|Year : 2014 | Volume
| Issue : 4 | Page : 439-441
Tuberculous osteomyelitis of the mandible: A rare case report
Siddharth Saurabh1, Braj Bhushan Mall2, Rani Somani3, Akanksha Mishra3
1 Department of Oral Medicine and Maxillofacial Radiology, RKDF Dental college, Bhopal, Madhya Pradesh, India
2 Department of Oral and Maxillofacial Surgery, UCMS College of Dental Surgery, Bhairahawa, Nepal
3 Department of Pedodontics, DJ Dental College, Modinagar, Uttar Pradesh, India
|Date of Submission||09-Jul-2014|
|Date of Acceptance||25-Feb-2015|
|Date of Web Publication||22-Apr-2015|
Department of Oral Medicine and Maxillofacial Radiology, RKDF Dental College, Bhopal - 462 026, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
When compared to pyogenic infections and neoplastic diseases involving the mandible, tuberculous osteomyelitis of the mandible is extremely rare. Hereby, we are reporting such a type of case in a 15-year-old male, who presented with a draining sinus over the right mandible since 3 months which later proved to be tuberculous osteomyelitis in absence of a primary focus and which responded well to anti-tubercular treatment.
Keywords: Osteomyelitis mandible, primary tuberculosis, tuberculous osteomyelitis
|How to cite this article:|
Saurabh S, Mall BB, Somani R, Mishra A. Tuberculous osteomyelitis of the mandible: A rare case report. J Indian Acad Oral Med Radiol 2014;26:439-41
|How to cite this URL:|
Saurabh S, Mall BB, Somani R, Mishra A. Tuberculous osteomyelitis of the mandible: A rare case report. J Indian Acad Oral Med Radiol [serial online] 2014 [cited 2023 Jan 31];26:439-41. Available from: http://www.jiaomr.in/text.asp?2014/26/4/439/155645
| Introduction|| |
In the developed countries, tuberculosis (TB) is uncommon which is not the case in developing countries. According to the World Health Organisation (WHO), approximately 3 million people die annually of TB which is more common in developing countries.  Another report says that there are about 20 million prevalent cases and 8 million new cases are reported every year.  Tuberculous osteomyelitis is a very rare entity occurring more often in young individuals and usually is detected in the late stage of the disease. The sites most commonly involved are dorsal and lumbar vertebrae and epiphysis and diaphysis of long bones. Flat bones, including those of skull and mandible are rarely affected. The occurrence of tuberculous osteomyelitis in the jaw bone is very low. ,,,, It seldom arouses clinical suspicion because of the rarity of tuberculous osteomyelitis of the mandible. We report a case of a 15-year-old male who presented with a draining sinus over the right mandible since 3 months which later proved to be tuberculous osteomyelitis in absence of a primary focus and which responded well to anti-tubercular treatment (ATT).
| Case Report|| |
A 15-year-old male reported to the Department of Oral and Maxillofacial Surgery, UCMS College of Dental Surgery, Bhairahawa, Nepal with swelling and pain along with a draining sinus over the right mandibular region of the face [Figure 1]. On history taking, it was revealed that the swelling was present from the last 3 months which was of spontaneous origin. The patient was prescribed multiple courses of antibiotics by general practitioners with no significant improvement. There was no past history of trauma, ATT and family history of tuberculosis. The patient was average built, moderately nourished and afebrile. The patient complained of generalized weakness and pain associated with the swelling since the last 3 months.
|Figure 1: Extra-oral photograph showing right unilateral diffuse swelling over the right body of the mandible with a sinus|
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No significant diagnostic information could be elicited from further general physical and systemic examination. Local examination revealed a swelling over the right mandibular region of approximately 3.5 × 3.5 cm size with an increase in the size of the swelling with time. Overlying skin was normal in color with tenderness on palpation and presence of a discharging sinus. Thick yellow-colored pus with blood was noticed on palpation. Margins of the sinus opening were hyperemic [Figure 1]. There was no significant peripheral lymphadenopathy. Intraoral examination did not reveal any pathology. Provisional diagnosis of space infection/periapical abscess was made while differential diagnosis included tuberculous osteomyelitis of the mandible and possible malignant bone tumor.
The patient was advised an intraoral periapical radiograph (IOPA) which did not reveal any periapical pathology; but posteroanterior (PA) view of the mandible revealed a well-defined, radiolucent, osteolytic lesion surrounding the right lower body of the mandible. The chest radiograph did not reveal any abnormality. Routine hematological findings with WBC count of 9600 cells/mm 3 and Hb of 11.4 gm/dl were found. Erythrocyte sedimentary rate was 60 mm at the end of 1 hour and Mantoux test was negative; serum HIV and HBsAg were negative. Computed tomography (CT) scan showed irregularity of right lower body of the mandible with areas of lyses and sclerosis and erosions at some place [Figure 2]. Excisional biopsy was performed and the specimen was sent for histopathological examination. Histopathological examination showed predominantly granulation tissue with scattered Langerhans type giant cells, many mononuclear cells, few epitheloid cells forming ill-defined granuloma at places with fibrous area, reactive bone trabeculae and areas of hemorrhages, suggestive of a granulomatous lesion, probably tuberculosis [Figure 3].
|Figure 2: Plain CT scan showing an osteolytic lesion in the body of the mandible on the right side|
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|Figure 3: Histopathological report (40× magnification) showing granuloma comprising epitheloid cells, lymphocytes and Langerhans giant cells (arrow), respectively|
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Based on the clinical, radiographic and histopathological examination a final diagnosis of tuberculous osteomyelitis of the mandible was made and the patient was given ATT: 2HRZE/4HR as per RNTCP-DOTS regimen Cat I. The patient responded well to the treatment and followed up to 1 year with complete remission and there was no evidence of recurrence and surgical corrective steps were taken.
| Discussion|| |
Tuberculosis is a chronic granulomatous disease that can affect various systems of the body. In humans Mycobacterium tuberculosis, Mycobacterium bovis and atypical mycobacterium causes the disease.  Tuberculosis of the mandible is considered a rare disease which apparently affects both sexes, with male preponderance. According to Chapotel, more than 60% cases of tuberculous osteomyelitis of the mandible are seen in patients less than 15 years of age;  but it can be seen in old age as well. Because of the presence of less cancellous bone in the mandible, occurrence of tuberculous infection in the mandible is extremely rare. ,,, The mandibular involvement is more frequent than maxilla  and within the mandible, the alveolar and angle regions have a greater predilection. ,
Tuberculosis of the jaw causes slow necrosis of the bone and may involve the entire mandible. The destruction of bone in radiographs appears as blurring of the trabeculae with irregular radiolucency. There is erosion of cortex which shows little tendency to repair. Gradually the bone is replaced by soft trabecular granulation tissue and appearance of caseation which is followed by softening and liquefaction. A soft periosteal abscess then forms presenting as a painless soft swelling. This cold abscess later on may burst either intra-orally or extra-orally forming single or multiple sinuses. This may result in a pathological fracture of mandible and sequestration. 
Tuberculosis of the mandible presents as a multifocal lesion elsewhere in body, involving other bones and lungs. Out of 64 cases reported up to 1939, about 43% of the patients with tuberculosis of the mandible had tubercular lesion in the bones elsewhere in the body. , Chaudhary et al. reported a case of tuberculosis of mandible in a 4-year-old child who failed to respond to antibiotics and tuberculosis was diagnosed subsequently.  Mishra et al. reported a primary TB of mandible who recovered after 2 years of ATT. 
The diagnosis of a case of tuberculous osteomyelitis of mandible is extremely difficult  as there are no specific signs which are pathognomic of the infection.  The only manifestation may be a localized swelling of the jaw which may be misdiagnosed as a pyogenic abscess or if sinuses are present, may be confused with other granulomatous diseases like actinomycosis. Finally the diagnosis must be established by histological examination of tissue and demonstration of the organisms in the lesions  and prompt treatment with ATT should be started as early as possible.
| Conclusion|| |
Despite its rare occurrence, tuberculous osteomyelitis should be considered as a differential diagnosis when routine therapy fails to bring about improvement in the lesions. Early detection of the disease results in complete cure and can lead to reversal of all destructive bony changes. If not diagnosed at the right time, this can lead to serious complications like tuberculous meningitis. Early diagnosis of tuberculous osteomyelitis helps in the reduction of the morbidity.
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[Figure 1], [Figure 2], [Figure 3]
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