Primary tuberculous osteomyelitis of the mandible in a 3-year-old child

Abstract

A 3-year-old girl child presented with swelling in her right lower jaw that had started 5 days previously. History revealed the child being non-immunised. Initial-evaluation revealed proptosis and bony hard swelling over the right body of the mandible. Radiological evaluation including a CT scan indicated expansile osteolytic lesion involving the body-ramus with onion-peel periosteal reaction suggesting osteomyelitis/malignancy. Blood investigations showed raised erythrocyte sedimentation rate and eosinophilia. Family screening for tuberculosis (TB) revealed that the patient, her father and siblings were PPD positive though chest screening and sputum examinations were negative in all of them. Lesion biopsy showed acute/chronic osteomyelitis with eosinophilia, tilting diagnosis towards eosinophilic granuloma/Hand-Schuller-Christian disease. Further investigations for diabetes insipidus, histiocytosis-X, skull-pelvic-femur radiographs, abdominal ultrasonography, ophthalmic consultation and PCR-TB test were negative. Histology, radiography, purified protein derivative (PPD)-positive result and history led to the diagnosis of primary TB of the mandible. Complete resolution occurred following antitubercular therapy. The case report emphasises that diagnosis of TB can sometimes be based on circumstantial evidence and positive response to antitubercular therapy even in view of a negative PCR result.

Figure 1

Frontal and side profile photographs showing diffuse swelling over the right cheek and body of the mandible with overlying skin normal.

Figure 2

Intraoral photograph of the mandibular right quadrant and vestibule showing no evidence of caries or swelling/cortical expansion.

Figure 3

Intraoral periapical radiograph showing crypt of first permanent molar seemingly destroyed in the anteroinferior region with the developing tooth drifted superiorly.

Figure 4

Orthopantamography showing ill-defined radiolucent osteolytic lesion involving the right body, inferior alveolar canal, basal bone, ramus of mandible and, extending superiorly up to neck of the condyle and sigmoid notch.

Figure 5

Mandibular occlusal view showing sclerosing osteitis and onion-peel appearance of the mandible.

Figure 6

CT scan axial image showing cystic lesion causing expansion of the right condyle and ramus with cortical breaks both buccally and lingually.

Figure 7

CT scan axial image showing multilocular cystic lesion involving the right ramus with a hyperdense lesion within suggesting a sequestrum.

Figure 8

CT scan axial image showing multilocular cystic lesion involving the right body of the mandible with cortical expansion and breaks buccally.

Figure 9

Sequestrum within the expansile lesion in the right ramus.

Figure 10

Facial view showing good resolution 12 months after anti-Koch's therapy.

Figure 11

Radiographic view 12 months after anti-Koch's therapy showing signs of resolution and reduction in periosteal reaction, healing of crypt around developing permanent first molar and normal development of second premolar crypt.