Osteomyelitis of the mandible in a child due to Bacteroides fusiformis

Osteomyelitis of the mandible in a child due to Bacteroidesfusiformis John V. Payne, M.D., M.P.H., Duna P. Dahlen, D.M.D., M. T. Silva, M.D., Gregory A. Culley, M.D., and Peggy Buckner, M.T. (A.S.C.P.), Hazard and Hindman, DEPARTMENTS HOSPITAL, CARE

OF PEDIATRICS AND

THE

DENTAL

AND

RADIOLOGY,

CLINIC

OF THE

APPALACHIAN KNOTT

COUNTY

Ky. REGIONAL AMBULANT

CENTER

A case is reported in which osteomyelitis history of trauma or underlying disease.

of the mandible

occurred

in a child with no

0

steomyelitis due to bacteroides species has been reported in recent years, usually in association with fractures or surgical infections. This report details a case of osteomyelitis of the mandible in a child who had sustained no injury to the bone ‘and who had no underlying disease to alter her immunity. The organism was found in. pure culture and not in association with other flora, as is often the case. CASE REPORT S. H., a 6-year-old white girl, had a large abscess of the left side of the face. She had been taking oral ampicillin for approximately 2 weeks for a dental abscess. No cultures were taken prior to institution of this therapy. The patient presented in the pediatric clinic because of the facial swelling. At this time a roentgenogram of the mandible revealed evidence of early osteomyelitic changes with a slight periosteal reaction of the body of the left mandible. The patient was admitted for treatment. Physical examination findings were essentially normal except for moderate redness and swelling of the left side of the face with a fluctuant area approximately 3 cm. in diameter. Moderately severe dental caries was obvious upon casual inspection of the oral cavity. Initial laboratory studies included a complete blood count, urinalysis, liver chemistries, calcium, and phosphorus, results of all of which were normal. A routine chest roentgenogram was unremarkable, and immunoglobulins were normal.. The abscess of the face was incised and approximately 10 ml. of purulent material was drained. A Gram stain of the drainage revealed many gram-negative bacteria resembling B&erodes fusiformis. Anaerobic fusobaeteria were isolated on culture of the drainage. The child underwent therapy with intravenous aqueous penicillin at a dosage of 250,000

44

Volume Number

43 1

Osteomyelitis

of mandible

45

Fig. 2. Roentgenogram taken after 1 week of antibiotic therapy showing periosteal reaction along the inferior border of the mandible and slight cortical erosion of the middle portion of the body of the left mandible.

units per kilogram per day for a total of 14 days of therapy. Roentgenographic examination of the mandible after 1 week of therapy revealed the development of a slight saucer-shaped cortical erosion in the middle portion of the body of the left mandible along with periosteal reaction extending from the angle of the mandible to the symphysis (Fig. 1). Follow-up radiographic examination 2 weeks later revealed these osteomyelitic changes to be present and regressing slightly. After completion of antibiotic therapy the patient was asymptomatic with regard to the facial swelling, and the drainage site was healing well. At this time periapieal and panoramic roentgenograms revealed periapical pathosis associated with the first permanent and first sand second primary molars. The first permanent molar was nonvital with severe furcation involvement. The first permanent molar was presumed to have been the focus of infection for the osteomyelitis, and this tooth was removed by simple extraction.

DISCUSSION

Leakel reported two cases of bacteroides osteomyelitis of the mandible in 1972. Both of these cases occurred in adults. One was a 52-year-old man who had sustained a compound, comminuted fracture of the mandible and the other an elderly woman who had undergone tooth extractions and who had allowed tobacco snuff to collect in the extraction site. Both these cases involved bacteroides species mixed with other flora in the cultures, Nettles and associates2 reported six cases of bacteroides infections in bone. All these were in adults, and all occurred following injury or surgery. None involved the mandible. A review of recent literature failed to reveal any other cases of bacteroides osteomyelitis in the mandible other than the two mentioned by Leake. We could find no reference to any such case in a child, and apparently such an occurrence in the absence of a fracture, surgery, or other invasion of the bone is unusual. Most other cases have involved bacteroides mixed other anaerobic organisms. It may be assumed that this condition exists more frequently than realized, though it may be overlooked unless anaerobic cultures and direct smears are performed. We acknowledge with thanks the helpful suggestions of J. 5. Giansanti, D.M.D., of the University of Kentucky College of Dentistry, and Dr. David Wilson of the University of Kentucky College of Medicine.

REFERENCES

1. Leake, I). L.: Bacteroides Osteomvelitis of the Mandible, ORAL Susc. 34: 585-588, 1972. 2. Nettles, 5. L., Kelly, P. I., Mar&, W. J., and Washington, J. A.: Musculoskeletal Infertions Due to Racteroides, J. Bone Joint Surg. 51: 230-238, 1969. Reprint requests to : Dr. John V. Payne Department of Pediatrics Appalachian Regional Hospital Hazard, Ky. 41701