Osteopetrosis-associated osteomyelitis of the jaws: a report of 4 cases

Phenotype-autosomal recessive osteopetrosis

Osteopetrosis (OPT) is a life-threatening disease characterized by increased bone mass caused by diminished osteoclast function/differentiation. The autosomal recessive forms, caused by biallelic variants in implicated genes, usually present in infancy. Without treatment, autosomal recessive OPTs are usually fatal within the first 10 years of life [1]. Here, we review the clinical features and associated pathophysiology of the autosomal recessive OPT. A greater understanding of these rare disorders will advance early diagnosis and optimal management.

Osteopetrosis: a rare case of portal hypertension

Osteopetrosis is a rare genetic bone disorder characterized by a defect in osteoclasts recruitment and function. Its manifestations are numerous and they mainly include skeletal and dental deformities, cranial nerve entrapment and infections. Over time, osteoclastic expansion invades bone marrow leaving little space for hematopoietic cells. As a result, extramedullary hematopoiesis takes place in the reticular system mainly in the spleen and liver. In these patients, portal hypertension can occur as a result of extramedullary hematopoiesis associated splenomegaly. We are reporting in this article a rare case of spontaneous bacterial peritonitis associated with portal hypertension in a patient with osteopetrosis.

Chronic paronychia in cats with patellar fracture and dental anomaly syndrome

CASE SERIES SUMMARY

The aim of this case series was to describe the clinical features and treatment of paronychia in cats diagnosed with patellar fracture and dental anomaly syndrome (PADS). Clinical records, photographs, microbiology, cytology and histopathology reports were collected, and follow-up was obtained. Five cats with paronychia were included. All five cats had multiple digits of multiple limbs affected and eventually underwent amputation of the third phalanx of one or multiple digits. A total of 36 digits were affected, 17% (n = 6/36) resolved with medical management and 83% (n = 30/36) were eventually treated successfully by amputation. The cats had treatment with numerous courses of antibiotics (range 7-20; mean 11 courses) over periods of time ranging from 10 to 67 months (mean 32 months).

RELEVANCE AND NOVEL INFORMATION

Chronic paronychia may be an additional clinical feature of PADS and the probable mechanism involves poor integrity of osteopetrotic bone, loss of normal nailbed anatomy and secondary osteomyelitis of the distal phalanx. Medical management with antibiotics, anti-inflammatory therapy and steroid treatment may improve the clinical signs in the short term; however, in severe instances, amputation of the third phalanx of the affected digit seems to be necessary to resolve repeated recurrences and discomfort. Additional information on the long-term outcome is required. In any cat with atraumatic patellar fractures and/or retained deciduous teeth, paronychia may require surgical management if medical management is unsuccessful.

A case series of uncommon causes of maxillary osteomyelitis: Understanding the pathology and recognizing the risks

Maxillary osteomyelitis is a rare event. With emergence of bisphosphonates, the incidence of jaw osteomyelitis has increased. We report five uncommon cases, with a comprehensive review of etiology and pathology. The correlation between osteonecrosis and osteomyelitis is discussed.

Longstanding Nonunion of Metatarsal Fractures in an Adult Patient with Autosomal Dominant Osteopetrosis: A Case Report

CASE

Osteopetrosis is a genetic condition that impairs bone turnover as the result of defects in osteoclast function and abnormal ossification of bone. Autosomal dominant osteopetrosis is often mild; however, the impaired fracture healing, increased density, and hardness of osteopetrotic bone present technical challenges for surgeons leading to complications with both nonoperative and operative treatment modalities. In this case report, we describe a patient treated empirically with ultrasonic bone stimulation for nonunion of fractures of multiple metatarsals after a failure of conventional therapy.

CONCLUSION

Ultrasonic bone stimulation may have a role in optimizing nonoperative management of osteopetrosis-related fractures in adults.

Effect of bisphosphonates on healing of tooth extraction wounds in infectious osteomyelitis of the jaw

OBJECTIVES

Antiresorptive agent-related osteonecrosis of the jaw (ARONJ) and infectious osteomyelitis of the jaw (OMJ) in antiresorptive-naïve patients are different disease entities. Although osteoclast inhibition is at the center of the pathogenesis of ARONJ, the role of osteoclast inhibition in infectious OMJ is unknown. The objective of this study was to determine the effect of bisphosphonate osteoclast inhibition in infectious OMJ.

METHODS

Osteomyelitis was induced in mice by S. aureus inoculation. The establishment of OMJ was verified by the culture of bone marrow samples obtained from the mandible. Infected animals received either zoledronic acid (ZA) or saline starting at week-2. Treated animals along with non-infected animals underwent tooth extractions at week-4 post-infection. Healing was assessed every week using in vivo micro-computed tomography and intraoral photos. Animals were euthanized at week-8 and cervical lymph nodes were assessed for lymphatic and blood vessels.

RESULTS

Tooth extraction wounds did not heal in animals with OMJ. These wounds were characterized by incomplete soft tissue coverage, sporadic bone fill in the sockets, and inflammatory cell accumulation in the connective tissue at 4 weeks after tooth extractions. Conversely, the majority of tooth extraction wounds in the infected animals treated with ZA had improved healing with better bone fill than even non-infected control animals. Consistently, atrophic lymphatic vessels were noted in the draining lymph nodes in animals with OMJ. However, infected animals treated with ZA had lymphatic vessels that were unaltered and showed a similar appearance to those in non-infected control animals.

CONCLUSION

ZA treatment promoted wound healing in the jaw with infectious osteomyelitis. Clearly, antiresorptive therapy is contraindicated in patients with ARONJ. However, our finding suggests that osteoclast inhibition is potentially an effectual remedy for infectious OMJ in antiresorptive-naïve patients.

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.

Skull pathology in 10 cats with patellar fracture and dental anomaly syndrome

CASE SERIES SUMMARY

The aim of this case series is to describe the clinical and radiological features of mandibular and maxillary abnormalities in cats diagnosed with patellar fractures and dental anomalies, a condition that we have named 'patellar fracture and dental anomaly syndrome' (PADS), also known previously as 'knees and teeth syndrome'. Where available, clinical records, skull and/or intraoral dental radiographs, head CT images, microbiology and histopathology reports were collected, and follow-up was obtained. Ten cats with mandibular or maxillary abnormalities were identified. Common clinical features included multiple persistent deciduous teeth, gingivitis and swellings of the jaw. Skull radiographs were available for 7/10 cats and head CT images were available for one cat. Findings included marked bony and periosteal proliferation, hypodontia, root resorption, root malformation and unerupted permanent teeth. Where available, microbiology and histopathology results were consistent with osteomyelitis.

RELEVANCE AND NOVEL INFORMATION

Mandibular and maxillary abnormalities are an additional unreported clinical feature of the rare condition that we have termed PADS. Radiologically, these lesions can have an aggressive appearance, which can mimic neoplasia. Medical management with antibiotic and anti-inflammatory therapy improves clinical signs in the short term; however, surgical extraction of persistent deciduous and unerupted permanent teeth, and debridement of proliferative and necrotic bone appear to be necessary for an improved outcome. Additional information on long-term outcome is required.

Pseudoacromegaly

Individuals with acromegaloid physical appearance or tall stature may be referred to endocrinologists to exclude growth hormone (GH) excess. While some of these subjects could be healthy individuals with normal variants of growth or physical traits, others will have acromegaly or pituitary gigantism, which are, in general, straightforward diagnoses upon assessment of the GH/IGF-1 axis. However, some patients with physical features resembling acromegaly - usually affecting the face and extremities -, or gigantism - accelerated growth/tall stature - will have no abnormalities in the GH axis. This scenario is termed pseudoacromegaly, and its correct diagnosis can be challenging due to the rarity and variability of these conditions, as well as due to significant overlap in their characteristics. In this review we aim to provide a comprehensive overview of pseudoacromegaly conditions, highlighting their similarities and differences with acromegaly and pituitary gigantism, to aid physicians with the diagnosis of patients with pseudoacromegaly.

Maxillary osteomyelitis associated with osteopetrosis: Systematic review

Osteopetrosis is a rare condition which presents increased bone density and deficient bone remodeling. The consequential complications include cranial nerve impairment due compression, bone fractures, and osteomyelitis. Maxillary osteomyelitis is uncommon even in osteopetrosis patients. This is a systematic review of the literature regarding the management and outcomes of maxillary osteomyelitis in patients with autosomal dominant osteopetrosis (ADO) type II. A case of this specific pathology is reported. There are 18 cases of maxillary osteomyelitis associated with ADO type II reported in the literature. The mean age of the patients reported was 33.5 (SD 15.9) years, and the male:female ratio was 1:1. Antibiotic therapy was variable, and amoxicillin with clavulanic acid was the main choice (33.33%). Surgery or sequestrectomy was performed in 88.89% of the studies. Complete healing was achieved in only 44.4% of cases. The treatment protocols remain controversial and often do not lead to complete healing. In the case that we report, complete healing was achieved after prolonged antibiotic therapy, hyperbaric oxygen therapy, and partial resection. In conclusion, the management of maxillary osteomyelitis in ADO type II patients is challenging, and complete resolution of the process is dependent on multiple interventions.

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.

Oral Rehabilitation of an Osteopetrosis Patient with Osteomyelitis

Osteopetrosis is a congenital disorder characterized by increasing osteoclastic function resulting in osteomyelitis in the jaws. Orofacial findings in osteopetrosis patients are unerupted, malformed, or delayed teeth and many dental caries due to vulnerable enamel and dentin and osteomyelitis. Many reports have described that maxilla is an uncommon site of occurrence for osteomyelitis due to cortical bone morphology and collateral circulation. This report aims to discuss clinical features and prosthodontic management of a patient with clinical features of adult form of osteopetrosis and osteomyelitis in both jaws. The patient has reported better masticatory and speech efficiency with removable dentures in maxillary and mandibular jaw and also self-esteem improvement and family interaction.

Maxillomandibular osteomyelitis associated with osteopetrosis

Osteopetrosis is a heterogeneous disorder characterized by abnormal bone remodeling and increased bone density primarily due to defective osteoclast resorption. The diagnosis is based on a history of numerous fractures and radiological findings indicative of osteosclerosis, usually sufficient for a definitive diagnosis. We present a quite rare case of osteopetrosis complicated by recurrent episodes of maxillomandibular osteomyelitis associated with cutaneous fistulization and purulent nasal discharge. We used intravenous antibiotic therapy and necrotic bone debridement that prevented the appearance of acute infections over a 3-year follow-up, but the complete healing of the case was not achieved.

Long-Term Follow-Up of Bimaxillary Osteomyelitis Associated with Autosomal Dominant Osteopetrosis: A Case Report

Osteopetrosis (OP) is a rare metabolic bone disease characterized by a generalized increase in skeletal mass. The disease is characterized by increased susceptibility to develop osteomyelitis of the jaws. We report a case of clinical and radiological progression of bimaxillary osteomyelitis in a patient with autosomal dominant OP. The patient presented non simultaneous osteomyelitis in both upper and lower jaws with time interval of 10 years. The osteomyelitis of maxilla resulted in oroantral fistula formation and required surgical closure with Bichat fat pad flap. The mandibular osteomyelitis resulted in sequestra formation and pathological fracture and required multiple debridement procedures. Both maxillary and mandibular osteomyelitic foci were persistent and healing required more than 2 years. The case confirms the possibility of development of non simultaneous bimaxillary osteomyelitis in patients with OP. The case enhances the need of close follow- up and preventive measures in patients with OP.

Clinical and Radiological Findings of Autosomal Dominant Osteopetrosis Type II: A Case Report

Osteopetrosis is a rare inherited genetic disease characterized by sclerosis of the skeleton caused by the absence or malfunction of osteoclasts. Three distinct forms of the disease have been recognized, autosomal dominant osteopetrosis being the most common. Autosomal dominant osteopetrosis exhibits a heterogeneous trait with milder symptoms, often at later childhood or adulthood. The aim of this case report is to present the clinical and radiographic features of a 35-year-old female patient with autosomal dominant osteopetrosis type II who exhibited features of chronic generalised periodontitis, and the radiographs revealed generalised osteosclerosis and hallmark radiographic features of ADO type II, that is, "bone-within-bone appearance" and "Erlenmeyer-flask deformity."

Osteopetrosis of the mandible masquerading as tubercular osteomyelitis

Osteopetrosis is a rare congenital (autosomal type) disorder of the skeletal system. Several variants have been described in the literature with grossly variant prognosis and clinical behaviour. Several reports of intractable osteomyelitis of the jaw bones secondary to osteopetrosis, particularly the mandible, have been published widely. However, there is no published report of the complete mandible sequestrating de novo, in the literature. An overview of this spectrum of sclerotic bone disease, its presentation in the oro-facial region, the diagnostic challenge it poses and the management dilemma it offers to the maxillofacial surgeon is discussed and a protocol for managing this disease effectively is presented. A clinical illustration of the complexities of management of osteopetrosis-induced osteomyelitis of jaw bones is demonstrated with a very rare case in which the entire mandible had sequestrated.

Clinicoradiological findings of benign osteopetrosis: report of two new cases

Osteopetrosis represents a heterogeneous group of rare, hereditary bone dysplasias that share the hallmark of increased bone density caused by osteoclast dysfunction. It can manifest through a spectrum of symptoms and severity, from neonatal onset with life-threatening complications ("malignant" autosomal recessive osteopetrosis) to two more benign conditions with the incidental radiographic findings, principally affecting adults (autosomal dominant osteopetrosis type I and type II). We report 2 new cases of autosomal dominant osteopetrosis type II. Both subjects were short in stature. Multiple healed fractures of long bones, diminished marrow spaces and hypoplastic maxillary sinuses were remarkable findings. To our knowledge they are the first reported cases of autosomal dominant type II of this disease in Iran.