[Oradlist] case for differential interpretation

Tom Underhill tunderhill at verizon.net
Fri Sep 26 09:57:29 PDT 2008

Hello Dr. Nambiar,

I found the clinical history that you provided most useful.  I would  
say that this is a refractory hematogenous osteomyelitis.  Management  
should be from a combined medical and surgical approach.

First, infectious disease consult.  Things to consider:
1.  Initial presentation was with pain, fever, and positive blood  
culture for G+ bacilli. The age of the patient is good for  
hematogenous origin.  Treatment with inappropriate  antibiotics or  
doses can result  in disease extension, sequestra formation and the  
development of refractory disease.    I am not an infectious disease  
expert, therefore I do not know if Gentamicin beads were an  
appropriate treatment.
2.  I would repeat blood cultures (drawn from 2 separate sites to  
exclude false positive from skin contamination).  Do culture and  
3.  Once the offending organism is isolated, place PICC for long term  
intravenous antibiotics.
4.  Follow serial sed rates to evaluate response to antibiotics.

Second, surgical consult.
 From the CT, we know that portions of the central bone are dead,  
i.e., large sequestra.  We know that the periosteum is working over  
time trying to out pace the infection.  Removal of sequestra will tip  
the battle in favor of the periosteum with regards to the chronic   
infection.  The cortical and cancellous bone remaining in the wound  
must bleed uniformly to ensure antibiotic perfusion.

Given the patient's young age, with combined medical and surgical  
intervention you may get a very good result and prevent loss of the  
hemimandible or mandible.

Please share follow up examination in 6 months or a year from now if  
you get them.

Good luck,
Tom Underhill

On Sep 25, 2008, at 4:37 AM, phrabha at um.edu.my wrote:

> Dear Colleagues,
> Attached herewith is a case of 12 year old child with a  
> continuously growing jaw. This case was referred to me for a  
> opinion. I have selected the  appropriate images, including  the CT  
> images for your perusal. Please assist so that I do not miss  
> anything .
> Thanking you.
> Phrabha Nambiar
> Faculty of Dentistry
> University of Malaya, Malaysia
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