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