Patient suffering from pain in the area of the mandibular molars with paresthesia in the lower lip. By clinical and radiographic examination your diagnosis:
A) Acute osteomyelitis.***
Oral paresthesia may be caused by manipulation or inflammation of a nerve or tissues around a nerve, direct damage to a nerve or tissues around a nerve, tum or impinging on or invading a nerve, pnmary neural tumor, and central nervous system tumor.
Osteomyelitis is caused by:
- contiguous spread from infected tissue or an infected joint prosthesis
- Blood-borne microorganisms (hematogenous osteomyelitis)
- open wounds (open fractures or bone surgery)
Trauma, ischemia and foreign bodies predispose to osteomyelitis. Osteomyelitis may form under a deep pressure ulcer.
Adjacency spread from adjacent infected tissues or open wounds accounts for about 80% of osteomyelitis; it is often polymicrobial. Staphylococcus aureus (both methicillin susceptible and resistant strains) is present in ≥ 50% of cases; other commonly occurring bacteria include streptococci, gram-negative microbes of digestive origin, and anaerobic bacteria. Osteomyelitis due to the infective spread of contiguity is common in the foot (in diabetic or arteritic patients), in traumatized or operated or altered bone by radiotherapy and in the bones close to pressure ulcers (hips, sacrum ). An infection of the teeth, gums and sinuses can spread to the skull.
Hematogenous osteomyelitis is usually caused by a single microbe. In children, Gram-positive bacteria are more common, usually affecting the metaphyses of the tibia, femur, or humerus. Hematogenous osteomyelitis in adults usually affects the vertebrae. Risk factors in adults include age, general impairment, hemodialysis, sickle cell disease, and injection drug use. Frequent infective microorganisms include the following:
- In elderly, debilitated or hemodialyzed adults: S. aureus (methicillin-resistant S. aureus [MRSA] is common) and Gram-negative enteric bacteria
- Among injecting drug users: S. aureus, Pseudomonas aeruginosa, and Serratia sp
- In case of sickle cell disease, liver disease, or immunosuppression: Salmonella sp
Fungus and mycobacteria can cause haematogenous osteomyelitis, usually in the immunocompromised patient or in areas of endemic infection with histoplasmosis, blastomycosis or coccidioidomycosis. The vertebrae are often affected.
pathophysiology:
Osteomyelitis tends to occlude local blood vessels, causing bone necrosis and local spread of infection. The infection can extend beyond the cortical bone and diffuse under the periosteum, with formation of subcutaneous abscesses, which can drain spontaneously through the skin.
In vertebral osteomyelitis, paravertebral or epidural abscesses may develop.
If treatment of acute osteomyelitis is only partially effective, low grade chronic osteomyelitis develops.
Symptomatology:
Patients with acute osteomyelitis of peripheral bones usually have weight loss, asthenia, fever, localized heat, edema, erythema, and local pain.
Vertebral osteomyelitis causes localized spinal pain and tenderness with paravertebral muscle contractures that do not respond to conservative treatment. At a later stage, the disease can cause compression of the spinal cord or nerve roots, with radicular pain and weakness or numbness of the extremities. Patients are often afebrile.
Chronic osteomyelitis causes recurrent episodes (for months to years) of bone pain, local tenderness and fistulas.
Osteomyelitis is caused by:
- contiguous spread from infected tissue or an infected joint prosthesis
- Blood-borne microorganisms (hematogenous osteomyelitis)
- open wounds (open fractures or bone surgery)
Trauma, ischemia and foreign bodies predispose to osteomyelitis. Osteomyelitis may form under a deep pressure ulcer.
Adjacency spread from adjacent infected tissues or open wounds accounts for about 80% of osteomyelitis; it is often polymicrobial. Staphylococcus aureus (both methicillin susceptible and resistant strains) is present in ≥ 50% of cases; other commonly occurring bacteria include streptococci, gram-negative microbes of digestive origin, and anaerobic bacteria. Osteomyelitis due to the infective spread of contiguity is common in the foot (in diabetic or arteritic patients), in traumatized or operated or altered bone by radiotherapy and in the bones close to pressure ulcers (hips, sacrum ). An infection of the teeth, gums and sinuses can spread to the skull.
Hematogenous osteomyelitis is usually caused by a single microbe. In children, Gram-positive bacteria are more common, usually affecting the metaphyses of the tibia, femur, or humerus. Hematogenous osteomyelitis in adults usually affects the vertebrae. Risk factors in adults include age, general impairment, hemodialysis, sickle cell disease, and injection drug use. Frequent infective microorganisms include the following:
- In elderly, debilitated or hemodialyzed adults: S. aureus (methicillin-resistant S. aureus [MRSA] is common) and Gram-negative enteric bacteria
- Among injecting drug users: S. aureus, Pseudomonas aeruginosa, and Serratia sp
- In case of sickle cell disease, liver disease, or immunosuppression: Salmonella sp
Fungus and mycobacteria can cause haematogenous osteomyelitis, usually in the immunocompromised patient or in areas of endemic infection with histoplasmosis, blastomycosis or coccidioidomycosis. The vertebrae are often affected.
pathophysiology:
Osteomyelitis tends to occlude local blood vessels, causing bone necrosis and local spread of infection. The infection can extend beyond the cortical bone and diffuse under the periosteum, with formation of subcutaneous abscesses, which can drain spontaneously through the skin.
In vertebral osteomyelitis, paravertebral or epidural abscesses may develop.
If treatment of acute osteomyelitis is only partially effective, low grade chronic osteomyelitis develops.
Symptomatology:
Patients with acute osteomyelitis of peripheral bones usually have weight loss, asthenia, fever, localized heat, edema, erythema, and local pain.
Vertebral osteomyelitis causes localized spinal pain and tenderness with paravertebral muscle contractures that do not respond to conservative treatment. At a later stage, the disease can cause compression of the spinal cord or nerve roots, with radicular pain and weakness or numbness of the extremities. Patients are often afebrile.
Chronic osteomyelitis causes recurrent episodes (for months to years) of bone pain, local tenderness and fistulas.
Diagnostic:
- VS or C-reactive protein
- RX, MRI or bone scintigraphy
- Culture of a bone sample and / or abscess.
(See also the clinical practice guidelines for the diagnosis and treatment of native vertebral osteomyelitis in adults.)
Acute osteomyelitis is suspected in cases of localized peripheral bone pain, fever, discomfort, or localized and persistent vertebral pain, especially in the presence of risk factors for bacteremia.
Chronic osteomyelitis is suspected in cases of persistent localized bone pain, especially in the presence of risk factors.
If osteomyelitis is suspected, NFS and VS or C-reactive protein, as well as rx without preparation of affected bone, are performed. Leukocytosis and elevations of ESR and C-reactive protein support the diagnosis of osteomyelitis. However, VS and C-reactive protein can be elevated in inflammatory conditions, such as rheumatoid arthritis, or normal in case of infection caused by indolent pathogens. Thus, the results of these tests should be evaluated based on clinical examination and imaging.
The rx are abnormal after 2 to 4 weeks, showing periosteal apposition, bone destruction, soft tissue swelling and, at the spine, a reduction in vertebral body height or pinching of the adjacent disc and destruction of the vertebral plateaus on the other hand. and other of this disc.
If the rx are not characteristic or if the symptoms are acute, CT and MRI are the current imaging techniques of choice to identify abnormalities and reveal adjacent infections, such as paravertebral or epidural abscesses or joint infections facet.
As an alternative, technetium-99m bone scans may be performed. Bone scintigraphy is abnormal earlier than rx without preparation but does not distinguish infection from fractures and tumors.
GB analysis using indium-111 labeled cells makes it possible to better identify the areas of infection observed on bone scintigraphy.
Bacteriological diagnosis is essential for optimal treatment of osteomyelitis; Bone needle biopsy or surgical excision and aspiration or debridement of the abscess provide specimens for culture and antibiograms. The cultivation of drainage fluid does not necessarily reveal the bacterium involved. Biopsy and culture should precede antibiotic therapy unless the patient is in shock or has neurological signs.
Treatment:
- Antibiotics.
- Surgical intervention in case of abscess, persistent general symptoms, potential vertebral instability or massive bone necrosis.
- Antibiotics:
Antibiotics that are effective against Gram-positive and Gram-negative microbes are administered pending culture and antibiogram results.
The initial antibiotic treatment of hematogenous osteomyelitis acute, should include a semi-synthetic penicillin resistant to the penicillinase (p. Ex., Nafcillin or oxacillin 2 g IV q 4 h) or vancomycin 1 g IV q 12 h (when MRSA is common in a community) and a 3rd or 4th generation cephalosporin (such as ceftazidime 2 g IV q 8 h or cefepime 2 g IV q 12 h).
Empirical treatment of chronic osteomyelitis caused by an infectious outbreak of soft adjacent tissues, particularly in diabetic patients, should be effective against anaerobic microorganisms further Gram-positive and Gram negative aerobic. Ampicillin / sulbactam 3 g IV q 6 h or piperacillin / tazobactam 3,375 g IV q 6 h are often used; vancomycin 1 g IV q 12 h is added when the infection is severe or MRSA has a high prevalence. Antibiotics should be administered parenterally for 4 to 8 weeks and adapted to the culture results.
- Surgery:
If any of the general signs (eg, fever, feeling sick, weight loss) persist or large areas of the bone are destroyed, the necrotic tissue is surgically debrided. Surgery may also be indicated to drain coexisting paravertebral or epidural abscesses or to stabilize the spine. Cutaneous grafts or pedicled flaps may be needed to close large surgical wounds. Broad-spectrum antibiotics should be continued for> 3 weeks after surgery. Long-term antibiotic therapy may be necessary.
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