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A 70-year-old man underwent Tc-methylene diphosphonate scintigraphy for staging of adenocarcinoma prostate. Scintigraphy revealed diffuse increased tracer uptake in skeletal system along with faint renal visualization, a pattern compatible with metastatic superscan. The scintigraphy also revealed increased radiotracer uptake in the body of the mandible-Lincoln sign or black beard sign. Radiological imaging revealed sclerotic lesions throughout the skeleton including the mandible, confirming widespread skeletal metastases. Lincoln sign is previously described in monostotic Paget disease of the mandible and in contiguous spread of oral malignancy. We describe this pattern in distant metastatic involvement from carcinoma prostate with coexistent superscan pattern.

Between January 1970 and August 1986, 3051 total hip arthroplasties (THAs) were performed at the authors' institution. Forty-seven hips in 43 patients developed deep infection. Using clinical and laboratory criteria, patients were classified into four modes of infection: (1) surgical contamination, which included hips (N = 13) with a suspicious clinical course (e.g., persistent elevation of sedimentation rate, early radiographic signs of loosening) without another identifiable source; (2) hematogenous spread, which included septic hips (N = 19) with a temporally related infectious source and an organism consistent with that source; (3) recurrent sepsis, septic failure in a previously infected hip (N = 13); and finally, (4) infection from direct or contiguous spread, which occurred in an additional two patients. Thus the majority of infections were nonsurgical. Patients with surgically acquired infections tended to present earlier, were less likely to require a Girdlestone procedure for salvage, and were more likely to be reimplanted (p = 0.024). The incidence of surgical infections decreased with the use of improved antiseptic techniques. The incidence of hematogenous infection, however, increased during the time that a cohort was followed. Additionally, in a previously septic hip, septic failure may occur as late as seven years after THA.

Several points can be made from analysis of the published cases of cutaneous mycobacteriosis and those in our series: 1) mycobacterial cutaneous infections are probably more common than is reported-we collected 34 cases over a 10-year period; 2) most patients with cutaneous infections caused by nontuberculous mycobacteria have significant underlying disease; 3) there is a relative lack of classic histologic features in patients with cutaneous mycobacteriosis, and there appear to be diverse forms of clinical presentation; 4) a high index of suspicion is needed in evaluating patients with possible cutaneous mycobacteriosis, and appropriate cultures must be done to establish the diagnosis. In attempting to provide a practical classification of cutaneous mycobacteriosis which includes infection by nontuberculous mycobacteria, we propose the following grouping, which uses simple terms, avoids confusing nomenclature, and incorporates pathophysiologic descriptions and prognostic information: 1) Mycobacteriosis caused by inoculation from an exogenous source. 2) Cutaneous mycobacteriosis caused by spread from an endogenous source. Contiguous spread originates most often with osteomyelitis, but also occurs through autoinoculation of the perirectal, oral, or vaginal skin as organisms are passed or expectorated from pulmonary or genitourinary tuberculosis. 3) Cutaneous mycobacteriosis caused by hematogenous spread. This group includes lupus vulgaris, nodules and abscesses, and acute disease with hemorrhagic pustules. Some mycobacterioses will be difficult to classify when inoculation or hematogenous spread cannot be ruled out. However, the system of classification we have proposed should help clinicians understand and diagnose the diverse forms of cutaneous mycobacterial infections.