Current diagnosis and treatment of skull base osteomyelitis / 临床耳鼻咽喉头颈外科杂志

Skull base osteomyelitis is a rare, refractory, and potentially fatal disease primarily caused by otogenic and sino rhinogenic infections. At times, it can mimic neoplasia complicating the diagnosis. With the use of antibiotics, advancements in diagnostic methods, and skull base surgical techniques, the mortality rate has significantly improved. However, the successful diagnosis and treatment of the disease is still challenging due to delayed diagnosis, lengthy treatment course, a tendency for relapse and lack of guidelines. Therefore, this article aims to review the progress in the diagnosis and treatment of skull base osteomyelitis.

Osteomielitis cervical asociada a otitis crónica. Presentación de un caso / Cervical osteomyelitis associated with chronic otitis. A case report

Introducción : La osteomielitis es la infección de estructuras óseas ya sea por inoculación directa a través de heridas, por vía hematógena a través de focos distantes o por contigüidad con estructuras vecinas como los oídos. Objetivo: Reportar un caso que demuestra la necesidad de seguimiento de las otitis medias con vistas a evitar recurrencias y complicaciones. Presentación del Caso: Paciente femenina, de 62 años de edad, tez blanca y ama de casa de la localidad de Baracoa, provincia Guantánamo, Cuba. Con antecedentes de otitis de un año de evolución que desarrolló osteomielitis crónica cervical y un cuadro neurológico caracterizado por cuadriparesia y dificultad para la acción asociado a la osteomielitis cervical. Se trató con vancomicina y levofloxacino durante 6 semanas y oxigenación hiperbárica con lo cual egresó totalmente rehabilitada. Conclusiones: El manejo inadecuado de la otitis puede desencadenar complicaciones graves y poco frecuentes como la osteomielitis cervical tal y como se presenta en este caso(AU)

Introduction: Osteomyelitis is the infection of the osseous structures associated with the direct inoculation of microorganisms through wounds, hematogenous route from distant focus of infection or the contiguity with neighboring structures like the ears. Objective: The aim of this paper is to demonstrate the need for medical follow-up of otitis media in order to avoid recurrence and complications of this disease. Case presentation: Sixty-two-year-old white woman, housewife, from Baracoa, Guantanamo Province, Cuba. The patient had antecedents of one-year history of otitis media. She developed cervical chronic osteomyelitis and a neurological picture that was characterized by quadriparesis and difficulty to carry out actions, which was associated with cervical osteomyelitis. She was treated with Vancomycin and Levofloxacin during 6 months and hyperbaric oxygenation that helped her to be totally recovered after discharge from hospital. Conclusions: Inadequate treatment of otitis can cause very serious and less frequent complications such as cervical osteomyelitis, as it is presented in this case(AU)

The Unknown Cause of Pott's Puffy Tumor ­ Importance of Early Diagnose

Pott's puffy tumor (PPT) is characterized by swelling of the glabelar region and osteomyelitis of the frontal bone, owing to a subperiosteal pseudoinflammatory tumor responsible for the detachment of the pericranium from the outer table of the skull. Nowadays, the incidence of PPT is very low, so this entity is frequently underdiagnosed. The late treatment and identification of PPT are strongly associated with intracranial complications, which could jeopardize the life of the patient. In the literature, PPT is described as a complication of frontal head trauma or of chronic sinusitis. There are a few cases reported in patients with frontal insect bites or in recreational nasal drug users, such as cocaine or methamphetamines. In the present case report, the authors describe the case of a 40-year-old male who was submitted to a frontal sebaceous cyst surgery. In the postoperative period, he developed an infectious process compatible with PPT. After an extensive review of the literature, no similar cases were identified. Therefore, in the opinion of the authors, sebaceous cyst surgery should be included in the short list of risk factors for the development of PPT.

Análise do perfil de atendimentos por osteomielite em pacientes acima de 60 anos em regiões brasileiras / Analysis of the profile of osteomyelitis care in patients over 60 years of age in Brazilian regions

Objetivo: Realizar uma análise estatística das internações de pacientes idosos com osteomielite, por região brasileira. Métodos: Foram pesquisadas informações de saúde disponíveis na plataforma do Departamento de Informática do Sistema Único de Saúde (DATASUS), avaliando-se, de 2012 a 2016, as variáveis: internações por osteomielite (M86 do CID-10), faixa etária acima de 60 anos, sexo e etnia. Resultados: De 78.967 pacientes internados por osteomielite no Brasil, 16.736 (21,19%) eram idosos, com a Região Sudeste registrando maior número de casos (7.163 internações; 42,79%), seguida da Nordeste (5.165; 30,86%), da Sul (2.462; 14,71%), da Centro-Oeste (1.162; 6,9%) e da Norte (784; 4,6%). O número de internações manteve-se relativamente constante, com média de 3.347 casos por ano. Pacientes de 60 a 69 anos foram os com maior registro (8.786 casos; 52,49%). Em segundo lugar, ficaram os de 70 a 79 anos (5.232; 31,2%) e, por último, os acima de 80 anos (2.718; 16,24%). Em relação ao sexo, o masculino notificou 9.232 internações (55,16%), com 7.504 (44,83%) para o feminino. A etnia branca apresentou maior número de notificações (6.117; 36,54%), principalmente nas Regiões Sudeste e Sul, seguida pela parda (4.947; 29,55%), que se destacou dentre as demais regiões. Conclusão: Diante da heterogeneidade de fatores que predispõem à osteomielite, com destaque para o diabetes mellitus, urge garantir um manejo precoce da infecção e de comorbidades causadoras, a fim de evitar complicações debilitantes ao idoso, bem como prevenir futuras recidivas e internações onerosas ao sistema de saúde brasileiro. (AU)

Objective: To perform a statistical analysis of hospitalizations of elderly patients with osteomyelitis, by Brazilian region. Methods: Health information available from the Informatics Department of the Unified Health System (DATASUS) platform was investigated, from 2012 to 2016. The following variables were assessed: admissions due to osteomyelitis (ICD-10 M86), age group over 60, gender and ethnicity. Results: Of the 78,967 patients hospitalized due to osteomyelitis in Brazil, 16,736 (21.19%) were elderly, with the Southeast Region having a higher number of cases (7,163 admissions - 42.79%), followed by the Northeast (5,165 - 30.86%), South (2,462 - 14,71%), Midwest (1,162 - 6,9%), and North (784 - 4,6%). The number of hospitalizations remained relatively constant, with an average of 3,347 cases per year. Patients aged 60 to 69 years were the ones with the highest registry (8,786 cases - 52.49%); in second place, those aged 70 to 79 years (5,232 - 31.2%) and, finally, those above 80 years old (2,718 - 16.24%). Regarding gender, males accounted for 9,232 hospitalizations (55.16%), with 7,504 (44.83%) for females. White people had the highest number of reports (6,177 - 36.54%), mainly in the Southeast and South Regions, followed by browns (4,947 - 29.55%), who were more prevalent in the other regions. Conclusion: In view of the heterogeneity of factors that predispose to osteomyelitis, especially diabetes mellitus, it is urgent that early management of the infection and causative comorbidities is ensured, in order to avoid debilitating complications for the elderly, as well as to prevent future relapses, and costly hospitalizations to the Brazilian health system. (AU)

La alveolitis dental en pacientes adultos del Policlínico René Bedia Morales. Municipio Boyeros / Dental Alveolitis in adult patients in René Bedia Morales policlinic at Boyeros municipality

RESUMEN Introducción: la alveolitis dentaria es una complicación pos-textracción dental, local, dolorosa y reversible del alveolo. Objetivo: caracterizar la alveolitis dental en pacientes adultos del Policlínico "René Bedia Morales", perteneciente al municipio Boyeros. Mareriales y métodos: se realizó un estudio descriptivo de corte transversal, en el Policlínico "René Bedia Morales", municipio Boyeros, provincia La Habana, en el periodo comprendido de septiembre de 2016 a septiembre de 2017. El universo estuvo constituido por 250 pacientes, de ambos sexos. Diagnosticados con alveolitis dental tras haberse realizado exodoncia durante ese periodo. La muestra quedó conformada por 187 pacientes que cumplieron con los criterios de inclusión y exclusión. Se estudiaron las variables: edad, sexo, tipo de alveolitis y factores asociados a las mismas. La información fue recogida en un modelo de recogida de datos, bajo su consentimiento informado. Resultados: el grupo de edad más afectado fue el de 35-59 años, con 47,59 %. Predominó el sexo femenino, con un 66,84 %. Prevaleció la alveolitis seca, en un 55,08 %. Relacionado con las conductas inadecuadas del paciente, la afectación fue de un 40,64 %. El no cumplimiento de las indicaciones postoperatorias y fumar, luego de la exodoncia, fueron los factores más asociados a la alveolitis seca; con un 53,48 % y un 41,18 %, respectivamente. Conclusiones: la alveolitis afectó fundamentalmente a los pacientes de 35-59 años de edad, del sexo femenino. Con mayor frecuencia predominó la alveolitis seca relacionada a las conductas inadecuadas del paciente (AU).

ABSTRACT Introduction: Dental alveolitis is a local, painful dental pos extraction complication which is reversible. Objective: Provide a characterization of dental alveolitis in René Bedia Morales policlinic at Boyeros Municipality. Materials and methods: A descriptive transversal study was performed in René Bedia Morales policlinic at Boyeros Municipality, in Havana Province. The study was performed in a time span between September 2016 to September 2017. The study universe was constituted by 250 patients of both sexes diagnosed with dental alveolitis after have made extractions in that period of time and the sample remained formed for 187 patients , that met with the criteria of inclusion and exclusion. Age, sex, type of alveolitis and associated factors were the variables considered in the present study. The data was collected in a input data form, under the patients concern. Results: The most affected age group was from 35 to 59 years old which represents a 47,59 %, being the feminine sex the predominant group which represents a 66,84 %. Dry alveolitis was predominant in 55,08 % related to inadequate behaviors within a 40,64 % The most frequent factors associated to the non-fulfillment of the pos operatory orders, such as smoking after having performed the procedure of exodontia with a 53,48 % and 41,18 % respectively. Conclusions: Alveolitis mainly affects patients within 35-59 years old, feminine sex, and also related to inadequate behaviors of the patients (AU).

Florid cemento-osseous dysplasia and peripheral giant cell granuloma in a patient with neurofibromatosis 1

Abstract: We report a 35-year-old mulatto female patient with neurofibromatosis Type 1 who presented with facial asymmetry. The patient had two lesions: florid cemento-osseous dysplasia associated with peripheral giant cell granuloma. She was referred for surgical treatment of the peripheral giant cell granuloma and the florid cemento-osseous dysplasia was treated conservatively by a multidisciplinary team. So far, no changes have been observed in the patient's clinical status. We observed no recurrence of peripheral giant cell granuloma. To the best of our knowledge, the present case is the first report of a patient with neurofibromatosis Type 1 associated with a giant cell lesion and florid cemento-osseous dysplasia.

Análise crítica do protocolo de tratamento da ferida operatória complicada após esternotomia para cirurgia cardíaca / Analysis of the treatment protocol for sternotomy wound infection after cardiac surgery

Introdução: As complicações de ferida operatória após esternotomia para acessos cirúrgicos para procedimentos cardiovasculares variam desde pequenas deiscências até mediastinite e osteomielite do esterno. Mediastinite e osteomielite do esterno associam-se a alto risco, alta morbidade e altas taxas de mortalidade, além de altas taxas de recidiva. O tratamento nos casos de maior gravidade envolvem internação hospitalar prolongada. A utilização de antibióticos por tempo prolongado, durante a internação, e após a alta, tem impacto importante no custo global do tratamento. Mais recentemente, uma opção de tratamento envolve o amplo debridamento cirúrgico da ferida em centro cirúrgico, preparo do leito da ferida com terapia por pressão negativa, seguida do fechamento da ferida com retalhos miocutâneos ou fasciocutâneos. Aparentemente, essa estratégia traz vantagens como a melhora na qualidade de vida do paciente, menor manipulação e menor incômodo ao doente, menos sobrecarga para os profissionais de saúde envolvidos nos cuidados, menor taxa de recidiva infecciosa e, assim, redução da morbidade do tratamento como um todo. Métodos: O presente estudo tem por objetivo realizar levantamento dos pacientes vítimas dessa grave complicação que tenham sido tratados segundo protocolo desenvolvido e aprimorado no Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor - HCFMUSP), e que tenham sido operados por um mesmo cirurgião plástico, a fim de analisar o perfil epidemiológico, e eventual indicador de pior prognóstico dentre os exames colhidos habitualmente desses pacientes. Foram avaliados, retrospectivamente, os prontuários dos pacientes atendidos no InCor - HCFMUSP vítimas de infecção de esternotomia durante o ano de 2014. As variáveis analisadas foram comorbidades, intervalo entre abordagens cirúrgicas, valores de Proteína C Reativa (PCR), procedimento empregado no fechamento da ferida, complicações do tratamento, entre outros. Resultados: Os dados são essencialmente descritivos e de caráter epidemiológico: observa-se a incidência de ao menos uma comorbidade em 84% dos pacientes; média de 2,5 procedimentos cirúrgicos por paciente, variando de 1 a 7 procedimentos; queda nos níveis de PCR em 75% dos pacientes já após o primeiro procedimento cirúrgico e mortalidade de 17%, entre outros dados. Conclusão: Os dados analisados nos permitem concluir que o método padronizado adotado trouxe impacto na redução da mortalidade global dos pacientes, além da redução de recidiva e reinternações. Identificamos, ainda, indicadores de pior prognóstico como PCR e leucograma no momento do diagnóstico e indicação da aplicação do protocolo.

Introduction: Surgical wound complications after sternotomy in cardiovascular procedures include small dehiscences, mediastinitis, and sternal osteomyelitis. Mediastinitis and sternal osteomyelitis are high-risk complications associated with high rates of morbidity, mortality, and recurrence. Treatment of the most severe cases involves prolonged hospitalization. Moreover, the long-term use of antibiotics during hospitalization and after discharge significantly increases the overall cost of treatment. A recent treatment option involves extensive surgical debridement of the surgical wound, treatment of the wound bed with negative pressure therapy, and closure of the wound with myocutaneous or fasciocutaneous flaps. The advantages of this strategy include improvement of the patient's quality of life, less manipulation and less discomfort for the patient, less burden on staff involved in care, lower rate of infection recurrence, and an overall reduction of treatment morbidity. Methods: The objective of this study was to conduct a retrospective survey of patients with surgical wound complications who were treated according to a protocol developed and improved by the Heart Institute of the Clinic Hospital of the School of Medicine of the University of São Paulo (Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo­InCor/HC-FM-USP), and who underwent surgery by the same plastic surgeon. The epidemiological profiles and possible indicators of worse prognosis were determined from routine examinations performed on these patients. The medical records of patients treated at InCor/HC-FM-USP who presented with sternotomy infection in 2014 were assessed retrospectively. The analyzed variables included comorbidities, interval between surgical procedures, C-reactive protein (CRP) levels, wound closure procedures, and treatment complications, among others. Results: The data are predominantly descriptive and epidemiological. At least one comorbidity was present in 84% of cases. The mean number of surgical procedures per patient was 2.5, ranging from 1 to 7. The CRP levels decreased in 75% of patients after the first surgical procedure, and the mortality rate was 17%. Conclusion: The standardized method adopted significantly decreased the overall mortality and the rates of recurrence and readmission. Indicators of worse prognosis, including CRP levels and the leukogram, were identified at the time of diagnosis and initiation of the treatment protocol.

Absceso del psoas y osteomielitis de la columna lumbar: Caso clínico / Psoas abscess and lumbar spine osteomyelitis: Case report

El absceso del psoas es una enfermedad infrecuente en niños. Puede tener una presentación clínica inespecífica, ser de inicio insidioso y relacionarse o no con fiebre. El tipo más frecuente en pediatría es primario; sin embargo, en ocasiones, puede ser de origen secundario y asociarse a infecciones graves, como la osteomielitis, por lo que se requiere un alto índice de sospecha para detectarlo y tratarlo oportunamente. Presentamos un caso atípico de absceso del psoas con infiltración del cuerpo vertebral de L2 en un paciente masculino de 14 años previamente sano, sin antecedente de traumatismo ni fiebre al momento del ingreso. Se realizaron una radiografía y una ecografía, pero el diagnóstico se confirmó a través de una resonancia nuclear magnética de columna lumbosacra. Conhemocultivos positivos para Staphylococcus aureus meticilino resistente, completó 2 semanas de tratamiento antibiótico endovenoso y 4 semanas por vía oral con negativización de cultivos y resolvió por completo la sintomatología inicial.

Psoas abscess is a common disease in children. It can have a nonspecific clinical presentation, insidious onset and sometimes fever. The most common type in children is the primary one; however, it can sometimes be of secondary origin and associated with severe infections such as osteomyelitis so a high index of suspicion is required to detect and treat it promptly. We present an unusual case of psoas abscess with infiltration of the vertebral body of L2 in a 14 year old male patient previously healthy with no history of trauma or fever on admission. X-ray and ultrasound were performed but the diagnosis was confirmed by magnetic resonance imaging of the lumbosacral spine. With positive blood cultures for methicillin-resistant Staphylococcus aureus he completed 2 weeks of intravenous antibiotic therapy and 4 weeks of oral antibiotic therapy with blood cultures negativization and resolution of symptoms.

Osteomielitis causante de fractura patológica: reporte de un caso / Pathological fracture resulting from osteomyelitis: report of a case

Las fracturas patológicas mandibulares son poco comunes, representanel 1 a 2% de todas las fracturas. Pueden ser defi nidas como fracturasque ocurren en regiones donde el hueso ha sido debilitado bajo un procesopatológico. Los factores de causa más comunes incluyen procesosquirúrgicos tales como extracciones de terceros molares, colocación deimplantes, osteonecrosis relacionada con bifosfonatos, osteorradionecrosisde la mandíbula, osteomielitis, infecciones, tumores o lesionesquísticas. La osteomielitis es una condición infl amatoria del hueso; estapatología es uno de los factores que puede determinar el debilitamientodel hueso mandibular y causar una subsecuente fractura patológica. Laosteomielitis mandibular se puede desarrollar si una infección primaria noes manejada adecuadamente. El tratamiento de las fracturas patológicaspuede representar un reto para el profesional de la salud y difi ere segúnla etiología de la misma. Se presenta un caso de una paciente de 54 añosde edad, con una fractura mandibular patológica causada por osteomielitis,la cual fue tratada con antibioticoterapia e intervención quirúrgica.

Pathological mandibular fractures are rare, accounting for between1 and 2% of all fractures. They can be defi ned as fractures thatoccur in regions where the bone has become weakened as a result of a pathological process. Common causal factors include surgicalprocedures such as third molar removal, implant placement, bisphosphonate-related osteonecrosis, osteoradionecrosis of the jaw,osteomyelitis, infections, tumors, and cystic lesions. Osteomyelitisis an infl ammatory condition of the bone; this pathology is one ofthe factors that may prompt weakening of the mandibular boneand cause subsequent pathological fracture. Osteomyelitis of themandible may develop if a primary infection is not properly treated.Treatment of pathological mandibular fractures can be challengingand varies according to their etiology. This article looks at the caseof a 54-year-old woman with a pathological mandibular fracture caused by osteomyelitis, which was treated by means of antibioticotherapy and surgical intervention.

Osteomielitis del maxilar secundaria a rinosinusitis en la infancia: Caso clínico / Maxillary osteomyelitis secondary to rhinosinusitis in children: Case report

La rinosinusitis es una patología muy frecuente en la infancia. Entre sus complicaciones, se encuentra la osteomielitis, rara complicación que, cuando se presenta, ocurre, principalmente, en lactantes y niños pequeños. El agente etiológico más frecuente es el Staphylococcus aureus. Clínicamente, se manifiesta con fiebre alta, edema de párpado inferior, rinorrea unilateral y edema palatino ipsilateral; luego se agrega un absceso sobre el área maxilar yuxtanasal y/o sobre los alvéolos dentarios. Secundariamente, pueden desarrollarse secuestros, expulsiones espontáneas de piezas dentarias y trayectos fistulosos, así como complicaciones orbitarias y endocraneales. El diagnóstico es, sobre todo, clínico; se confirma con tomografia computada. El tratamiento es médico quirúrgico. Se presenta un niño de 5 años de edad con rinosinusitis complicada con osteomielitis del hueso maxilar, cuyo germen responsable fue el Staphylococcus aureus meticilino resistente.

Rhinosinusitis is a very common childhood condition. Osteomyelitis is an unusual complication, which mainly occurs in toddlers and young children. The most frequent etiologic agent is Staphylococcus aureus. Iniatially, it is characterized by fever, low eyelid edema, unilateral rhinorrhea and ipsilateral palatine edema. Subsequently, abscesses develop in the maxillar yuxtanasal and/or the dental alveolar area. Secondary, it can be complicated by sequestrations, spontaneous expulsion of dental pieces and/or fistula, as well as orbital and intracranial complications. The diagnosis is based on clinical findings and is confirmed by computed tomography findings. The treatment is clinical and surgical. Here we report a five year old child, with rhinosinusitis complicated by osteomyelitis of maxillary bone, mediated by a methicillin-resistant Staphylococcus aureus infection.

Diagnóstico y tratamiento de displasia fibrosa madura complicada con osteomielitis crónica. Reporte de caso / Diagnosis and treatment of mature fibrous dysplasia complicated by chronic osteomyellitis. Case report

La displasia fibrosa es una lesión congénita, lentamente progresiva que puede provocar graves alteraciones morfológicas y funcionales, y estar sujeta a complicaciones de tipo infeccioso. En este reporte de caso se presenta a un paciente masculino de 8 años de edad diagnosticado con una displasia fibrosa madura luego de un hallazgo incidental durante un examen de rutina, el paciente durante el curso de los últimos cinco años ha presentado osteomielitis a repetición en el sitio de biopsia y de exfoliación dentaría, el cuadro clínico se ha tratado mediante curetajes y aseos quirúrgicos y con la indicación antibiótica de clindamicina sin resultados positivos. Se concluye que el manejo de las displasias fibrosas maduras puede ser difícil una vez que se ha instalado un proceso infeccioso crónico sin poder dar de alta al paciente, manteniéndolo permanentemente en control. (AU)

Fibrous dysplasia is a slowly progressive congenital lesion that can cause serious morphological and functional alterations , and complications of infectious type . This case report presents a 8 years old male patient diagnosed with a mature fibrous dysplasia after an incidental finding during a routine examination, the patient during the course of the last five years has been presented recurrent osteomyelitis episodes in the biopsy site and temporal tooth during exfoliation, it has been treated by surgical curettage and clindamycin with no positive results. We conclude that the management of mature fibrous dysplasia can be difficult once a chronic infectious process has been installed without being able to discharge the patient, constantly keeping it in control.(AU)

Condroblastoma de presentación atípica en concomitancia a osteomielitis crónica operado con cirugía radical: caso clínico / Chondroblastoma of atypical presentation in conjunction with chronic osteomyelitis operated through radical surgery: clinical case

INTRODUCCIÓN: El condroblastoma es un tumor óseo benigno representando menos del 1 por ciento del total de tumores óseos; se presenta principalmente en jóvenes. De etiología controversial, se desarrolla habitualmente en centros secundarios de osificación en huesos largos. No hay casos que describan su existencia junto a osteomielitis ni su tratamiento quirúrgico. CASO CLÍNICO: Mujer de 15 años con antecedente de osteomielitis de inicio reciente, diagnosticada con cintigrafía y biopsia en escápula izquierda; a pesar de tratamiento médico antibiótico con cloxacilina persiste dolor, eritema, impotencia funcional y aumento de volumen progresivo. Cintigrafía de control confirma nula respuesta a tratamiento inicial. Tomografía computada (TC) informa probable proceso tumoral osteolítico cortical con reacción de partes blandas en casi la totalidad de la escápula incluyendo cavidad glenoidea. Biopsia quirúrgica informa condroblastoma sospecha de variante agresiva resolviéndose con escapulectomía total con resección de cabeza humeral y posterior pexia clavículo-humeral. Biopsia definitiva de pieza quirúrgica informa osteomielitis crónica y condroblastoma agresivo. Evolución favorable en controles posteriores sin signos de recidiva local ni a distancia. DISCUSIÓN: La nula respuesta clínica al tratamiento inicial y su progresión hizo sospechar un proceso tumoral no diagnosticado inicialmente debido a que la biopsia no incluyó focos del condroblastoma. El manejo clásico del condroblastoma consiste en curetaje y relleno con autoinjerto; pero debido a la localización atípica, posibilidad de malignización y coexistencia con proceso osteomielítico crónico se optó por cirugía innovadora que consistió en resección total y posterior pexiaclavículo-humeral

INTRODUCTION: A Chondroblastoma is a benign bone tumor, corresponding to less than 1 percent of all bone tumors, and affecting mainly young people. Commonly developing in secondary centers of ossification in large bones, there are no cases describing its existence along with osteomyelitis, nor its surgical treatment. CLINICAL CASE: Woman (15 Y/O) with a history of osteomyelitis onset caused by a recent fall is diagnosed through scintigraphy and biopsy in the left scapule. Despite treatment with cloxacillin, pain persisted, erythema developed, with a progressive increase of volume and functional impotence. Control scintigraphy confirms no response to initial treatment. Computed Tomography (CT) informs of a probable cortical osteolysis tumoral process with soft tissue reactions in almost the entire scapule including glenoid cavity. Surgical biopsy shows chondroblastoma and, suspecting an agressive variant, it is resolved to perform a total scapulectomy with resection of scapule head and subsequent humerus-claviclepexia. Definitive biopsy of surgical piece shows chronic osteomyelitis and agressive chondroblastoma. The evolution of the patient is normal on follow-up controls, not presenting any signs of local neither distant relapse. DISCUSSION: The non-existence of a response to the initial treatment and its progression made us suspect of a natural process that was not diagnosed initially because the biopsy didn't include chondroblastoma focus. The usual chondroblastoma treatment consists of curetting and autograft filling; but due to the atypical location, and the possibility of coexistence with malignant and chronic osteomyelitic process we chose to apply an innovative surgery that consisted of total resection and subsequent pexia.

Osteomielitis mandibular como complicación de la enfermedad de Albers-Schõmberg / Mandibular osteomyelitis as a complication of Albers-Schomberg disease

La enfermedad de Albers-Schõmberg u osteopetrosis es un raro padecimiento óseo. La osteomielitis mandibular es una infrecuente complicación de esta enfermedad. Por ello y por lo interesante de la presentación clínica de ambas entidades, nos propusimos como objetivo presentar este caso. Este paciente masculino de 32 años con antecedentes de enfermedad de Albers- Schõmberg de tipo adulta benigna que dos años atrás acudió a consulta y refirió haberse realizado una exodoncia once meses antes, a partir de lo cual presentó aumento de volumen facial y dolor de intensidad variable con períodos de agudización. Luego del estudio clínico e imagenológico se llegó al diagnóstico de una osteomielitis mandibular como complicación de su enfermedad de base. Se aplicó terapia antimicrobiana, exéresis del hueso necrótico y oxígeno hiperbárico. A los dos años acudió a consulta con una reagudización del proceso, se le produjo la expulsión espontánea de un secuestro óseo y se decidió la realización de una mandibulectomía parcial más reconstrucción con placa mandibular. En estos momentos el paciente no presenta signos de reagudización del proceso y se mantiene bajo vigilancia estricta a los tres meses de realizada la intervención quirúrgica(AU)

Albers-Schomberg disease or osteopetrosis is a rare bone condition. Mandibular osteomyelitis is an infrequent complication of this disease. It was for this reason, alongside the peculiar clinical presentation of both entities, that we decided to present this case. A male 32-year-old patient with a history of benign adult Albers-Schomberg disease attended consultation two years ago and stated to have undergone exodontia eleven months before, after which he had had facial swelling and pain of variable intensity with acute episodes. Clinical and imaging studies led to the diagnosis of mandibular osteomyelitis as a complication of his underlying condition. Treatment consisted of antimicrobial therapy, exeresis of the necrotic bone and hyperbaric oxygen. Two years later the patient came back to consultation with a relapse of the acute pain process. Spontaneous expulsion of an osseous sequestrum was performed, followed by partial mandibulectomy and reconstruction with a mandibular plate. At this moment the patient does not present any signs of relapse of the acute pain process. Three months after surgery, he remains under strict surveillance(AU)

A Case of IgM Deficiency with B Cell Deficiency Detected by ABO Discrepancy in a Patient with Acute Osteomyelitis

ABO discrepancy refers to an inconsistency between red cell and serum typings and has various causes, including hypogammaglobulinemia. IgM deficiency is a rare disorder that may accompany several conditions such as infection and autoimmune disorders. Here, we describe a case of IgM deficiency discovered during the evaluation of an ABO discrepancy in a 16-yr-old Korean boy. ABO blood grouping showed that while his cell type was O+, serum typing detected only anti-A (3+). Anti-B was not detectable at room temperature but was graded at 1+ at 4degrees C. ABO genotyping revealed an O/O genotype. His serum IgG, IgA, and IgM concentrations were 770 mg/dL (reference range: 800-1,700 mg/dL), 244 mg/dL (reference range: 100-490 mg/dL), and 13.5 mg/dL (reference range: 50-320 mg/dL), respectively. He was diagnosed with acute osteomyelitis on the basis of clinical presentation and imaging studies. The symptoms gradually improved within 3 weeks of treatment. However, the ABO discrepancy and IgM deficiency persisted even 6 months after recovery and lymphocyte subset analysis revealed CD19+ B cell deficiency. To the best of our knowledge, IgM deficiency detected by ABO discrepancy in a patient with acute osteomyelitis has not been reported before.

A Case of IgM Deficiency with B Cell Deficiency Detected by ABO Discrepancy in a Patient with Acute Osteomyelitis

ABO discrepancy refers to an inconsistency between red cell and serum typings and has various causes, including hypogammaglobulinemia. IgM deficiency is a rare disorder that may accompany several conditions such as infection and autoimmune disorders. Here, we describe a case of IgM deficiency discovered during the evaluation of an ABO discrepancy in a 16-yr-old Korean boy. ABO blood grouping showed that while his cell type was O+, serum typing detected only anti-A (3+). Anti-B was not detectable at room temperature but was graded at 1+ at 4degrees C. ABO genotyping revealed an O/O genotype. His serum IgG, IgA, and IgM concentrations were 770 mg/dL (reference range: 800-1,700 mg/dL), 244 mg/dL (reference range: 100-490 mg/dL), and 13.5 mg/dL (reference range: 50-320 mg/dL), respectively. He was diagnosed with acute osteomyelitis on the basis of clinical presentation and imaging studies. The symptoms gradually improved within 3 weeks of treatment. However, the ABO discrepancy and IgM deficiency persisted even 6 months after recovery and lymphocyte subset analysis revealed CD19+ B cell deficiency. To the best of our knowledge, IgM deficiency detected by ABO discrepancy in a patient with acute osteomyelitis has not been reported before.

Absceso vertebral secundario a pancreatitis / Abcès vertébral après une pancréatite / Vertebral abscess secondary to pancreatitis

Introducción: la pancreatitis aguda es una enfermedad inflamatoria que con frecuencia facilita condiciones para el desarrollo de procesos infecciosos. Objetivo: exponer la osteomielitis vertebral como una infrecuente complicación ósea de la pancreatitis. Descripción: se presenta el caso clínico de un paciente masculino de 55 años con antecedentes de litiasis vesicular, obeso y bebedor ocasional, que después de una pancreatitis aguda necrotizante desarrolló diabetes mellitus tipo 1 y absceso espinal con fístula paravertebral. La presencia de secreción, síntomas dolorosos lumbares, así como estudios humorales e imaginológicos, confirman la osteomielitis en T10. Se practicó el drenaje por costotransversectomía, la antibioticoterapia y el corsé, y el paciente resultó curado y sin limitaciones neurológicas. Conclusiones: el drenaje oportuno y dirigido hacia el área de colección purulenta, la antibioticoterapia de amplio espectro y la inmovilización externa, garantizan la curación y previenen las complicaciones óseas, en esta infrecuente entidad(AU)

Introduction: acute pancreatitis is an inflammatory disease commonly paving the way for infectious processes. Objective: discuss vertebral osteomyelitis as an infrequent bone complication of pancreatitis. Description: a clinical case is presented of a male 55-year-old patient with a history of gallstones, obese and an occasional drinker, who developed type 1 diabetes mellitus and a spinal abscess with a paravertebral fistula after suffering from acute necrotizing pancreatitis. The presence of secretion and lumbar pain symptoms, as well as the results of humoral and imaging studies, confirmed the diagnosis of osteomyelitis at T10. Treatment consisted of drainage by costotransversectomy, antibiotic therapy and a corset. The patient was cured without any neurological limitation. Conclusions: timely drainage aimed at the area of purulent collection, broad spectrum antibiotic therapy and external immobilization ensure recovery and prevent bone complications in this infrequent condition(AU)

Introduction: la pancréatite aiguë est une affection inflammatoire aboutissant habituellement à des processus infectieux. Objectif: montrer l'ostéomyélite vertébrale comme une complication osseuse rare de la pancréatite. Description: le cas d'un patient du sexe masculin, âgé de 55 ans, avec une histoire de lithiase vésiculaire, obèse et buveur occasionnel, souffrant après une pancréatite aiguë nécrosée d'un diabète sucré type 1 et d'un abcès spinal avec une fistule paravertébrale, est présenté. La suppuration, la douleur lombaire, et les examens humoraux et d'imagerie ont confirmé une ostéomyélite au niveau de T10. Le drainage par costo-transversectomie, l'antibiothérapie, et le corset orthopédique ont guéri le patient complètement et sans limites neurologiques. Conclusions: le drainage de la collection purulente, les antibiotiques à large spectre et l'immobilisation externe assurent la guérison et préviennent les complications osseuses de cette rare affection(AU)

Evolução clínica e tomográfica da osteomielite frontal: relato de caso / Clinical and tomography evolution of frontal osteomyelitis: case report

INTRODUÇÃO: A osteomielite frontal é uma complicação de rinossinusite que pode ter evolução aguda ou crônica. Há reação inflamatória com aumento da pressão intra-óssea, isquemia e necrose local, levando à formação de abscesso ósseo. Não havendo drenagem, ocorrerá descolamento do periósteo, invasão de partes moles e piora da isquemia com posterior sequestro ósseo. MÉTODO: Relato de caso de um paciente internado em serviço de emergência de outra instituição por complicação de rinossinusite que foi encaminhado para o Serviço de Otorrinolaringologia do Hospital Universitário Professor Edgard Santos da Universidade Federal da Bahia. RELATO DE CASO: Paciente masculino, 16 anos, apresentou-se ao serviço de emergência de outra instituição com cefaleia, vômitos e febre que evoluiu com edema periorbitário e frontal à esquerda, cursando com flutuação palpebral e frontal.Submetido à drenagem de abscesso palpebral e frontal, com antibioticoterapia de amplo espectro sem melhora. Encaminhado para o nosso serviço mantendo edema e flutuação em região frontal e edema leve em região periorbitária esquerda. A endoscopia nasal evidenciou edema em meato médio à esquerda e a tomografia computadorizada mostrou sinusite fronto-etmoidal à esquerda e sinais de osteomielite frontal com sequestro ósseo e empiema epidural.Submetido à cirurgia endoscópica nasossinusal, acesso externo para exérese do osso frontal acometido e drenagem do empiema epidural. Evoluiu com remissão da doença. CONSIDERAÇÕES FINAIS: A falência no diagnóstico e no tratamento das complicações da rinossinusite pode levar a sequelas e complicações fatais.O diagnóstico de osteomielite frontal é firmado pela suspeita clinica e confirmado por exames radiológicos.A cirurgia está indicada quando a evolução for insidiosa, havendo sequestro ósseo ou complicações intracranianas.

INTRODUCTION: The frontal osteomyelitis is a complication of rhinosinusitis which can evolve to acute or chronicle. There is inflammatory reaction by the increasing of intraosseous pressure, ischemia and local necrosis, leading to bone abscess formation. There is no drainage, it will occur detachment of the periosteum, soft tissue invasion and worsening of ischemia with subsequent bone sequestration. METHOD: Case report of an inpatient in an emergency service of another institution by the complication of rhinosinusitis who was referred to the Otorhinolaryngology Service of University Hospital Professor Edgard Santos of Federal University of Bahia. CASE REPORT: Male patient, 16 years-old, presented himself to the ER of another institution with cephalea, vomits and fever which evolved to periorbital edema and frontal to the left, moving to palpebral fluctuation and frontal. Subjected to frontal and palpebral abscess drainage, with broad-spectrum antibiotic therapy with no improvement. He was referred to our service keeping edema and fluctuation in region frontal and light edema in left periorbital region. The nasal endoscopy showed edema in meatus to the left and the computerized tomography showed fronto-ethmoid sinusitis to the left and signs of frontal osteomyelitis with bone sequestration and epidural empyema. Subjected to sinasal endoscopy surgery, external Access or removal of the frontal one affected and epidural empyema drainage. Evolved to the remission of the disease. FINAL CONSIDERATIONS: Failure in the diagnosis and rhinosinusitis complication treatment can lead to sequalae and fatal complications. The diagnosis of the frontal osteomyelitis is confirmed by the clinical suspicion and confirmed by radiological examination. The surgery is indicated when the evolution is insidious, there is bone sequestration and intracranial complications.

Úlcera de Marjolin associada a ulceração e osteomielite crônicas / Marjolin's ulcer associated with ulceration and chronic osteomyelitis

Doente do sexo masculino, de 78 anos, portador de uma úlcera venosa crônica na perna esquerda, com cerca de 24 anos de evolução, complicada por carcinoma espinocelular. Após o estadia mento da doença, o tratamento preconizado foi amputação acima do joelho esquerdo. A úlcera de Marjolin é a transformação maligna de uma lesão ulcerosa crônica. Trata-se de um fenômeno relativamente raro. A neoplasia maligna mais frequentemente descrita na literatura é o carcinoma espinocelular, seguido do basalioma, sarcoma e melanoma. A sua patogenia permanece pouco compreendida.

This report describes a 78-year old male patient with a chronic venous ulcer on his left leg for the past 24 years, complicated by a squamous-cell carcinoma. After staging of the disease, the treatment administered was amputation of the leg above the knee. Marjolin's ulcer consists of the malignant transformation of a chronic ulcerative lesion. It is a relatively rare phenomenon. The malignant tumor most commonly described in the literature is squamous cell carcinoma, followed by basal-cell carcinoma, sarcoma and melanoma. The pathogenesis of Marjolin's ulcer remains to be fully clarified.

A Case of Atypical Skull Base Osteomyelitis with Septic Pulmonary Embolism

Skull base osteomyelitis (SBO) is difficult to diagnose when a patient presents with multiple cranial nerve palsies but no obvious infectious focus. There is no report about SBO with septic pulmonary embolism. A 51-yr-old man presented to our hospital with headache, hoarseness, dysphagia, frequent choking, fever, cough, and sputum production. He was diagnosed of having masked mastoiditis complicated by SBO with multiple cranial nerve palsies, sigmoid sinus thrombosis, and septic pulmonary embolism. We successfully treated him with antibiotics and anticoagulants alone, with no surgical intervention. His neurologic deficits were completely recovered. Decrease of pulmonary nodules and thrombus in the sinus was evident on the follow-up imaging one month later. In selected cases of intracranial complications of SBO and septic pulmonary embolism, secondary to mastoiditis with early response to antibiotic therapy, conservative treatment may be considered and surgical intervention may be withheld.