Infección por bartonella henselae en pacientes pediátricos. Lesión pseudotumoral de calota. Reporte de caso

Los tumores de calota en pacientes pediátricos poseen múltiples etiologías. Dentro de las causas pseudotumorales, las infecciones juegan un rol importante, siendo la osteomielitis por Bartonella henselae (Enfermedad por Arañazo de Gato) una posibilidad diagnóstica rara, pero que debe ser estudiada y descartada. Se presenta el caso de una lactante de 1 año, con lesión expansiva de calota, a nivel frontal derecho, hipervascularizada e infiltrativa. Se realizó estudio con ultrasonido, tomografía cerebral y cintigrama óseo. Se realizó resección quirúrgica completa de la lesión, con preservación de la duramadre y zona fontanelar, además de un cuidadoso trato con el seno sagital superior. Evolucionó sin complicaciones perioperatorias. El resultado de la biopsia fue compatible con proceso inflamatorio crónico, osteomielitis supurada. Tinción de Warthin Starry positiva sugerente de Bartonella henselae. Se descartó etiología tuberculosa y fúngica. Serología positiva para Bartonella henselae. La paciente completó antibioticoterapia, azitromicina y cotrimoxazol, con evolución clínica favorable.

Calvarial tumors in pediatric patients have multiple etiologies. Among the pseudotumoral causes, infections play an important role, being Bartonella henselae osteomyelitis (Cat Scratch Disease) a rare diagnostic possibility, but it should be studied and ruled out. We present the case of a 1 year old infant, with an expansive lesion of the calvaria, at right frontal level, hypervascularized and infiltrative. Ultrasound, brain tomography and bone scintigram were performed. Complete surgical resection of the lesion was performed, with preservation of the dura mater and fontanel area, in addition to a careful treatment with the superior sagittal sinus. The patient evolved without perioperative complications. The biopsy result was compatible with a chronic inflammatory process, suppurative osteomyelitis. Positive Warthin Starry stain suggestive of Bartonella henselae. Tuberculous and fungal etiology was ruled out. Positive serology for Bartonella henselae. The patient completed antibiotic therapy, azithromycin and cotrimoxazole, with favorable clinical evolution.

Reconstrucción primaria con implantes personalizados después de resección de gran tumoración craneofacial / Primary reconstruction with customized implants after resection of a large craniofacial tumor

Reportamos la reconstrucción inmediata con implantes personalizados en la región craneofacial en una paciente mujer de 22 años con tumoración craneofacial de 12x15 cm en la región fronto orbito cigomático izquierdo que correspondió a fibroma oscificante. Se realizó la reconstrucción con un implante hecho a medida basado en imágenes tomográficas. El implante de polieteretercetona (PEEK) fue seleccionado para reemplazar la pérdida ósea y para restaurar la anatomía facial. No hubo necesidad de ajuste transquirúrgico del implante; ni se presentaron reacciones de rechazo, infección o exposición del implante en el periodo posoperatorio. Aunque el hueso autólogo es preferido para implantes, resulta difícil adecuarlos en situaciones de un compromiso extenso como en el caso presentado; por ello los implantes de PEEK son actualmente una opción en términos de biocompatibilidad, resistencia, duración, conductividad térmica y traslucencia radiográfica.

We report the immediate reconstruction with personalized implants in the craniofacial region in a 22-year old female patient with a craniofacial tumor of 12x15 cm in the left zygomatic orbital frontal region that corresponded to an ossifying fibroma. The reconstruction was performed with a custom-made implant based on tomographic images. The polyetheretherketone (PEEK) implant was selected to replace bone loss and restore facial anatomy. There was no need for transsurgical adjustment of the implant, no rejection, infection or implant exposure in the postoperative period. Although autologous bone is preferred for implants, it is often limited in the morbidity of the donor site, the difficulty of giving shape mainly to the borders and the limitation of the area to be donated; therefore the PEEK implants are currently an option in terms of biocompatibility resistance, duration, thermal conductivity and radiographic translucency.

Osteoma craniofacial: estudo de 35 casos / Craniofacial osteoma: study of 35 cases

Introdução: O osteoma é um tumor benigno de crescimento lento, composto de osso esponjoso ou compacto, originado no periósteo dos ossos craniofaciais. Objetivo: Relatar o perfil epidemiológico de pacientes portadores de osteomas craniofaciais. Métodos: Foi realizado um estudo multicêntrico retrospectivo dos casos diagnosticados no Serviço de Neurocirurgia do Hospital Governador João Alves Filho (Aracaju/SE), durante o período entre janeiro de 1999 a junho de 2008 e no Laboratório da Disciplina de Patologia Bucal da Faculdade de Odontologia de Pernambuco - FOP, da Universidade de Pernambuco - UPE, no período de julho de 1992 a julho de 2008. Foram analisados os indicadores gênero, faixa etária, localização topográfica, sintomatologia, tratamento, a partir de ficha própria de coleta de dados. Resultados: Foi observado que 14 casos (40%) possuíam localização craniana, enquanto em 21 casos (60%) o acometimento era facial. A localização topográfica craniana mais freqüente foi o osso frontal (57%), seguido pelo temporal (14%). Na face, o osso mandibular predominou com 67% dos casos. O gênero feminino mostrou-se predominante, com 60% dos casos. As lesões foram mais freqüentes na segunda década de vida (40%), independentemente se o acometimento foi craniano ou facial. Apresentaram-se comumente assintomáticas (62%), sendo os casos sintomáticos em sua maioria com localização craniana (57%). Conclusões: Os osteomas cranianos e faciais são mais freqüentes no osso frontal e mandibular, respectivamente. O gênero feminino e a segunda década de vida mostram mais acometimento. A maioria dos casos apresentou-se assintomática, porém, sintomáticos quando cranianos.

Introduction: Osteoma is a benign slow growth tumor, constituted by compacted or sponged bone with the origin in the skull and face periosteum. Objective: To report the epidemiologic pattern of patients with craniofacial osteomas. Methods: A multicentric retrospective study was done, regarding the cases diagnosed at Governador João Alves Filho Hospital Neurosurgery Service (Aracaju/SE) between January, 1999 and June, 2008 and at the Pernambuco School of Dentistry Oral Pathology Laboratory (FOP/UPE), between July, 1992 and July, 2008. It was analyzed gender, age, topographic site, symptomatology and treatment, through an own paper for data collection. Results: It was observed that 14 cases (40%) were in the skull and 21 cases (60%) in the face. At the skull, the frontal bone was most prevalent (57%), followed by temporal bone (14%). In the face, the mandible represented 67% of all cases. Lesions in females were predominant, with 60% and in the second decade of life (40%). They were mostly asymptomatic (62%), with the symptomatic cases frequently in the skull (57%). Conclusion: The skull and facial osteomas occur frequently in the frontal bone and mandible, respectively. The women and second decade of life show more involvement. Most cases appeared to be asymptomatic, being symptomatic when at the skull.

Ewing's Sarcoma Mimicking a Meningioma in Radiological Findings: A Case Report

Ewing's sarcoma is an uncommon primary bone tumor. Primary Ewing's sarcoma of the cranium is extremely rare and constitutes only 1% of all Ewing's sarcoma cases. Usually, primary Ewing's sarcoma of the carnium manifests as an expansile osteolytic malignant bone tumor with or without intracranial extension. We report here the radiological findings of a case of Ewing's sarcoma mimicking a meningioma in an 18-year-old man.

Primary Intraosseous Malignant Fibrous Histiocytoma of the Skull: A Case Report

Malignant fibrous histiocytoma(MFH) is a rare primary neoplasm that constitutes less than 1% of the malignant tumors of bone, and involvement of the skull is very rare. We present a case of malignant fibrous histiocytoma of the skull, presenting an intraosseous lesion in a 43-yr-old woman. She had a rapidly growing, tender mass in the right parietal region. A plain radiograph showed an osteolytic lesion of the right parietal bone. Magnetic resonance imaging revealed that the lesion showed heterogeneous low signal intensity on T1-weighted images and slightly high signal intensity on T2-weighted images. No evidence of an extraosseous extension to the adjacent dura and soft tissue was found, and a wide excision of the parietal bone was performed. Histologically, the tumor was a typical MFH displaying pleomorphic spindle cells in a storiform pattern. The results of immunohistochemical stainings revealed that the tumor cells were positive for vimentin, alpha-1-antitryp-sin, and p53, and negative for smooth muscle actin, S100 protein, desmin, and MyoD1. Three months later, a mainly cystic, recurrent mass was developed at the previously operated site. Before the resection, we first performed the percutaneous aspiration cytology, revealing diagnostic multinucleated pleomorphic cells. There-after, she had to receive repetitive resections of recurrent or residual lesions, and she died of postoperative meningoencephalitis two years after the first operation.

Clinical and Radiological Analysis of Scalp Masses

OBJECTIVE: The authors report an analysis of clinical data including incidence, clinical manifestations, diagnostic tools and surgical treatment of neoplasms of scalp and calvarium in adults. METHODS: The clinical, radiological, and pathological records of 67 patients who underwent mass excision in scalp or skull at our department during recent five years were reviewed. RESULTS: The mean age was 43 years(range 16 to 85 years) and male to female ratio was 42 : 25. There were 62 scalp and five calvarial masses. Among scalp masses, there were 52 tumors, three vascular lesions, three inflammatory lesions and four miscellaneous lesions. The scalp tumors were composed of 44 benign lesions and nine malignant lesions. The most common type of scalp tumor was lipoma, followed by epidermoid and dermoid. The calvarial masses consisted of four osteomas and one eosinophilic granuloma. Surgical excision was carried out in all cases. CONCLUSION: Most scalp and calvarial masses are benign lesions, however, surgical excision seemed to be indicated in most cases for diagnosis and treatment.

Imaging diagnosis of skull epidermoid cyst:analysis of four cases / 中华放射学杂志

Objective To study the CT and MR imaging features of skull epidermoid cyst. Methods CT and MR findings of 4 cases of pathologically proved skull epidermoid cyst were analyzed and correlated with operative and pathologic reports.Results CT and MR appearances of skull epidermoid cyst were as follows:(1)crater-form or scalloping deossification with sclerotic border and fatty density focus was detected on CT.(2)The lesions were isointense to hypointense relative to normal white matter in T1-weighted image,prominent hyperintense in T_2-weighted image,mild to moderate hyperintense in diffusion-weighted imaging(DWI),and isointense to hypointense in apparent diffusion coefficient(ADC) map on MR.Proton MRS revealed lactate(Lac)peaks at 1.3 ppm and amino acids(AAs)at 0.9 ppm. (3)No enhancement was found in substance region of all tumors on both enhanced CT and enhanced MR examinations.Conclusion CT and MR appearances of skull epidermoid cyst have unique features which are very helpful in the diagnosis of skull epidermoid cyst.

Intracranial Inflammatory Pseudotumors: MRI and CT Findings

PURPOSE: The purpose of this study was to describe the MR imaging and CT findings of intracranial inflammatory pseudotumors. MATERIALS AND METHODS: We reviewed the MR imaging (n=8) and CT (n=4) studies of eight patients (M:F = 4:4, mean age: 41 years) with pathologically proven intracranial inflammatory pseudotumor. The findings were then evaluated with regard to location, shape, MR signal intensity, CT density and degree of contrast enhancement of the lesion, surrounding parenchymal edema, adjacent bone change and the location of accompanying extracranial lesion. RESULTS: In two patients, the parietal convexity was involved unilaterally, with no extracranial mass, and in the other six, the middle cranial fossa was involved unilaterally and extracranial mass was present. The lesion also involved the tentorium in four cases, the cavernous sinus in four, the anterior cranial fossa in one, and the posterior cranial fossa in one. The location of extracranial mass was the mastoid and middle ear cavity in two cases, the infratemporal fossa in two, both the infratemporal fossa and paranasal sinuses in one, and the orbit in one. MR images showed diffuse dural thickening in all eight cases, leptomeningeal thickening in four, and focal meningeal-based mass in two. As seen on T1-weighted images, the lesions were isointense to gray matter in eight cases, and on T2-weighted images were hypointense in seven cases and isointense in one. Marked homogeneous contrast enhancement was seen in all eight cases. The lesions seen on brain CT, performed in two cases, were isodense. Adjacent brain parenchymal edema and the destruction of adjacent bones were each seen in five cases. CONCLUSION: The characteristic MR findings of intracranial inflammatory pseudotumors are(1) diffuse dural thickening;(2) a focal meningeal-based mass which on T2-weighted images is seen as hypointense; and marked (3) contrast enhancement : these findings are, however, nonspecific. In order to differentiate these tumors, an awareness of these findings is, however, useful.