Letter to the Editor: Spina Ventosa Involving Bilateral Proximal Phalanx in a 6-year-old Girl: A Multifocal Tuberculosis

Dear Editor-in-Chief, Having read the article “Tuberculous Dactylitis (Bilateral Spina Ventosa) of Proximal Phalanx in a 6-Year-Old Girl: A Case Report” by Tonk et al. published in Journal of Orthopaedic Case Reports 2025 December,15(12):168-171 with keen interest, I want to congratulate the authors for diagnosing tubercular dactylitis in a 6-year-old girl with complaints of painful swelling in her right middle finger and left ring finger for 8 months, and managing successfully with anti-tubercular therapy for 12 months 1. I wish to present some additional information regarding this case that I believe is worth mentioning and useful for the readers. The tuberculous (TB) dactylitis of the proximal phalanx of the middle finger of one hand and the ring finger of another hand, as in this case report, represents the rare pattern and manifestation of multifocal tuberculosis, with only a few case reports and series reported 2,3,4,5. This bilateral involvement represents the multifocal genre of tuberculosis, which is defined as “the involvement of two or more non-contiguous extrapulmonary sites, with or without associated pulmonary TB” 6. It accounts for 5–10% of all osteoarticular cases 7. Tubercular dactylitis in children becomes uncommon after 5 years and scarce after 10 years of age,with 85% of cases in children younger than 6 years 3. The incidence of tubercular dactylitis among children has been reported to be 0.65% by Hardy and Hartmann 2 and 6.9% by Herzfeld and Tod, respectively 8. The bones of the hands are more frequently affected than those of the feet 2. The proximal phalanx of the index and middle fingers is the most common site of the tubercular dactylitis 2. Based on the clinicopathological presentation and radiological appearances, the left hand is supposed to be at stage 2 and the right hand at stage 3, according to the three-stage classification for tubercular dactylitis proposed by Agarwal et al. 5. A few differential diagnoses, which need to be added to the list, include syphilitic dactylitis and enchondroma 3,5. At last, the statement “Fieilchenfeld in 1896 described TB dactylitis roentgen-graphically in children” mentioning the reference to Pearlman et al. is worth noting to draw serious attention here 1. and Warren were the first to mention Feilchenfeld in their article and quoted “It is of historic interest that Feilchenfeld 3, in May of 1896, described 9, and gave the reference of Steindler A. Reconstruction Surgery of the Upper Extremity, p. 197. New York, 1923 New York; London: D. Appleton and Co 10. However, after reading thoroughly the primary source i.e “‘Tuberculous Dactylitis (Spina Ventosa)’, nor in the whole book, although Renken was mentioned on the same page 197 as “The disease has been known for many years and was identified as tuberculosis by Renken in 1886 10.” Ever since its first inception by Pearlman et al., Feilchenfeld has been quoted subsequently by many authors in their articles, some mentioning Pearlman et al. and others mentioning some other secondary sources. I believe this needs to be addressed here to highlight the importance of cross-checking all the references and going back to the original primary sources. To sum-up, this case report represents the rare manifestation of the multifocal genre of tuberculosis with an uncommon pattern. The clinical presentation, age, site, and characteristics of infection in the present index case corresponded with the available literature.