Recalcitrant osteomyelitis following tooth extraction in a case of malignant osteopetrosis

Maxillary osteomyelitis in a young female with osteopetrosis: unveiling an uncommon connection

Osteopetrosis encompasses a spectrum of conditions marked by heightened bone density due to faulty osteoclast-mediated bone resorption, leading to an accumulation of immature bone and thickened cortical structures. This condition gives rise to bone fragility, blood cell irregularities, nerve entrapment and growth challenges, all stemming from disrupted bone remodelling. Craniofacial distinctiveness, encompassing anomalies in the skull and jaw, is a frequent occurrence. Osteopetrosis presents a range of clinical signs, including facial and dental anomalies. The diagnostic process involves thorough clinical and radiological assessments, often obviating the need for genetic testing. Interestingly, few prior reports have delved into the specifics of craniofacial and dental issues in osteopetrosis. The presented case showcases rare occurrence of maxillary osteomyelitis. The diagnosis was established through a combination of history, clinical, radiographic and laboratory findings. The patient declined surgical intervention, leading to the implementation of conservative management involving regular irrigation alongside systemic antibiotic therapy.

Non-radiation and non-drug-induced maxillary osteomyelitis: Study of underlying risk factors, presentation, management and treatment outcomes

Background

Osteomyelitis of the jawbone is mostly secondary to radiation exposure or bone remodelling drugs, with the mandible being commonly involved. Maxillary osteomyelitis risk is low owing to its high vascularity. This study was undertaken to evaluate risk factors, presentation, management and outcomes of maxillary osteomyelitis caused due to reasons other than irradiation and bone remodelling drugs.

Methods

Patient records diagnosed with maxillary osteomyelitis were evaluated for demographic details, risk factors, clinical presentation, radiological features, treatment performed and outcomes.

Results

In 38 patients with non-irradiated and non-drug-induced osteomyelitis, 13 involved the maxilla, seven were localized to the posterior maxilla and 10 showed paranasal sinus involvement. Dissemination to the cavernous sinus and cerebral spread was seen in one. Clinical findings included oroantral communication, pain and draining sinus. Imaging showed diffuse bone destruction areas with or without evidence of bony sequestrum. The most common systemic risk factor was diabetes mellitus. Maxillary osteomyelitis was associated with tooth extraction in eight cases. Surgical management included debridement, sequestrectomy, functional endoscopic sinus surgery, maxillectomy and reconstruction of soft tissue defect with local and regional flaps. Complete recovery was seen in 11 patients. Mortality was seen in two patients with mucormycosis having disseminated infection.

Conclusion

Compared with previous literature, a relatively higher ratio of maxillary involvement was reported. Diabetes mellitus was the most common risk factor, followed by osteopetrosis and tooth extraction. Osteomyelitis secondary to mucormycosis in immunocompetent patients was relatively localized and gave favourable response to management compared with patients with diabetes mellitus.

Isavuconazole in the Treatment of Aspergillus fumigatus Fracture-Related Infection: Case Report and Literature Review

Aspergillus fracture-related infection (FRI) is a rare, but severe complication in trauma surgery. The optimal antifungal treatment for Aspergillus osteomyelitis, including FRI, has not been established yet, as only cases have been documented and data on bone penetration of antifungal drugs are scarce. We describe a patient with Aspergillus fumigatus FRI of the tibia who was treated with isavuconazole after developing liver function disturbances during voriconazole therapy. Isavuconazole, the active moiety formed after hydrolysis of the prodrug isavuconazonium sulfate by plasma esterases, was administered in a maintenance dose of 200 mg q24 h, followed by 150 mg q24 h. The patient completed a six-month antifungal treatment course. Although fracture union was not achieved during six months of follow-up after therapy cessation, no confirmatory signs of FRI were observed. Additionally, two literature searches were conducted to review available data on antifungal treatment of Aspergillus osteomyelitis and bone penetration of antifungals. One hundred and eight cases of Aspergillus osteomyelitis, including six (5.6%) FRI cases, were identified. Voriconazole and (lipid formulations of) amphotericin B were the most commonly used antifungals. In three (2.8%) cases isavuconazole was prescribed as salvage therapy. Data on antifungal bone penetration were reported for itraconazole, voriconazole, amphotericin B, anidulafungin and 5-fluorocytosin. Isavuconazole might be a promising alternative for the treatment of Aspergillus osteomyelitis. However, standardized case documentation is needed to evaluate the efficacy of isavuconazole and other antifungals in the treatment of Aspergillus osteomyelitis, including FRI.

Case report of osteomyelitis of the mandible in osteopetrosis and management considerations

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Management guidelines in mandibular osteomyelitis in Osteopetrosis.

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A female patient with osteopetrosis presented osteomyelitis after teeth extraction.

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Our case suggests the importance to maintain at maximum existing mandibular bone.

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Dental prevention could reduce occurrence of osteomyelitis in Osteopetrosis.

Introduction and importance

Osteopetrosis is a poorly known and probably underdiagnosed pathology. It is caused by various genetic abnormalities resulting in osteoclast dysfunction. Functional and aesthetic consequences have a major impact on the patient’s quality of life. Ten percent of osteopetrosis cases develop osteomyelitis that usually involves the mandible. Management of this complication remains complex and often unsatisfactory.

Case presentation

We report a case of a 62-year-old woman with osteopetrosis, complicated by mandibular osteomyelitis with intra-oral bone exposure and submental fistulas. Management was performed with antibiotic therapy and surgical necrotic resection. This cured the fistulas but the bone exposure persisted.

Discussion

This case report highlights the difficulty of achieving complete healing of osteomyelitis in osteopetrosis. Antibiotic therapy, surgical management, or even hyperbaric oxygen therapy are required, but must be adapted to the case. A free flap procedure is undesirable but, when it is necessary, a bone marrow transplant could be considered to restore osteoclast function.

Conclusion

The management of mandibular osteomyelitis in patients with osteopetrosis must adapt to the situation and severity. To avoid most cases of osteomyelitic complications in patients suffering from osteopetrosis, we propose that a preventive strategy of better dental care should be considered.

Extensive maxillary osteomyelitis following tooth extraction in a patient with osteopetrosis

Osteopetrosis (OP), also known as marble bone disease is an extremely rare inherited skeletal disorder, characterised by abnormal functioning of the osteoclasts that results in incremental bone deposition with lack of normal bone remodelling. This leads to the formation of hard and brittle bone can readily fracture. The compromised quality of marrow tissue with poor vascularity reduces bone healing and increases the risk of infections. The risk of jawbone osteomyelitis in patients with OP is high and invariably involves mandible. Involvement of maxilla is rare and has been sparingly reported in the literature. This paper highlights a case of extensive necrosis of maxilla and mid-face skeleton following tooth extraction in a patient with OP. Review of the English literature identifying 23 previously published reports of maxillary osteomyelitis in patients with OP is also presented. Demographic details, history of tooth extraction, extent of involvement, clinical presentation, imaging finding, treatment provided and the outcome have been discussed.

Osteopetrosis: presenting as maxillary osteomyelitis

Osteopetrosis is a rare congenital disease presenting with recurrent fractures, hematopoietic insufficiency and hepatosplenomegaly. Though osteomyelitis is a known complication in osteopetrosis, osteopetrosis presenting as osteomyelitis is rare. Management consists of multidisciplinary approach for complications and bone marrow transplant for the infantile form of disease.

Ultrastructural Analyses of Alveolar Bone in a Patient With Osteomyelitis Secondary to Osteopetrosis: A Review of the Literature

Osteopetrosis is a generic term for generalized sclerotic conditions caused by rare genetic disorders. Decreased osteoclastic activities disturb bone remodeling, resulting in greater mineral density and greater compressive strength; therefore, bone fracture is a major physical symptom of osteopetrosis. Osteomyelitis of the maxilla or mandible is a common and well-documented complication of osteopetrosis. Local infection, such as odontogenic infection, is more likely to lead to osteomyelitis, and treatment strategies can be challenging. However, detailed ultrastructural analyses of bone from patients with osteopetrosis and odontogenic infection are limited. This report describes a case of osteomyelitis of the maxilla and mandible secondary to osteopetrosis in an adult patient and presents ultrastructural data of alveolar bone tissue analyzed by contact microradiography, electron probe microanalysis, and x-ray diffraction. Cases of osteomyelitis of the jaw secondary to osteopetrosis also are reviewed.

Marble Bone Disease: A Rare Bone Disorder

Osteopetrosis, or marble bone disease, is a rare skeletal disorder due to a defective function of the osteoclasts. This defect renders bones more susceptible to osteomyelitis due to decreased vascularity. This disorder is inherited as autosomal dominant and autosomal recessive. Healthcare professionals should urge these patients to maintain their oral health as well as general health, as this condition makes these patients more susceptible to frequent infections and fractures. This case report emphasizes the signs and symptoms of marble bone disease and presents clinical and radiographic findings. 

CLCN7 and TCIRG1 mutations differentially affect bone matrix mineralization in osteopetrotic individuals

Osteopetrosis is an inherited disorder of impaired bone resorption, with the most commonly affected genes being CLCN7 and TCIRG1, encoding the Cl(-) /H(+) exchanger CLC-7 and the a3 subunit of the vacuolar H(+) -ATPase, respectively. We and others have previously shown that the disease is frequently accompanied by osteomalacia, and that this additional pathology is also found in Tcirg1-deficient oc/oc mice. The remaining question was whether osteoid enrichment is specifically associated with TCIRG1 inactivation, or whether CLCN7 mutations would also cause skeletal mineralization defects. Here we describe a complete osteologic assessment of one family carrying a novel mutation in CLCN7 (D145G), which impairs the activation and relaxation kinetics of the CLC-7 ion transporter. The two siblings carrying the mutation in the homozygous state displayed high bone mass, increased serum levels of bone formation markers, but no impairment of calcium homeostasis when compared to the other family members. Most importantly, however, undecalcified processing of an iliac crest biopsy from one of the affected children clearly demonstrated a pathological increase of trabecular bone mass, but no signs of osteomalacia. Given the potential relevance of these findings we additionally performed undecalcified histology of iliac crest biopsies from seven additional cases with osteopetrosis caused by a mutation in TNFRSF11A (n=1), CLCN7 (n=3), or TCIRG1 (n=3). Here we observed that all cases with TCIRG1-dependent osteopetrosis displayed severe osteoid accumulation and decreased calcium content within the mineralized matrix. In contrast, there was no detectable bone mineralization defect in the cases with TNFRSF11A-dependent or CLCN7-dependent osteopetrosis. Taken together, our analysis demonstrates that CLCN7 and TCIRG1 mutations differentially affect bone matrix mineralization, and that there is a need to modify the current classification of osteopetrosis.

Osteopetrosis, osteopetrorickets and hypophosphatemic rickets differentially affect dentin and enamel mineralization

Osteopetrosis (OP) is an inherited disorder of defective bone resorption, which can be accompanied by impaired skeletal mineralization, a phenotype termed osteopetrorickets (OPR). Since individuals with dysfunctional osteoclasts often develop osteomyelitis of the jaw, we have analyzed, if dentin and enamel mineralization are differentially affected in OP and OPR. Therefore, we have applied non-decalcified histology and quantitative backscattered electron imaging (qBEI) to compare the dental phenotypes of Src(-/-), oc/oc and Hyp(-/0) mice, which serve as models for OP, OPR and hypophosphatemic rickets, respectively. While both, Src(-/-) and oc/oc mice, were characterized by defects of molar root formation, only oc/oc mice displayed a severe defect of dentin mineralization, similar to Hyp(-/0) mice. Most importantly, while enamel thickness was not affected in either mouse model, the calcium content within the enamel phase was significantly reduced in oc/oc, but not in Src(-/-) or Hyp(-/0) mice. Taken together, these data demonstrate that dentin and enamel mineralization are differentially affected in Src(-/-) and oc/oc mice. Moreover, since defects of dental mineralization may trigger premature tooth decay and thereby osteomyelitis of the jaw, they further underscore the importance of discriminating between OP and OPR in the respective individuals.

Osteomyelitis of the mandible in a patient with osteopetrosis. Case report and review of the literature

Osteopetrosis is a rare hereditary bone disorder presenting with variable clinical features and is characterized by an increase in bone density and reduction of marrow spaces that result from a defect in the function of osteoclasts and, consequently, a decrease in bone turnover. This disease is generally divided into three types: severe infantile malignant autosomal recessive, intermediate mild autosomal recessive, and benign autosomal dominant. The prognosis of the first two types is very poor and is characterized by an early onset, usually within the first decade of life, and early death. The benign-type is characterized by a later onset and a longer life span. Ten percent of osteopetrosis cases develop osteomyelitis that usually involves the mandible. The osteomyelitis is generally caused by tooth extraction or pulpal necrosis. The leading cause of the increased rate of infection is thought to be a lack of adequate bone vasculature. Treatment of osteomyelitis secondary to osteopetrosis is controversial. Treatment regimens include high-dose systemic antibiotics coupled with thorough debridement of necrotic bone and primary closure of soft tissues, if possible. Hyperbaric oxygen has been used for the treatment of chronic osteomyelitis.

When bone becomes marble: Head and neck manifestations of osteopetrosis

Osteopetrosis is a genetically determined bone disease resulting from malfunction of osteoclastic activity, leading to excessive deposition of immature bone. This may result in complete agenesis of the paranasal sinuses, oral complications and multiple cranial neuropathies. The case of a 12-year-old boy with osteopetrosis is presented.

Osteomyelitis of Maxilla in Infantile Osteopetrosis: A Case Report with Review of Literature

Osteopetrosis is a rare genetic disorder that causes generalized sclerosis of bone due to a defect in bone resorption and remodeling. It is usually manifesting in two basic forms: An autosomal dominant benign form (osteopetrosis tarda) and an autosomal recessive malignant form (osteopetrosis congenita). A third form, the intermediate recessive type, has also been reported. Dental abnormality may be attributed to pathological changes in bone remodeling. Osteomyelitis is well documented as a complication of osteopetrosis and is severe and difficult to treat. This is a case of 8-year-old boy with osteopetrosis presenting with the complaint of swelling of left side of face.

Osteopetrosis complicated by osteomyelitis of the maxilla and mandible: light and electron microscopic findings

This report presents a case of osteopetrosis in a 25-year-old male, which was complicated by the development of osteomyelitis in the maxilla and mandible following traumatic injury and tooth extractions. The osteomyelitis in the mandible was refractory to marginal resection and antibiotic therapy. Partial resection with mandible reconstruction was then carried out. Light and backscattered electron scanning microscopy revealed sclerosis of spongy bone and variations in mineral density of the bone matrix. There was also a prominent periosteal bone formation in regions affected by osteomyelitis. An 18-month follow-up showed absence of active infections in the face and oral structures, with a focal area of bone exposure in the right parasymphysis. However, development of anemia and bone marrow deficiency will likely affect prognosis. The importance of preventive oral health care and dental/periodontal managements in osteopetrosis is emphasized.

Maxillomandibular osteomyelitis in osteopetrosis. Report of a case and review of the literature

INTRODUCTION

Osteopetrosis is a rare hereditary group of bony displasias. They range from a devastating metabolic disease (including severe malignant infantile osteopetrosis) to other conditions with a more benign phenotype (autosomal dominant osteopetrosis I and II).

CASE REPORT

Several case reports have been published of infectious complications affecting the mandible but maxillary affectation is quite rare. We present the case of a 23-year-old woman with a malignant recessive form of osteopetrosis complicated by repeated episodes of osteomyelitis (caused by actinomyces) of the mandible and maxilla.

Maxillofacial aspects in malignant osteopetrosis

OBJECTIVE

Malignant osteopetrosis (MO) is a rare hereditary disease that affects young children. Its physiopathology is explained by a basic defect in osteoclast precursor cells, with a radiographic image of diffuse sclerosis and increased bone density. The bone contains an increased number of structurally abnormal osteoclasts. Infections commonly occur because the neutrophils exhibit reduced chemotactic response and decreased ability of bacterial phagocytosis.

PATIENT

A white female patient aged 9 months, of mixed descent, was diagnosed at birth as having MO after bone marrow biopsy. Dental examination revealed the presence of four teeth, all of which had enamel hypoplasia and no carious lesions. After bone marrow transplantation (BMT), an erythematous lesion appeared on the alveolar ridge on day 2, with signs of tooth exfoliation. On day 7, there was gingival bleeding, edema, and erythema at the region of the maxillary incisors with grade 3 mobility, without changes in food intake.

RESULTS

Concerning the oral cavity, the patient maintained grade 1 tooth mobility without tooth exfoliation or other oral alterations.

CONCLUSION

Accurate diagnosis and careful therapeutic planning are important to avoid the secondary complications of the disease.

Imaging findings of bisphosphonate-associated osteonecrosis of the jaws

BACKGROUND AND PURPOSE

Bisphosphonates are drugs that decrease bone turnover by inhibiting osteoclast activity. An association between the use of bisphosphonates and osteonecrosis of the maxilla and mandible has recently been described. This study describes the imaging findings of bisphosphonate-associated osteonecrosis of the jaws.

MATERIALS AND METHODS

This is a retrospective series of 15 clinically diagnosed patients, identified at 3 centers. Eleven patients were women, of whom 6 had breast cancer, 3 had osteoporosis, and 2 had multiple myeloma. Of the 4 male patients, 2 had prostate cancer, 1 had multiple myeloma, and 1 had osteoporosis. The age range of the patients was 52-85 years (average, 68 years). The mandible was the clinical site of involvement in 11 patients, and the maxilla was involved in 4 patients. Imaging consisted of orthopantomograms in 14 patients, CT scans in 5 patients, and radionuclide bone scan in 1 patient. Nine patients had sequential imaging. Two radiologists reviewed the images.

RESULTS

All of the patients had a degree of osseous sclerosis, most commonly involving the alveolar margin, but lamina dura thickening and full-thickness sclerosis were also observed. The sclerotic change encroached on the mandibular canal in 3 patients. Less commonly encountered findings included poorly healing or nonhealing extraction sockets, periapical lucencies, widening of the periodontal ligament space, osteolysis, sequestra, oroantral fistula, soft tissue thickening, and periosteal new bone formation.

CONCLUSIONS

The most common finding in bisphosphonate-associated osteonecrosis was osseous sclerosis. This varied from subtle thickening of the lamina dura and alveolar crest to attenuated osteopetrosis-like sclerosis.

Osteopetrosis complicated by osteomyelitis of the mandible: a case report including characterization of the osteopetrotic bone

A case of a 53-year-old Japanese man with osteopetrosis complicated by osteomyelitis of the mandible is presented. The patient experienced frequent exacerbations and remissions of osteomyelitis of the mandible, despite undergoing several surgical debridements and sequesterectomies with appropriate antimicrobial therapy, for 3 years. Finally, the patient underwent mandibular segmental resection followed by reconstruction with a titanium reconstruction plate. Fifty-one months after surgery there is no evidence of recurrent osteomyelitis of the mandible, suggesting that a more radical surgical approach is preferable for patients with severe complications resulting from osteopetrosis. Also presented here are the histopathological and biochemical features of the osteopetrotic bone. The osteopetrotic cortical bone was morbidly sclerotic with compact and irregular laminations. Degradation of osteocytes in the osteopetrotic bone was due to hypoxia and lack of nutrition resulting from osteosclerosis. There were no significant differences between osteopetrotic and normal bone according to X-ray diffraction, Fourier transform infrared spectroscopy, collagen content or mineral content. Micro-Vickers hardness measurements showed that osteopetrotic bone was significantly harder than normal bone, and the standard deviation of hardness was greater in osteopetrotic bone. Such a loss of integrity in osteopetrotic bone is considered to be a primary reason for the greater risk of a variety of complications such as pathological fracture and refractory osteomyelitis.