To The Editor:

We read with interest the article by Ohtera et al.(1) but we do not agree that skeletal tuberculosis with spinal involvement is rare in children. Tuli, et al. reported osseous tuberculosis associated with spinal tuberculosis in 12%, Friedman in 15.6%(2) and Martinez SF et al.(3) in 50% of the patients(2).

Skeletal tuberculosis commonly occurs due to hematogeneous spread from primary foci (lung, urogenital organ, glands, gastrointestinal tract) rather than from spine(2).

We also do not agree that pulmonary lesions are rarely associated with tuberculous osteomyelitis. Approximately 50% of patients with osseous tuberculosis may have pulmonary involvement(3).

We do agree that skeletal tuberculosis may not have pathognomonic clinical or radiological features. But clinically constitutional features, absence of history of trauma, insidious course, relatively less prominent inflammatory features (redness, tenderness, raised local temperature), absence of ear/throat infection and serous discharge are more suggestive of tuberculous rather than pyogenic osteomyelitis. Radiologically minimal periosteal reaction in long bones, osteopenia, relative absence of sequestrum and slow destruction of joints are more suggestive of tuberculosis (2).

We also do not agree with the author that the incidence of bone tuberculosis is low in children. Actually the cited reference by the authors states that solitary cystic tuberculosis is uncommon in children. Common forms of tuberculosis in children may have irregular multiple lytic lesions, erosion or rarefaction of the epiphysis/metaphysis, sclerosis and thickening of small bones of hand and feet (spina ventosa)(3).

The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

References:

1. Ohtera K, Kura H, Yamashita T, Ohyama N. Long-term follow-up of tuberculosis of the proximal part of the tibia involving the growth plate. A case report. J Bone Joint Surg Am. 2007;2:399-403.

2. Tuli SM. Clinical Features. In: Tuli SM (ed.) Tuberculosis of skeletal system; 2nd ed. New Delhi, Jaypee Brothers,1997:177-182.

3. Martinez SF, Canale ST. Tuberculosis and other unusual infections. In: Canale S T (ed). Campbell’s operative Orthopaedics; 10th ed;Philadelphia, Mosby,2003:713-729.