Mandibular osteomyelitis

Case contributed by Dr Henry Knipe

Presentation

Jaw pain and swelling.

Patient Data

Age: 15-20 years
Gender: Male
CT

The right mandibular body has central lucency with cortical destruction and smooth periosteal reaction. 45 tooth has been extracted. 

MRI

An aggressive process is centred on the right mandibular body, centred inferior to the extracted 45 tooth. Cortical breach and periostitis are noted. There is enhancing tissue extends through the cortical breach on both the buccal and lingual surfaces with surrounding ill-defined contrast enhancement. Abnormal low T1 bone marrow signal extends to the 33 and to the angle of the mandible on the right. 

Incidental note is also made of a thyroglossal duct cyst located in the midline at the anterior aspect of the hyoid bone.

Case Discussion

The imaging features are of an aggressive process with both infective (i.e. osteomyelitis) and tumour (e.g. gnathic osteosarcoma) within the differential diagnosis. Recent tooth extraction and smooth periosteal reaction favours osteomyelitis. The patient went on to bone biopsy. 

Histopathology

MACROSCOPIC DESCRIPTION: "Right posterior mandible": Four white and pink hard bony pieces of tissue between 5-10mm. Specimen placed in decal.

MICROSCOPIC DESCRIPTION: Sections show decalcified bony fragments composed of woven bone trabeculae with intervening marrow fibrosis. Osteoblastic rimming is present. The paucicellular fibrous tissue contains bland spindle cells. No mitoses are identified. Occasional aggregates of mononuclear chronic inflammatory cells are identified. No acute or granulomatous inflammation is seen. There is no evidence of atypia or malignancy. Immunohistochemical results confirm the presence of scattered CD138 positive chronic inflammatory cells (plasma cell morphology distorted by decalcification process).

DIAGNOSIS: Right posterior mandible, biopsy: Reactive woven bone with medullary fibrosis; no definite tumour seen.

COMMENT: The histological features are non-specific and no definite tumour is seen. The differential diagnosis includes chronic osteomyelitis. Clinical and radiological correlation is recommended.

A diagnosis of osteomyelitis was made based on clinical, radiological, and pathological evidence and the patient proceeded to a long-term course of antibiotics. 

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Case information

rID: 53419
Case created: 17th May 2017
Last edited: 25th Sep 2017
Inclusion in quiz mode: Included

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