FUNGAL OSTEOMYELITIS OF ZYGOMATICO MAXILLARY

COMPLEX – A RARE CASE

Dr. Ghulam SaqulainM.B.B.S., D.L.O., F.C.P.S

Head of Department of ENTCapital Hospital, Islamabad

CASE HISTORY

Name: Khawaja Abdul Rehman Age: 55 Years Sex: Male Admission No: 2569 Card No: 10827 PD Address: H.No 8041, Sadiq

Abad Rawalpinndi DOA: 04.03.04 DOD:

16.03.04 DOA: 09.04.04 DOD:

16.04.04 DOA: 25.5.05 DOD:

29.06.05

Presenting Complaint: Swelling below the Eye 5 months

Past History: Medical No history of any significant

disease No history of allergy Surgical Not significant

Family History: Nothing Significant

Personal History Married, 3 sons and 4 daughters. No addiction.

EXAMINATIONGENERAL PHYSICAL EXAMINATION

A old man sitting anxiously in bed, well oriented to time, place and person.

Anaemia Jaundice Clubbing

Absent

Cyanosis Palpable Nodes

Contd.

Temp: A febrile

Pulse: 84 beats per min. Regular,

BP: 130/80 mm Hg.

…GENERAL PHYSICAL EXAMINATION

SYSTEMIC EXAMINATION

Resp. System: CVS:

NAD CNS: GIT:.

E.N.T EXAMINATION

NASAL EXAMINATION

Inspection: Anterior Rhinoscopy: Normal Mucosa, turbinates and septum

noted. Posterior Rhinoscopy: NAD

Palpation: No Tenderness over cheeks

EXAMINATION OF THROAT

Poor oral hygiene

EXAMINATION OF EARS Normal findings noted.

LOCAL EXAMINATION Revealed a small ovoid

swelling 1 cm x 1.5 cm on and below the lateral part of right infra orbital region. The swelling was cystic in consistency with poorly delineated rounded margins. No signs of inflammation noted. Swelling was immobile

INVESTIGATIONS CP 15.03.04

WBC 6600 ul NE% 63% Ly% 28% MO%06% EO% 03%

Hb 15.4 g/dl PLT 136,000 ul

ESR 07mm/1st hr. HCV Ab Negative HBs Ag Negative

FBG 100 mg/dl(Range60 -110mg/dl)

RBG 145mg/dl (Range110-160mg/dl)

Montoux Test: -ve Urea 47 mg/ dl Creatinine 1.7 mg/dl ALAT 33 U/L Alkaline Phos. 117 U/L Total bilirubin 1.9 mg/dl

Plain Radiograph of PNS No bone erosion

noted

X-Ray Chest Normal.

Provisional Diagnosis: Infra-Orbital Cyst

Treatment: Inj. Ceftim 1 gm I/V BD Tab. Mytil 500 mg BD

Fluid Aspirated For Cytology/ Culture sensitivity (4.3.4) Fluid Cytology: Findings consistent

with Acute Inflammation/ Abscess were noted

Culture Sensitivity: No organism found after 48 hrs incubation at 37 degree C.

Follow Up

Swelling Reappeared soon after discharge of patient from hospital

Patient Readmitted for Excision Biopsy

Surgical Exploration

Surgical Exploration was planned after due preparation

Procedure: On Exposure through a horizontal incision

on right infra orbital region, a collection of pus was found under the periosteum.

Drainage of pus was performed along with curettage of bone underneath.

Antral lavage performed, which did not reveal any collection of pus in Maxillary Sinus. Also no communication was noted between the sinus wall and cyst cavity.

Samples sent for histopathology and Culture Sensitivity

More extensive surgery deferred pending further investigations.

Post Operative Treatment: Antibiotic

In Ward Inj. Ceftim 1 gm I/V BD Inj. Ampicillin 500 mg I/V TDS

On Discharge Tab. Mytil 500 mg BD Cap. Kefril 500 mg TDS

Analgesics Stitches Removed after a week

Histopathology (21.04.04) Chronic Non Specific Inflammation

Culture Sensitivity Growth of Staph coagulase negative(Probably skin commensal flora?)

Wound transformed into a sinus discharging blood and pus.

There was no or little response to different groups of antibiotics.

Therefore Further investigations were planned.

Repeat X-Ray PNS: (8.8.04)

CT Scan31.05.05

Destruction of zygomatic arch and part of anterior wall of maxilla noted on the right side.

Sinus tract was visualized

Peri-orbital fat and muscles appear normal

Maxillary antrum, Infra temporal fossa appears normal.

Findings are Compatiable with Chronic Osteomyelitis

Operation (18.06.05) Wound Debridement +

Sequestrectomy + Curettage of underlying bone + Bone surface polished with diamond burr.

Histopathology (20.06.2005) Lab #: H-335-05.

Chronic Osteomyelitis due to Fungal Infection. The morphology of hyphae is suggestive of Aspergillus

sp.

Medical Treatment: Tab. Nizoral 400 mg BD. 6 weeks