ri
1-y tu A case report Jinichi Fukuda, DDS, PhD,n Yoji Shingo, DDS,b and Haruhiko Fukuoka, Japan SCHOOL
OF
MEDICINE,
FUKUOKA
Miyako,
DDS, PhD,”
UNIVERSITY
A case of tuberculous osteomyelitis of the mandible in a 76-year-old woman is reported. The patient sought treatment for a periostitis of the left side of the mandible. A purulent discharge was evident. Roentgenographic examination of the mandible revealed bone destruction from the midmandible to the ramus on the left side. The diagnosis was made by microscopic examination of the specimen from the involved bone. This case proved to be primary tuberculous osteomyelitis caused by the absence of the primary (ORAL
focus. SURC
ORAL
MED
ORAL
PATHOL
1992;73:278-80)
uberculous osteomyelitis of the mandible is extremely rare. Chapotelt reported only 50 cases involving the mandible reported in the literature up to 1922, and an additional 14 cases were reported by Meng2 between 1922 and 1939. More recently Khosla3 and Park et a1.4 reported tuberculous osteomyelitis of the mandible. Tuberculous infection of the mandible may occur through a carious tooth or an area of gingivitis, or by hematogenous spread of the bacilli from a primary focus of infection elsewhere in the body.5 CASEREPORT
On Aug. 25, 1989,a 76-year-oldwoman consultedour departmentwith swellingand pain of the left sideof the mandiblethat hadpersisted1 week after a tooth extraction. The day after the extraction the patient noticeda soft tissueswellingaroundthe left mandible,which gradually increasedand becamefluctuant and tender. The patient visited anotherdentist, who incisedthe fluctuant area on the buccalaspectof that extraction site. The patient wasthen referred to our department for diagnosis and treatment. The patient had undergone hip replacement for osteoarthritis in March 1989. She was being treated for hypertension. The patient was of average build and was well nourished. There was a moderate swelling on the left side of the face, that extended from the midmandible to the parotid region. aAssociate Professor, Department of Dentistry and Oral Surgery. bStaE, Department of Dentistry and Qral Surgery. cProfessor and Chief, Department of Dentistry and Oral Surgery. 7/12/31979 278
Fig. 1. chest tuberculosis.
roentogenogram
show-s no evidence
of
This region was not discolored but was warm and tender. The submandibular lymph nodes were slightly eniarged but were not tender. Hypesthesia of the left side of the lower lip and trismus were present. Intraoral examination revealed swelling extending from the extraction site to the mucobuccal fold. This swelling was painful to palpation, and thick yellow pus exuded through the incised wound.
Volume73 Number 3
Fig. 2. Orthopantomogram shows uniform radiolucent area and unclear mandible canal in body of left mandible.
Chest roentgenogram revealed no evidence of tuberculosis (Fig. 1). OrthopantomographLy of the left mandible revealed a uniform radiolucent area extending from the extraction site to the mandibular angle (Fig. 2). Laboratory findings included white blood cell count, 6400 cells/mm3; red blood cell count, 394 X lo4 cells/mm3; hemoglobin, 12.5 gm/dl; hematocrit, 38.0%; platelet count, 26.7 x lo4 cells/mm3; blood sugar, 208 mg/dl; aspartate aminotransferase, 56 IU; alanine aminotransferase, 44 IU; lactate dehydrogenase,411 IU; erythrocyte sedimentation rate, 80 mm/hr; C-reactive protein, 7.2 mg/dl; sugar in urine, 1000 mg/dl. The clinical diaLgnosr:s on admission were acute periostitis of the left mandible, and diabetes mellitus. The patient was hospitalized for periostitis of the mandible and for diabetes mellitus on Aug. 26, 1989. Antibiotic (cep;halosporin) treatment was started to control the infection. After 3 weeksof administration aspartate aminotransferase and al.anineaminotransferase values were elevated to 105 IU and 186IU, respectively, so the cephalosporin was discontinued. The area was irrigated daily and the discharge of pus continued. Roentgenographic examination of the mandible showed that bone destruction was present from the midmandible to the ascending ramus on the left side (Fig. 3). From Oct. 4, 1989, synthetic penicillin (ampicillin) was administered; however, the bone destruction of the mandible of thle left side progressed.On Oct. 12, 1989, saucerization was performed with the patient under general anesthesia, and the body of the mandible was found to be filled with pinkish gray granulation tissue. Microscopic examination of the resected specimen revealed destruction of the bone and fibrosis of the marrow. In the connective tissue were numerous tubercles composed of centrally placed Langhans giant cells, epithelioid cells, and a peripheral infiltration of lymphocytes and plasma cells (Fig. 4). Bacteriologic findings of sputum and pus from the intraoral sinus were negative. A skin test with purified protein derivative of tuberculin was positive (35 X 35mm). The final diagnosis was primary tuberculous osteomyelitis of the left mandible. Immediately after diagnosis routine antituberculous therapy with streptomycin and isonicotinic acid hydrazide was initiated. Becauseof the patient’s liver
Tuberculous osteomyelitis of mandible
279
Fig. 3. Orthopantomogram showsbone destruction from midmandible to ascending ramus on left side (arrows).
Fig. 4. Photomicrograph of resected bone specimen shows destruction of bone and granulomatous lesion with aggregates of epithelioid cells, Langhans giant cells, and foci of caseousnecrosis.
dysfunction, the use of stronger antituberculous therapy was not feasible. Follow-up roentgenograms revealed evidence of bony healing with no indication of recurrence of the osteomyelitis. When discharged on Feb. 2, 1990, the patient was given isonicotinic acid hydrazide, to be continued for an indefinite period. DISCUSSION
Tuberculosis of the mandible is generally the result of the hematogenous spread of pulmonary tuberculosis.3>6-pMeng2 reported that about 43% of the patients with tuberculosis of the mandible had tuberculous lesions in the bones elsewhere in the body. Our patient had no history of pulmonary or osseous tuberculous lesions. A right hip replacement arthroplasty was performed in March 1989, and at that time roentgenograms had revealed no evidence of tuberculosis. Thus the tuberculous infection was not considered to have spread from another tuberculous focus. In this case it was believed that a periapical granu-
Fukuda, Shingo, and Miyako
280
ORALSURGORAL MEDOKALPATHOL March 1992
loma containing tuberculous granulation tissue may have been present and that removal of an infected tooth caused the spread of the infection to the adjacent bone.
5. Cohen L. Oral ruberculosis. ORAL SURGORAL MED ORAL PATHOL 1958;12:430-7. 6. Stuteville OH, Hulswit FF. Tubercuious osteomyelitis of the
REFERENCES
9. Allan IM. Tuberculous osteomyelitis of the mandible: report
1. Chapotel. Tuberculose mandibuiarie. Rev Odont 1930;51:44454. 2. Meng CM. Tuberculosis of the mandible. .I Bone Joint Surg 1940;22:17-27. 3. Khosla VM. Tuberculous osteomyelitis of the mandible: report
of case. J Oral Surg 1970;28:848-53. 4. Park TW, Ahn HK, You DS, Lee WY, Lee KH. Tuberculous osteomyelitis of the mandible: report of a case. Oral Radio1 1987;13:183-5.
mandible with report of case. J Oral Surg 1948;6:255-9. I. Pekarsky RL. Tuberculous osteomyelitis of the mandible. ORAL SURG ORAL MED ORAL PATHOL 1954;7:2188-92. 8. Spilka CJ. Tuberculosis of mandible: report of case. J Oral
Surg 1955;13:69-70. of a case. Br J Plast Surg 1956;9:240-5. Reprint requests:
Jinichi Fukuda, DDS, PhD Department of Dentistry and Oral Surgery School of Medicine Fukuoka University 7-45-1, Nanakuma, Jonanku Fukuoka 8 14-01, Japan
1-y tu A case report Jinichi Fukuda, DDS, PhD,n Yoji Shingo, DDS,b and Haruhiko Fukuoka, Japan SCHOOL
OF
MEDICINE,
FUKUOKA
Miyako,
DDS, PhD,”
UNIVERSITY
A case of tuberculous osteomyelitis of the mandible in a 76-year-old woman is reported. The patient sought treatment for a periostitis of the left side of the mandible. A purulent discharge was evident. Roentgenographic examination of the mandible revealed bone destruction from the midmandible to the ramus on the left side. The diagnosis was made by microscopic examination of the specimen from the involved bone. This case proved to be primary tuberculous osteomyelitis caused by the absence of the primary (ORAL
focus. SURC
ORAL
MED
ORAL
PATHOL
1992;73:278-80)
uberculous osteomyelitis of the mandible is extremely rare. Chapotelt reported only 50 cases involving the mandible reported in the literature up to 1922, and an additional 14 cases were reported by Meng2 between 1922 and 1939. More recently Khosla3 and Park et a1.4 reported tuberculous osteomyelitis of the mandible. Tuberculous infection of the mandible may occur through a carious tooth or an area of gingivitis, or by hematogenous spread of the bacilli from a primary focus of infection elsewhere in the body.5 CASEREPORT
On Aug. 25, 1989,a 76-year-oldwoman consultedour departmentwith swellingand pain of the left sideof the mandiblethat hadpersisted1 week after a tooth extraction. The day after the extraction the patient noticeda soft tissueswellingaroundthe left mandible,which gradually increasedand becamefluctuant and tender. The patient visited anotherdentist, who incisedthe fluctuant area on the buccalaspectof that extraction site. The patient wasthen referred to our department for diagnosis and treatment. The patient had undergone hip replacement for osteoarthritis in March 1989. She was being treated for hypertension. The patient was of average build and was well nourished. There was a moderate swelling on the left side of the face, that extended from the midmandible to the parotid region. aAssociate Professor, Department of Dentistry and Oral Surgery. bStaE, Department of Dentistry and Qral Surgery. cProfessor and Chief, Department of Dentistry and Oral Surgery. 7/12/31979 278
Fig. 1. chest tuberculosis.
roentogenogram
show-s no evidence
of
This region was not discolored but was warm and tender. The submandibular lymph nodes were slightly eniarged but were not tender. Hypesthesia of the left side of the lower lip and trismus were present. Intraoral examination revealed swelling extending from the extraction site to the mucobuccal fold. This swelling was painful to palpation, and thick yellow pus exuded through the incised wound.
Volume73 Number 3
Fig. 2. Orthopantomogram shows uniform radiolucent area and unclear mandible canal in body of left mandible.
Chest roentgenogram revealed no evidence of tuberculosis (Fig. 1). OrthopantomographLy of the left mandible revealed a uniform radiolucent area extending from the extraction site to the mandibular angle (Fig. 2). Laboratory findings included white blood cell count, 6400 cells/mm3; red blood cell count, 394 X lo4 cells/mm3; hemoglobin, 12.5 gm/dl; hematocrit, 38.0%; platelet count, 26.7 x lo4 cells/mm3; blood sugar, 208 mg/dl; aspartate aminotransferase, 56 IU; alanine aminotransferase, 44 IU; lactate dehydrogenase,411 IU; erythrocyte sedimentation rate, 80 mm/hr; C-reactive protein, 7.2 mg/dl; sugar in urine, 1000 mg/dl. The clinical diaLgnosr:s on admission were acute periostitis of the left mandible, and diabetes mellitus. The patient was hospitalized for periostitis of the mandible and for diabetes mellitus on Aug. 26, 1989. Antibiotic (cep;halosporin) treatment was started to control the infection. After 3 weeksof administration aspartate aminotransferase and al.anineaminotransferase values were elevated to 105 IU and 186IU, respectively, so the cephalosporin was discontinued. The area was irrigated daily and the discharge of pus continued. Roentgenographic examination of the mandible showed that bone destruction was present from the midmandible to the ascending ramus on the left side (Fig. 3). From Oct. 4, 1989, synthetic penicillin (ampicillin) was administered; however, the bone destruction of the mandible of thle left side progressed.On Oct. 12, 1989, saucerization was performed with the patient under general anesthesia, and the body of the mandible was found to be filled with pinkish gray granulation tissue. Microscopic examination of the resected specimen revealed destruction of the bone and fibrosis of the marrow. In the connective tissue were numerous tubercles composed of centrally placed Langhans giant cells, epithelioid cells, and a peripheral infiltration of lymphocytes and plasma cells (Fig. 4). Bacteriologic findings of sputum and pus from the intraoral sinus were negative. A skin test with purified protein derivative of tuberculin was positive (35 X 35mm). The final diagnosis was primary tuberculous osteomyelitis of the left mandible. Immediately after diagnosis routine antituberculous therapy with streptomycin and isonicotinic acid hydrazide was initiated. Becauseof the patient’s liver
Tuberculous osteomyelitis of mandible
279
Fig. 3. Orthopantomogram showsbone destruction from midmandible to ascending ramus on left side (arrows).
Fig. 4. Photomicrograph of resected bone specimen shows destruction of bone and granulomatous lesion with aggregates of epithelioid cells, Langhans giant cells, and foci of caseousnecrosis.
dysfunction, the use of stronger antituberculous therapy was not feasible. Follow-up roentgenograms revealed evidence of bony healing with no indication of recurrence of the osteomyelitis. When discharged on Feb. 2, 1990, the patient was given isonicotinic acid hydrazide, to be continued for an indefinite period. DISCUSSION
Tuberculosis of the mandible is generally the result of the hematogenous spread of pulmonary tuberculosis.3>6-pMeng2 reported that about 43% of the patients with tuberculosis of the mandible had tuberculous lesions in the bones elsewhere in the body. Our patient had no history of pulmonary or osseous tuberculous lesions. A right hip replacement arthroplasty was performed in March 1989, and at that time roentgenograms had revealed no evidence of tuberculosis. Thus the tuberculous infection was not considered to have spread from another tuberculous focus. In this case it was believed that a periapical granu-
Fukuda, Shingo, and Miyako
280
ORALSURGORAL MEDOKALPATHOL March 1992
loma containing tuberculous granulation tissue may have been present and that removal of an infected tooth caused the spread of the infection to the adjacent bone.
5. Cohen L. Oral ruberculosis. ORAL SURGORAL MED ORAL PATHOL 1958;12:430-7. 6. Stuteville OH, Hulswit FF. Tubercuious osteomyelitis of the
REFERENCES
9. Allan IM. Tuberculous osteomyelitis of the mandible: report
1. Chapotel. Tuberculose mandibuiarie. Rev Odont 1930;51:44454. 2. Meng CM. Tuberculosis of the mandible. .I Bone Joint Surg 1940;22:17-27. 3. Khosla VM. Tuberculous osteomyelitis of the mandible: report
of case. J Oral Surg 1970;28:848-53. 4. Park TW, Ahn HK, You DS, Lee WY, Lee KH. Tuberculous osteomyelitis of the mandible: report of a case. Oral Radio1 1987;13:183-5.
mandible with report of case. J Oral Surg 1948;6:255-9. I. Pekarsky RL. Tuberculous osteomyelitis of the mandible. ORAL SURG ORAL MED ORAL PATHOL 1954;7:2188-92. 8. Spilka CJ. Tuberculosis of mandible: report of case. J Oral
Surg 1955;13:69-70. of a case. Br J Plast Surg 1956;9:240-5. Reprint requests:
Jinichi Fukuda, DDS, PhD Department of Dentistry and Oral Surgery School of Medicine Fukuoka University 7-45-1, Nanakuma, Jonanku Fukuoka 8 14-01, Japan
