Osteomyelitis Variolosa

Abstract

Modern travel has now brought smallpox within a day's reach of Europe and America. The acute disease should cause little trouble in diagnosis, but manifestations other than the well known rash are often forgotten or indeed unknown. Clearly radiology has no part to play in the diagnosis of acute smallpox, but the radiographic appearance of bone infection by the virus of smallpox is usually typical and diagnostic. It is important to remember that the clinical signs may be slight ; there may be little evidence of smallpox and the patient may even be unaware of any such infection. The purpose of this report is to draw attention to the changes found in osteomyelitis variolosa, and to serve as a reminder that a bone infection which fails to respond to treatment occurring in persons who have recently left a country in which smallpox is endemic may not be pyogenic in origin. The first reference to such a complication was by Bidder in 1 873. Until recently the first and only mention ofthe disease in British literature was that by Neve in 1887. The whole subject was then reviewed in detail by Cockshott and MacGregor in 1958 and 1959. A recent epidemic of smallpox in Nyasaland gave us the opportunity of studying many patients with this condition, and we made a deliberate attempt to assess its frequency and the clinical findings. Usually between 2 and 5 per cent of young children with smallpox will develop osteomyelitis variolosa (Cockshott and MacGregor 1958, Middlemiss 1962). The largest series so far reported comes from Nigeria where thirty-four cases were found during eighteen J. C. DAVIDSON AND P. E. S. PALMER to offer. Malnutrition is prevalent in the Lilongwe district and the state of nutrition of smallpox patients was assessed but no correlation between malnutrition and the incidence of smallpox was found : nevertheless the most severe cases of osteomyelitis occurred in association with anaemia and malnutrition. Because of the high incidence of sickle-cell anaemia and its association with salmonella osteitis in Nigeria, Cockshott and MacGregor AND P. E. S. PALMER THE JOURNAL OF BONE AND JOINT SURGERY (Figs. 7 and 8). Remoulding takes place extremely slowly and may require a year or more

Osteological evidence for smallpox: A possible case from seventeenth century Ontario

“…Very few recorded cases are known for individuals over 15. In Davidson and Palmer's (1963) large sample none were over 15 years and 93% were under 10 years of age.…”

“…Nevertheless, there are cases reported in the literature of individuals having ages of onset of up to 21 years (cited in Cockshott and MacGregor, 1958). The study by Davidson and Palmer (1963) of an epidemic with an extremely high incidence of osteomyelitis variolosa provides information on the age distribution of bone involvement. Of the 82 cases of osteomyelitis, 805% were under 6 years of age and none was over 14.…”

“…Viral diseases, e.g., measles, smallpox, and influenza, had severe effects on "virgin soil populations" in the Pacific, Australia, and the Americas, but in the palaeopathological literature there is almost no reference to skeletal changes as a consequence of viral infections (although see Ortner and Putschar, 1981227). However, in the radiological literature (Edeiken, 1981:801-803; Resnick and Niwayama, 1981:2220-2223, it is well recognized that very specific bone changes (osteomyelitis variolosa) result from smallpox in up to 20% of cases (Davidson and Palmer, 1963). The fact that smallpox has an effect on bones has been recognized since at least 1568 (by Pare; see Creighton, 1965469).…”

Osteomyelitis variolosa

“…80% of these involved the elbow, 20% the hands and wrists, and 18% the ankles and feet [2,3]. Variolar involvement of the knees, hips, shoulders, skull, spine, thorax, or pelvis was rare [2][3][4][5]. A review of studies into osteomyelitis variolosa over the past 50 years shows a predominant involvement of the elbow joint.…”

A history of osteomyelitis from the Journal of Bone and Joint Surgery

“…28 Bone infection can be late, silent and often unexpected. It is usually symmetrical and almost always multiple.…”