This is a 2-1/2 month old female whose mother 
brought her to the ED with a chief complaint of refusing 
to use her right arm since she had awoken that 
morning.  Also, the child had been noted to be warm to 
touch for one day, but her temperature was not 
checked.  Mother had also observed that the child's 
right wrist appeared slightly swollen and red for one 
day.  The patient had spent the previous day in the care 
of her aunt.  No history of trauma was given.  Four days 
prior, she had a one day episode of fever occurring 
approximately 24 hours after receiving her first set of 
immunizations.  Her oral intake was good.  Urinary 
output was normal.  No vomiting or diarrhea.  She had 
a 2-3 day history of clear nasal drainage.
     PMH - She was a full term vaginal delivery without 
complications.  Birth weight 3.5 kg.  Prenatal history 
was significant for maternal syphilis for which she was 
treated.
     Exam showed a healthy appearing female infant.  
The exam was normal except for a seemingly tender 
right wrist (cries with palpitation).  No deformity was 
noted.  No tenderness in right upper arm.  No skin 
abnormalities.  Radiographs of the wrist were obtained.

View wrist radiographs.


     Question:  This radiograph shows?  (1) lytic lesions, 
(2) artifacts, (3) surgically induced lesions from internal 
fixation devices, (4) pathologic fracture, (5) normal bone
     Question:  What do you think is the cause of these 
findings?  (1) fibrous dysplasia, (2) enchondroma, (3) 
giant cell tumor, (4) lymphoma, (5) congenital syphilis, 
(6) osteomyelitis

     A skeletal survey is obtained.

View shoulder radiographs.


View elbow radiographs


View lower extremity radiographs


     There is soft tissue swelling of the right wrist with 
destructive lytic changes of the metaphyses of the right 
radius and ulna.  There is periosteal reaction of the 
distal ulna and possibly the distal radius.
     The shoulder radiographs are probably normal.
     The elbow radiographs show some mild periosteal
reaction of the humerus which is difficult to appreciate.
     The lower extremities show periosteal reaction of the 
femurs and tibiae.  There are destructive metaphyseal 
abnormalities of the medial aspects of the tibiae.  These 
findings are compatible with the Wimberger sign of 
congenital syphilis.  There is scalloping and destruction 
of the upper medial tibial metaphyses bilaterally with 
diaphyseal periosteal new bone deposition.  There is 
also some destruction of the left fibula proximally with 
periosteal reaction.
     Radiographs of the skull (not shown here) showed 
no intracranial calcifications.  The sella turcica was 
normal.  Radiographs of the spine, ribs, chest and 
abdomen were normal.

     Discussion:  One must consider several etiologies of 
cystic/lytic lesions on pediatric radiographs; several 
which predispose to pathologic fractures.  The 
differential diagnosis includes: simple bone cyst (lucent 
lesion, sharply demarcated, presents as pathologic 
fracture), fibrous dysplasia (radiolucent area 
in long bones, beginning in early childhood), giant cell 
tumor (eccentric lucent lesion in metaphysis of long 
bones, not involving the joint, 20% malignant), 
enchondroma (benign, lucent, well-demarcated near 
epiphysis in children and adults), chondroblastoma 
(rare, benign eccentric oval lucency in epiphysis), 
lymphoma, infection (fungal infection, cystic 
osteomyelitis), angiomatous lesion (lucent metaphyseal 
lesion, rare congenital malformation) and syphilis of the 
bone.
     Syphilis of the bone is rare.  There are two forms.  
The infantile form involves the metaphyseal regions of 
multiple bones.  The juvenile form is diffuse or localized 
with subperiosteal thickening.  This case most likely 
represents a syphilitic lesion because of the location of 
the lucent area and the mother's history of syphilis 
during pregnancy.

     The etiology of syphilis is the spirochete Treponema 
pallidum.  Syphilis is described in three stages.  Stage 
one is the manifestation of the painless chancre usually 
found on the genitalia.  If untreated, within a few 
months, syphilis develops into stage two in which the 
patient develops a maculopapular rash which is 
generalized and often involving the palms and soles.  
During stage two the patient often has flu-like 
symptoms including malaise, headache, 
lymphadenopathy, fever, and arthralgias.  These 
symptoms of stage two may wax and wane over a 
period of many years.  The tertiary stage manifests 
years later as neurosyphilis, aortitis, and gummatous 
changes of the skin, bone, and viscera.  Transmission 
of the spirochete is via sexual contact or 
transplacentally.  The risk of transplacental 
transmission is nearly 100% during the second stage of 
syphilis and slowly decreases thereafter.  Fetuses 
infected with syphilis may develop hydrops fetalis and 
may be premature or stillborn.  Congenital syphilis may 
present in a variety of ways.  Common features include 
rhinitis, the saddle bridge nose, and Hutchison teeth.  
Other clinical findings include hepatosplenomegaly, 
lymphadenopathy, neurocutaneous lesions, 
osteochondritis, hemolytic anemia, and 
thrombocytopenia.  Treatment for congenital syphilis is 
10-14 days of IV penicillin G.  If more than one day of 
therapy is missed the entire course must be restarted.

References
     1.  Syphilis, Section 3.  In:  Peter G, Hall CB, Halsey 
NA, et al (eds).  1997 Red Book:  Report of the 
Committee on Infectious Diseases, 24th edition. 
American Academy of Pediatrics, Elk Grove Village, IL, 
1997, pp509-514.
     2.  Bubbly Lesions of Bone.  In:  Eisenberg RL.  
Clinical Imaging:  An Atlas of Differential Diagnosis.  
Aspen Publishers, Aspen, CO, 1998, pp508-609.
     3.  Azimi P.  Sprichetal Infections, Chapter 201.  In:  
Nelson WE, Behrman R, Kliegman R, et al (eds).  
Textbook of Pediatrics, 15th edition.  WB Saunders Co, 
Philadelphia, PA, 1996, pp853-856.