Roopa Viraraghavan, MD, MPH

FigureA 15-year-old Hispanic boy with a 9-month history of mildly painful unilateral facial swelling presented to the emergency department (ED) when the swelling worsened and began to impinge on his visual field. The mass measured 88 cm. Diffuse petechiae were also present. 

The patient had no recent fevers, cough, or weight loss. His medical history was notable for chronic thrombocytopenia and reactive arthritis, for which he had been hospitalized. His maternal grandmother had systemic lupus erythematosus; his mother had died of congestive heart failure and emphysema.

The white blood cell count was 8300/?L, with 66% segmented neutrophils, 0% bands, 11% monocytes, and 22% lymphocytes. The hemoglobin level was 14.1 g/dL, and the platelet count was 53,000/?L. The C-reactive protein level was 5.5 mg/L. Blood cultures were negative. Antibody titers for

 infections were negative. Serological studies were positive for Epstein-Barr virus-viral capsid antigen IgG, but negative for IgM. They were positive for Cytomegalovirus IgG, but again negative for IgM. Chest films showed no abnormalities.

MRI scans showed inflammation with cortical erosion and a round fluid collection, suggestive of an abscess, adjacent to the mandibular ramus on the right (A and B). The patient was hospitalized with a diagnosis of osteomyelitis of the mandible and an abscess in the masseter muscle. Therapy with clindamycin and ceftriaxone was started initially, with no clinical response.

A biopsy of the mass was obtained via an incision in the patient's mouth. Acid-fast bacillus smear and fungal stains of the specimen were negative. Histological examination showed a noncaseating granulomatous reaction with no evidence of malignancy.

Results of an angiotensin-converting enzyme inhibitor assay were negative for sarcoidosis. Purified protein derivative (tuberculin) (PPD) skin test results were negative. Cultures for 

 showed no growth. Blood tests revealed a low CD4+ cell count and poor B cell response to 

 antigens. A nitroblue tetrazolium test result was within normal limits and an enzyme- linked immunosorbent assay for HIV infection was also negative. The platelet count was 60/?L .

Empiric treatment for tuberculosis with isoniazid, rifampin, pyrizinamide, and ethambutol was started. The mass shrunk to 4 4 cm within 5 days. The patient was transferred to the public health department and followed up as an outpatient by his primary physician.

Tuberculous osteomyelitis is uncommon; it usually involves vertebrae (ie, Potts disease). Bone and joint infections can originate from hematogenous spread, direct seeding, extension from a regional lymph node, or extension from adjacent infected bone. Bone infection can be complicated by a soft tissue abscess because of an extension of the infection through the epiphysis. This was probably the case with this teenager.

The most common sites of skeletal tuberculosis are the knee, hip, elbow, and ankle. The process usually evolves over months to years. The tuberculin skin test result is reactive in 80% to 90% of cases. This was not the case with this patient. Culture of joint fluid or a bone biopsy usually yields the organism.

Although this patient had not been born in or had not lived in a developing country, he is a child of immigrants and, with his history of chronic swelling, skeletal tuberculosis with abscess was a major consideration after malignancy was ruled out.

This patient completed a year of antituberculous treatment. At follow-up, results of another PPD test were negative, there was no remaining deformity, and MRI scans demonstrated clear improvement (C and D). A year after he finished treatment, the mass had not returned.

American Academy of Pediatrics. Tuberculosis. In: Pickering LK, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2006: 678-698. 

American Thoracic Society, CDC, and the Infectious Diseases Society of America. Treatment of tuberculosis. MMWR. 2003;52(RR-11):1-77. 

Hoffman EB, Crosier JH, Cremin BJ. Imaging in children with spinal tuberculosis. A comparison of radiography, computed tomography and magnetic resonance imaging. J Bone Joint Surg Br. 1993;75:233-239. 

Starke JR. Mycobacterium tuberculosis. In: Long SS, Pickering LK, Prober CG, eds. Principles and Practice of Pediatric Infectious Diseases. New York: Churchill Livingstone; 2002:791-810. 

Vallejo JG, Ong LT, Starke JR. Tuberculous osteomyelitis of long bones in children. Pediatr Infect Dis J. 1995;14:542-546. 

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Roopa Viraraghavan, MD, MPH

Articles

Tuberculosis of the Mandibular Bone and Masseter Muscle Abscess