A review of 63 Nigerian children with salmonella osteomyelitis showed that in all but 2 of them the disease occurred in association with HbS either in the homozygous state (57 patients) or in heterozygous combination with other haemoglobins (4 patients). Osteomyelitis was most prevalent during the first 2 years of life, and boys were more often affected than girls. In the majority, multiple sites were involved and lesions were usually bilateral and often symmetrical. Salmonella sp. was isolated from blood or pus, or both, in all patients. In some patients additional pathogens were also isolated from blood or pus. Clinical presentation was variable. In many patients the illness was slight and they were treated entirely as outpatients, but serious toxaemia, severe bone lesions with pathological fractures, and chronic suppuration occurred in others. Most patients responded well to chloramphenicol and conservative management. There were 4 deaths. 17 patients recovered with sequelae. It is suggested that the peculiar susceptibility of patients with sickle cell anaemia to salmonella osteomyelitis is due to spread of salmonella from the intestine facilitated by devitalisation of gut caused by intravascular sickling, and that infarcts in bone became infected either by transient bacteraemia or by activation of dormant foci of salmonella in bone marrow when tissues are devitalised. It is further suggested that immunological defects in sicklers may impair host response to infection, while haemolysis and hepatic dysfunction, both of which occur in sickle cell anaemia, favour propagation of salmonellae.
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