductionof the joint space in the affected hip, and there is halfan inch of real shortening and restriction of full flexionof that joint.
DISCUSSION
In all cases a blood-culture was made before treatmentwas begun, and any pus recovered from the cases wassent for bacteriological examination. The organismsrecovered from all these children were reported as
Staph. aureus, and all were found to have the samecultural characteristics. A further attempt was madeto establish their identity by bacteriophage typing 1and they were all reported as phage type 29/31. Abouthalf of all pathogenic staphylococci cannot be phagetyped at all, but of the remainder some fifty differentstrains can be differentiated by their reactions. Thefact, therefore, that these five strains were all of thesame phage type seems a reasonable indication that
they had originated from a common source.Despite careful investigation of the home environment
no direct source of the organism could be traced, butthe close living conditions were almost certainly respon-sible for the multiplicity and persistence of the infection.Acute pyogenic infections of bone or joint, though by
no means uncommon, are not an everyday occurrence,and the surprise which greeted the arrival in the wardof the second case from the same family grew almostto incredulity when the third child appeared. I havenot been able to find any comparable published report.
SUMMARY
In a family of seven children described, there were,besides multiple examples of cutaneous infections, threecases of acute infection of bone or of joint. The infectingorganism was a Staph. aureus, demonstrated by bacterio-phage typing to be the same in all three cases and thesame as that recovered from the nasal mucosæ of twoof the remaining four children of the family.
I wish to thank Dr. J. Trueta and Mr. J. C. Scott fortheir kind permission to publish these cases; Dr. J. R.O’Brien for the bacteriological examinations; and Dr.V. D. Allison, of the Staphylococcal Reference Laboratory,Colindale, London, for bacteriophage typing all the organisms.
1. Wilson, G. S., Atkinson, J. D. Lancet, 1945, i, 647.
