Primary tuberculous osteomyelitis of the mandible: A rare case report
A 13-year-old female of Asian Indian origin reported to our hospital for evaluation of swelling and pain on the right side submandibular region of the face. History obtained from the parents revealed that the swelling was present for past 2 months. The patient was prescribed multiple courses of antibiotics, but there was no significant improvement. The patient was moderately built, nourished, and afebrile at the time of examination. The patient gave a history of generalized weakness, weight loss for 2 months, and pain associated with the swelling.\nGeneral physical and systemic examinations did not give any significant diagnostic information. Extra oral examination revealed a unilateral diffuse solitary swelling over the right submandibular region of mandible measuring 2 × 3 cm in size. The overlying skin was normal in color, but swelling was tender on palpation with a discharging sinus []. On pressing the swelling, thick yellow pus discharge with blood was noticed. Margins of sinus opening were hyperemic. Multiple cervical lymph nodes on the right submandibular group of lymph nodes were enlarged and tender. A panoramic radiograph revealed an ill-defined, radiolucent, osteolytic lesion surrounding the developing right permanent second molar []. A provisional diagnosis of residual chronic dento alveolar abscess was made, while the differential diagnosis included tuberculous osteomyelitis of mandible or malignant bone tumor.\nHer chest radiograph did not reveal any evidence of TB []. Hematological finding included WBC counts of 8800 cells/mm3 and Hb of 11.50 gm/dl. Erythrocyte sedimentary rate raised to 38 mm and Mantoux test was 10 × 10 mm. Her serum HIV test was negative. Magnetic resonance imaging of neck showed evidence of osteomyelitis of right mandible involving the inferior margin of distal body of the mandible (from 2nd molar root abscess) [Figures –]. The length of the tract measured 2.34 cm and thickness was 0.6 cm. Computed tomography (CT) scan showed enlarged submandibular lymph nodes measuring 1 × 1 cm (nonspecific lymphadenitis).\nFine needle aspiration cytology of the swelling was also performed. A typical ceseous material with white cheesy appearance was aspirated, which on microscopic examination demonstrated necrotic calls, a large number of neutrophils, few lymphocytes, and few clusters of epitheloid cells, suggesting tuberculoid or caeseating granuloma. Right submandibular lymphadenopathy was also noted. Based on the above clinical findings, corroborated by history and various investigations, a diagnosis of primary tuberculous osteomyelitis of mandible was made.\nSinus tract excision with scooping of the cavity was done under local anesthesia. An extraoral submandibular incision was given to approach the mandible in the affected site. Necrotized bone was found distal to 46, involving the body of mandible with sequestrum formation in the angle area. The lesion was surgically drained and curetted and sent for histopathological examination.\nThe patient was started on standard antitubercular chemotherapy (2HRZE/4HR). The dosage was INH 75 mg, rifampicin 150 mg, ethambutol 275 mg, and pyrazinamide 400 mg. After 2 months of therapy, she improved markedly with decrease in swelling. Panaromic radiograph shows radio-opacity in relation to 47 (bone formation). She is under regular follow-up with continuation of AKT [].