Osteomyelitis of the mandible leading to pathological fracture in a tuberculosis patient: A case report and review of literature
Rajeev M. Gadgil, Ajay R. Bhoosreddy, Bipin R. Upadhyay Department of Oral Medicine and Radiology, MGV’S KBH Dental College and Hospital, Panchavati, Nashik, Maharashtra, India
CASE REPORT CASE ABSTRACT
Osteomyelitis is an inflammatory condition of the bone, beginning in the medullary cavity and haversian systems and extending to involve the periosteum of the affected area. Although other etiological factors, such as traumatic injuries, radiation, and certain chemical substances, among others, may also produce inflammation of the medullary space, the term “osteomyelitis” is mostly used in the medical literature to describe a true infection of the bone induced by pyogenic microorganisms. Tuberculous osteomyelitis is an uncommon disease entity. Here, we present a case of osteomyelitis of mandible leading to pathological fracture of mandible, in which pulmonary tuberculosis involvement was detected only subsequently. The oral physicians thus play a crucialKey words: role in recognizing high-risk patients and initiating prompt isolation and evaluation.
Mandible, osteomyelitis, pathological fracture, tuberculosis Introduction Pulmonary tuberculosis remains the most common form of the disease, but any organ system can be Osteomyelitis of the jaws is a disease that has affected involved.[2] Skeletal tuberculosis accounts for 6.6% of mankind since prehistory. Today, medical and dental extra-pulmonary cases thought to occur secondary specialists continue to treat osteomyelitis of various to lympho-hematogenous dissemination to the bone types with the recognition that osteomyelitis of the jaws at the time of initial pulmonary infection with local differs significantly from osteomyelitis of the long bones reactivation at a later date. Tuberculous osteomyelitis and at other skeletal sites. These differences are due to of the jaws constitutes less than 2% of it; therefore, a different group of pathogens, the presence of teeth, a involvement of head and neck region is rare.[2] different blood vessel density, an oral environment, a thin mucosa as opposed to skin, one jaw that is mobile Case Report and the other that is fixed, the more frequent presence of foreign bodies, and the commonality of head and A 38-year-old, married male patient, a public transport neck radiotherapy.[1] driver by occupation, reported to the department of oral medicine and radiology with a chief complaint Tuberculosis (TB) is a chronic infectious, granulomatous of pain in the lower right back region of the jaw since disease caused in humans by Mycobacterium 4 months. Swelling was present in the same region tuberculosis and less frequently by Mycobacterium since 15 days and pus discharge through the skin since bovis.[2] The disease infects an estimated 20%-43% of 8 days. The pain was initially intense and gradually the world’s population. Mycobacterium avium, bovis, became dull aching in nature, associated with fever kanasasii, and scrofulaceum have also been implicated.[3] followed by exfoliation of the tooth 2 months back, leading to deranged occlusion. A swelling was noticed in the same region 15 days back which pointed out Access this article online extraorally to drain in the right submandibular region Quick Response Code: Website: associated with severe discomfort during eating. www.atmph.org Patient had limping gait because of gangrene of the left foot, which was operated 6 years back for which DOI: 10.4103/1755-6783.102071 patient was hospitalized for 15 days, but the gangrene is still present. Patient is a chronic alcoholic and consumes about 300 ml-500 ml of alcohol daily since
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Dr. Rajeev M. Gadgil, 101, Professor, Department of Oral Medicine and Radiology, M.G.V.’s K.B.H. Dental College and Hospital, Panchavati, Nashik-422003, Maharashtra,Annals of Tropical India. E-mail: Medicine [email protected] and Public Health | Jul-Aug 2012 | Vol 5 | Issue 4 383 Gadgil, et al.: Osteomyelitis of the Mandible leading to pathological fracture in a Tuberculosis patient last 15 years. Patient also had a habit of cigarette Cross-sectional mandibular occlusal view smoking; 5-6 cigarettes daily since 5-6 years. Patient Lateral oblique view for Rt. body of the mandible has had about 12-15 kg weight loss with evening rise OPG in temperature, sometimes with chills since 4 months. PA chest view (screening for tuberculosis) Patient looked pale and weak. All hematological tests were non-contributory, except Patient had a noticeable asymmetry of the face, and an for mild anemia. extra oral swelling seen in the right side of the mandible, approximately 5 cm × 4 cm in size, with a limited mouth Radiological findings opening and a scar seen on the right submandibular region On IOPA with 45 47 region: A diffuse radiolucency associated with an extraoral draining sinus. The skin in the crown of 47, involving the enamel and surrounding the sinus is puckered and erythematous and dentin, suggestive of caries and ill-defined periapical slight pus-like discharge evident from the sinus [Figure 1]. radiolucency seen with 45 47 [Figure 3]. On an intra-oral examination, a tooth is missing in the mandibular right posterior region (46) as suggested by On cross-sectional occlusal view of the mandible: the patient in the history. A deranged occlusion and Overriding of lower border of the mandible with 45 47 badly carious 47 with tenderness to percussion with 45 region, suggesting pathological fracture [Figure 4]. and 47. Crepitus between 45 and 47 felt with slight abnormal mobility of the mandibular right anterior On lateral oblique view for the right body of the fragment. Intraoral exposed bone in the lower right mandible and OPG: Diffuse ill-defined radiolucency buccal vestibule was also seen [Figure 2]. with interspersed radio-opacity seen extending from mesial of 44 to distal of 47, involving entire height Based on the history and clinical evaluation, a provisional of the mandible from the alveolar crest up to the diagnosis of chronic suppurative osteomyelitis of lower border of the mandible, showing a moth-eaten the mandible with a possible pathologic fracture was appearance. Loss of continuity of the lower border of established. the mandible [Figures 5 and 6].
Considering the patients past medical history, Chest PA view showed extensive active Koch’s his occupation and recent weight loss following infiltration seen at the left mid zone. Right upper hematological tests were advised: zone fibrotic with Koch’s infiltration of hilum and Complete blood cell counts mediastinum. The chest X-ray suggested bilateral Hemoglobin %, bleeding, and clotting time active Koch’s more on the left side [Figure 7]. Blood glucose levels (fasting and post-prandial) Tri dot (screening for HIV) The possibility of skeletal and pulmonary tuberculosis cannot be ruled out as the patient also had a gangrene Other radiographic investigations advised were: of the left foot, which even after surgical treatment did Intraoral periapical radiograph (IOPA) with 45 47 region. not improve.
Figure 2: Intraoral exposed bone in the mandibular right buccal Figure 1: Extraoral pus discharging sinus vestibule
384 Annals of Tropical Medicine and Public Health | Jul-Aug 2012 | Vol 5 | Issue 4 Gadgil, et al.: Osteomyelitis of the Mandible leading to pathological fracture in a Tuberculosis patient
Figure 3: Intraoral periapical radiograph with 45 47 region Figure 4: Mandibular cross sectional occlusal radiograph
Figure 6: Orthopantomograph
Figure 5: Lateral oblique view for the Rt. body of the mandible Discussion
Despite all the benefits associated with the advances in medicine and dentistry, the development of microorganisms resistant to commonly used antibiotics, the increased number of patients treated with steroids and other immunocompromising drugs, and the rising incidence of AIDS, diabetes, and other medically-compromising conditions have led to resurgence in the incidence of osteomyelitis of the jaws secondary to systemic conditions.[1]
Systemic factors which alter host immunity and may facilitate development of acute and secondary chronic osteomyelitis of the jawbones are diabetes mellitus, autoimmune disorders, AIDS, agranulocytosis, anemia (especially sickle cell), leukemia, syphilis, malnutrition, chemotherapy, corticosteroid and other Figure 7: PA view chest radiograph immunosuppressive therapy, alcohol and tobacco, drug abuse, prior major surgery, herpes simplex virus infection, A diagnosis of chronic suppurative osteomyelitis herpes zoster, and cytomegalovirus infection.[1] of the right side of the body of the mandible leading to pathological fracture coexisting with pulmonary Although tuberculosis is rare in developed countries, it tuberculosis was clear. is very common and endemic in developing countries.[4]
Annals of Tropical Medicine and Public Health | Jul-Aug 2012 | Vol 5 | Issue 4 385 Gadgil, et al.: Osteomyelitis of the Mandible leading to pathological fracture in a Tuberculosis patient A resurgence of tuberculosis has been documented in In a case of pathological mandibular fracture, the surgeon both developed and developing countries since 1986. will frequently be facing a scenario of a systemically The most important reason for this is the association immunocompromised individual, with grossly infected between tuberculosis and the spread of HIV infection. It bone which is non-viable.[6] In cases where there is is estimated that HIV positive patients have a 113-fold little or no potential for normal union, the bone is increased risk of contracting tuberculosis, whereas the excised until normal bleeding bone is encountered. The risk for AIDS is increased 170-fold.[1] The increasing continuity defect created is maintained with a locking incidence of tuberculosis and HIV co-infection and the reconstruction plate and then reconstructed primarily emergence of drug resistance worldwide pose a major or secondarily. This treatment method is used for cases threat, particularly in developing nations.[5] of osteoradionecrosis, bisphosphonate osteonecrosis, and osteomyelitis.[6] Tuberculosis of the head and neck region generally involves a mass in the cervical region. Oral manifestations Conclusion of tuberculosis occur in approximately 3% of cases, involving long-standing pulmonary and/or systemic This case illustrates the importance of a high index of infection.[5] Orofacial presentation of tubercular disease suspicion when evaluating a patient with an unusual destructive bone lesion, particularly in a susceptible includes swelling, pain, loosening of teeth, and even epidemiologic and clinical setting.[4] Although a rare displacement of tooth buds. Other manifestations may occurrence, the presence of tuberculosis must lurk in include an ulcer, granulomas, involvement of salivary the deepest recesses of the dental professional’s mind glands and temporomandibular joint, and tuberculous when clinical findings of osteomyelitis do not conform lymphadenitis.[5] to routine therapy.[5] Tuberculous osteomyelitis is quite rare and constitutes References less than 2% of skeletal tuberculosis. Jaw involvement is even rarer and usually affects older individuals. In 1. Baltensperger M, Eyrich G, editors. Osteomyelitis of the jaws. Berlin the younger age group, tuberculous involvement of the Heidelberg; Springer-Verlag; 2009. jaw is highly unlikely and sporadic instances have been 2. Erasmus JH, Thompson IO, van der Westhuijzen AJ. Tuberculous osteomyelitis of the mandible: Report of a case. J Oral Maxillofac reported in the literature. The spread of infection may Surg 1998;56:1355-8. be through an extraction socket or mucosal opening 3. Crompton GK, Haslett C, Chilvers ER. Diseases of the respiratory associated with an erupting tooth or by regional system. In: Haslett C, Chilvers ER, Hunter JA, Boon NA, editors. extensions of soft tissue lesions to underlying bone or Davidson’s principles and practice of medicine. 18th ed. London: Churchill Livingstone; 1999. p. 347-53. hematogenous spread. Apical osteitis and periodontitis 4. Hakimi M, Hashemi F, Zare Mirzaie A, Hassan Pour A, Kosari H. with horizontal bone loss or as a widespread destructive Tuberculous osteomyelitis of the long bones and joints. Indian osteolytic lesion are some of the various types of J Pediatr 2008;75:505-8. 5. Chaudhary S, Kalra N, Gomber S. Tuberculous osteomyelitis of the clinical presentations and may be mistaken for a dental mandible: A case report in a 4-year-old child. Oral Surg Oral Med Oral abscess, especially in absence of systemic symptoms.[5] Pathol Oral Radiol Endod 2004;97:603-6. Orofacial tuberculosis is often difficult to diagnose, and 6. Coletti D, Ord RA. Treatment rationale for pathological fractures of it should be a rare but important consideration in the the mandible: A series of 44 fractures. Int J Oral Maxillofac Surg 2008;37:215-22. differential diagnosis of lesions that appear in the oral [5] cavity. Current recommendations for the treatment Cite this article as: Gadgil RM, Bhoosreddy AR, Upadhyay BR. of osseous tuberculosis include a 2 month initial phase Osteomyelitis of the mandible leading to pathological fracture in a of isoniazid, rifampin, pyrazinamide, and ethambutol tuberculosis patient: A case report and review of literature. Ann Trop followed by a 6 to 12 month regimen of isoniazid and Med Public Health 2012;5:383-6. rifampin.[4] Source of Support: Nil, Conflict of Interest: None declared.
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