Home | About us | Editorial board | Ahead of print | Current issue | Archives | Search | Submit article | Instructions | Subscribe | Advertise | Contact us |  Login 
National Journal of Maxillofacial Surgery
 
Print this page Email this page Small font sizeDefault font sizeIncrease font size
Users Online: 832
 


 
Table of Contents
CASE REPORT
Year : 2014  |  Volume : 5  |  Issue : 2  |  Page : 188-191  

Tuberculous osteomyelitis of the maxilla: A rarest of rare case report


1 Department of Oral Medicine and Radiology, Sudha Rustagi Dental College and Hospital, Faridabad, Haryana, India
2 Department of Prosthodontics, Sudha Rustagi Dental College and Hospital, Faridabad, Haryana, India
3 Department of Orthodontics, Krishna Dental College, Ghaziabad, India
4 Department of Oral Medicine and Radiology, K.D. Dental College, Mathura, Uttar Pradesh, India

Date of Web Publication10-Apr-2015

Correspondence Address:
Ramesh Gupta
A-49 Kalkaji, New Delhi - 110 019
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-5950.154833

Rights and Permissions
   Abstract 

Tuberculosis is a chronic granulomatous systemic infectious disease caused by Mycobacterium tuberculosis. The oral lesions found in tuberculosis are relatively rare and may present as ulcers, erythematous patches, indurated lesions, nodules or as bony jaw lesions. Oral tubercular lesions sometimes present a confusing clinical presentation and can be overlooked. Hence, we document a case of tuberculous osteomyelitis of the maxilla in a 19-year-old female patient, who was initially treated for multiple periodontal dental abscesses, which later proved to be tubercular osteomyelitis of the maxilla. Although it is a rare occurrence, the differential diagnosis of tuberculous osteomyelitis must always be considered when it fails to respond to routine therapy.

Keywords: Maxilla, osteomyelitis, tuberculosis


How to cite this article:
Gupta R, Garg M, Gupta AK, Anand C. Tuberculous osteomyelitis of the maxilla: A rarest of rare case report. Natl J Maxillofac Surg 2014;5:188-91

How to cite this URL:
Gupta R, Garg M, Gupta AK, Anand C. Tuberculous osteomyelitis of the maxilla: A rarest of rare case report. Natl J Maxillofac Surg [serial online] 2014 [cited 2019 Nov 20];5:188-91. Available from: http://www.njms.in/text.asp?2014/5/2/188/154833


   Introduction Top


Tuberculosis is a chronic granulomatous systemic infectious disease prevalent worldwide, which can affect any part of the body, including the oral cavity. It is usually caused by inhalation of infected airborne droplets containing the M. tuberculosis bacillus, which is an aerobic, slender, non-motile, non-encapsulated, non-sporing, rod-shaped organism, ranging from 2 to 5 μm. [1],[2]

Oral tuberculous lesions are relatively rare. Oral manifestations in tuberculosis occur in 3% of the cases involving long-standing pulmonary or systemic infection. [3] Oral lesions may present as ulcers, erythematous patches, indurated lesions, nodules or as bony jaw lesions. [4] Bony tuberculosis of the jaw is an uncommon form of extrapulmonary tuberculosis and is very rare. Tuberculosis of the jaw is more common in children below the age of 18 years. [5] Tubercular infections can be recognized as primary and secondary. Primary lesions develop when the tuberculosis bacilli are directly inoculated into the oral tissues of a person who has not acquired immunity to the disease. Secondary infection of the oral tissues can result from either a hematogenous or lymphatic spread. [6],[7] The involvement of the maxilla by tuberculous infection is the rarest of rare, although tuberculous osteomyelitis of the mandible has been reported and is more common than that in the maxilla, as it contains a lesser amount cancellous bone. [8],[9] The oral tubercular lesions can sometimes present with a confusing clinical presentation. Hence, we document a case of tuberculous osteomyelitis of the maxilla in a 19-year-old female, who was initially suspected for multiple periodontal abscesses, which later proved to be tubercular osteomyelitis of the maxilla.


   Case Report Top


A 19-year-old female patient reported to the Department with a complaint of mobile teeth along with a history of pus discharge since three months. The history revealed that the patient had a painful swelling in the upper front region of the face three months back, which later subsided due to formation of multiple draining sinuses. The medical history revealed that the patient had generalized weakness, weight loss, and episodic fever for the last one month. On general examination, the patient was poorly nourished and thin built. On extra oral examination a diffuse swelling was present in the middle third of the upper left and right side of the face, which extended from the right to the left mid pupillary line mediolaterally and from the ala tragus line, 4 cm inferior to the infraorbital margin. Superoinferiorly the swelling was slightly tender on palpation [Figure 1]. On intraoral examination, multiple draining sinuses were present with reference to the 23, 26 and 14, 15 extraction socket region; there was discharge of pus from all the sinuses and from the extraction socket [Figure 2], [Figure 3] and [Figure 4]. On digital palpation (using index finger and thumb) a very unusual finding was found, the maxillary teeth and maxillary arch in their entirety were movable, like a paper-thin bone [Video 1]. There was no carious tooth associated with the sinuses, so on the basis of the above-mentioned history and clinical presentation a provisional diagnosis of multiple periodontal abscesses was made. Routine hematological, radiological, and histopathogical investigations were carried out. On the hematological investigation, the erythrocyte sedimentation rate (ESR) was seen to be very high, which indicated a deep-seated infection. On a panoramic examination, diffuse bone loss in the maxilla, involving all the maxillary teeth, was seen [Figure 5]. A sputum examination for acid fast bacilli (AFB) was inconclusive. A chest x-ray showed that the bronchovascular markings were accentuated and in the left upper zone Pulmonary Koch's was found [Figure 6]. A Montoux test was advised, which came positive (>10 mm). A cytological smear taken from the sinus drainage was stained with Ziehl-Neelsen and Periodic acid-Schiff (PAS), but revealed only polymorphonuclear leucocytes and few lymphocytes. Fine needle aspiration cytology (FNAC) showed no granulomatous lesion. A serological examination for M, tuberculosis antibody was performed, which showed a raised level of IgG and IgM antibodies. Finally, an incisional biopsy, which is considered the gold standard, was performed in the extraction socket 14, 15 region [Figure 7]. It showed granulomas of varying sizes and shapes, consisting of central Langhan's giant cells, epitheloid cells, surrounded by lymphocytes, and few plasma cells [Figure 8]. The above-mentioned features are consistent with a tuberculous granuloma, a chronic granulomatous lesion. Therefore, a final diagnosis of pulmonary tuberculosis as a primary lesion, with a secondary lesion in the maxilla, was made. The standard anti-tubercular therapy for bone tuberculosis was started. At the four-week follow up, a marked improvement in the overall health was noticed, with an overall reduction in the mobility of the maxillary bone and teeth [Figure 9] and [Video 2].
Figure 1: Profile picture of the patient

Click here to view
Figure 2: Intraoral view showing multiple draining sinuses

Click here to view
Figure 3: Intraoral sinuses with reference to the 23, 25 region

Click here to view
Figure 4: Draining sinuses with reference to the 14, 15 extraction socket

Click here to view
Figure 5: Panoramic x-ray showing diffuse bone loss in the maxilla

Click here to view
Figure 6: Chest x-ray shows bronchovascular markings are accentuated, with left upper zone Pulmonary Koch's

Click here to view
Figure 7: Photomicrograph showing multinucleated giant cells

Click here to view
Figure 8: Incisional biopsy done with reference to the 15 region

Click here to view
Figure 9: Post-treatment picture showing complete healing of the sinuses

Click here to view






   Discussion Top


In spite of the dramatic improvement in public health, tuberculosis still remains a dreaded disease in today's world. A majority of the cases belong to the developing countries, with the highest incidence in the Indian and African subcontinent. [10],[11] The epidemiology of tuberculosis differs considerably with ethnicity, age, and socioeconomic group. [11],[12] Primary oral tuberculosis is rare because of various barriers present in the oral cavity, such as, intact oral mucosa, salivary enzymes, tissue antibodies, and oral saprophytes. Any breach in these barriers can lead to infection by the tubercle bacilli. [2],[10] Tuberculous osteomyelitis is even rarer and constitutes less than 2% of skeletal TB. Jaw involvement of the maxillary bone by TB infection is extremely rare. [8],[9] The radiographic appearance of TB of the jaws or alveolar bone is similar to that caused by other pyogenic organisms. It usually appears as a blurring of the trabecular pattern, with irregular areas of radiolucency. [13]

Generally the diagnosis of tuberculosis has been made on the basis of clinical findings and radiographs, along with sputum examination showing AFB bacilli. In recent times, more advanced investigations like a DNA probe and polymerase chain reaction assays allow a more sensitive and rapid diagnosis. [13] The smears and culture for AFB from the oral lesions and the sputum have been negative in our case, which can be due to many reasons. High immunity of the patient, small numbers of tubercle bacilli in the oral lesion or a previous history of prolonged antibiotic consumption. [14] In our case, the very rarest of rare finding was noticed, the entire maxillary arch was moving like a paper-thin bone and drastic reduction was seen in the mobility after initiating anti-tuberculosis treatment.


   Conclusion Top


Tuberculous osteomyelitis of the maxilla is an extremely rare condition of the oral cavity. It can present in an unusual form in the oral cavity and can be misdiagnosed. With the recent reversal in the incidence of tuberculosis; it must always be included in the differential diagnosis. Concurrent pulmonary lesions should also alert the oral physician to locate a primary site of the disease in the body, before diagnosis of oral tuberculosis is considered.

 
   References Top

1.
Dinkar AD, Prabhudessai V. Primary tuberculous osteomyelitis of the mandible: A case report. Dentomaxillofac Radiol 2008;37:415-20.  Back to cited text no. 1
    
2.
Bhatt AP, Jayakrishnan A. Tuberculous osteomyelitis of the mandible: A case report. Int J Paediatr Dent 2001;11:304-8.  Back to cited text no. 2
    
3.
Karthikeyan BV, Pradeep AR, Sharma CG. Primary tuberculous gingival enlargement: A rare entity. J Can Dent Assoc 2006;72:645-8.  Back to cited text no. 3
    
4.
Chesnutt MS, Prendergast TJ. Lung-pulmonary tuberculosis. In: Tierney LM, McPhee SJ, Papadakis MA, editors. Current Medical Diagnosis and Treatment. 41 st ed. New York: McGraw- Hill; 2002. p. 309-17.  Back to cited text no. 4
    
5.
Dimitrakopoulos I, Zouloumis L, Lazaridis N, Karakasis D, Trigonidis G, Sichletidis L. Primary tuberculosis of the oral cavity. Oral Surg Oral Med Oral Pathol 1991;72:712-5.  Back to cited text no. 5
    
6.
Ebenezer J, Samuel R, Mathew GC, Koshy S, Chacko RK, Jesudason MV. Primary oral tuberculosis: Report of two cases. Indian J Dent Res 2006;17:41-4.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.
Eng HL, Lu SY, Yang CH, Chen WJ. Oral tuberculosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:415-20.  Back to cited text no. 7
    
8.
Fukuda J, Shingo Y, Miyako H. Primary tuberculous osteomyelitis of the mandible. A case report. Oral Surg Oral Med Oral Pathol 1992;73:278-80.  Back to cited text no. 8
    
9.
Gupta KB, Manchanda M, Yadav SP, Mittal A. Tubercular osteomyelitis of mandible. Indian J Tuberc 2005;52:147-50.  Back to cited text no. 9
    
10.
Hock-Liew E, Shin-Yu L, Chuang-Hwa Y, Wei-Jen C. Oral tuberculosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:415-20.  Back to cited text no. 10
    
11.
Nwoku LA, Kekere-Ekun TA, Sawyer DR, Olude OO. Primary tuberculous osteomyelitis of the mandible. J Maxillofac Surg 1983;11:46-8.  Back to cited text no. 11
[PUBMED]    
12.
Rivera H, Correa MF, Castillo-Castillo S, Nikitakis NG. Primary oral tuberculosis: A report of a case diagnosed by polymerase chain reaction. Oral Dis 2003;9:46-8.  Back to cited text no. 12
    
13.
Prabhu SR, Sengupta SK. Bacterial Infections Due to Mycobacteria A. Tuberculosis. Oral Diseases in the Tropics. Oxford: Oxford University Press; 1993. p. 195-202.  Back to cited text no. 13
    
14.
Smith WH, Davies D, Mason KD, Onions JP. Intraoral and pulmonary tuberculosis following dental treatment. Lancet 1982;1:842-4.  Back to cited text no. 14
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

Top
   
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
    References
    Article Figures

 Article Access Statistics
    Viewed1514    
    Printed25    
    Emailed0    
    PDF Downloaded289    
    Comments [Add]    

Recommend this journal