Saturday, November 24, 2012

Facial Lesion in a Child

Case presented by Dr Munqithe M Jabir, Addiwaniya, Iraq who writes:
"Can I please have your opinion about this problematic case.
The patient is a female child with a swelling on her left cheek for the past three months.  It discharges pus through many openings (carbuncle-like!!).  There has been no change although many courses of different antibiotics, but, recently it has responded slowly to Rifampicin 150mg twice daily and Clarithromycin 250 mg twice daily.  Complete blood picture and ESR are normal."

Here is a Video. 
1. Embedded toothbrush foreign body in cheek - report of an unusual case.
Sathish R, Suhas S, Gayathri G, Ravikumar G, Chandrashekar L, Omprakash TL.  Eur Arch Paediatr Dent. 2011 Oct;12(5):272-4.
Source: Oral and Maxillofacial Surgery, Sri Siddhartha Dental College, India. [This was suggested by Brian Maurer's comment]

2. Pediatr Dermatol. 2010 Jul-Aug;27(4):410-1.
Cutaneous facial sinus tract of dental origin.Mardones F, Oroz J, Muñoz C, Alfaro C, Soto R.
Dermatology Department, Hospital Clínico, Universidad de Chile, Santiago, Chile.
Abstract: Cutaneous sinus tract on the head and neck area in a child may originate from dental disease. A high degree of clinical suspicion and complementary tests are often needed, as the diagnosis is usually not straight forward. Anatomical correlation is also useful in tracing the affected tooth or teeth. We present the case of a boy with a facial sinus tract that originated from periapical abscesses of maxillary molars.


  1. From Brian Maurer, Tarrifville, CT:
    "This appears to be a chronic draining sinus of some sort. Has there been any discharge noted inside the cheek through Stenson’s duct? One thinks about the possibility of a bacterial parotitis secondary to a plugged duct or a branchial cleft cyst, though admittedly the area seems to be situated a bit anterior from the usual location.

    Was a wound culture done at some point?

    This infection will most likely continue to recur until it is surgically debrided.

    [Brian's comment made me think of "Dental Sinus" which would be unusual in a young child, but easy to evaluate by looking in her mouth.]

  2. To reach a good differential diagnosis we need a more elaborative history, giving details about the initial lesion and how it progress over 3 months period. Clinical findings more than just inspection; including texture, temperature,symptomatic or not are all imporatant clues to reach a final diagnosis. Last but not least are the investigation results, which should be included by the presenter, especially culture report for discharge. Considering the exposed area of a child in Iraq cutaneous Leishmaniasis must be included in the differential and can easily be confirmed by a simple smear.

  3. From Larry Eron, Honolulu, Hawaii: "If this were from a dental abscess, the purulent discarge would have a foul odor from the anaerobic organisms that cause such an abscess. The periapical abscess would be visible on dental Xray. It would appear as if the origin of the purulent material were a cystic structure, which elsewhere on the body would frequently turn out to be a sebaceous cyst. Given the extent of the lesion on the skin, it would require an extensive excisional procedure followed by a skin graft. Obviously, it would be best to avoid this from a cosmetic standpoint. If it is responding to rifampin and clarithromycin, I would continue it. The response to these antibiotics might suggest a mycobacterial origin. Has it been cultured? If so, including mycobacterial cultures? If it fails to clear, I would consider an excisional procedure if Xrays are unrevealing.
    Has an Xray been performed to r/o a foreign body such as a thorn? Any exposures to animals or tropical fish?"

  4. From Jon Karnes, Augusta, Maine: "This case makes me at least consider chronic granulomatous disease as well as occult dental disease/draining sinus. In addition to cultures and targeted antimicrobial therapy, they might consider an immune workup to include the nitroblue tetrazolium dye test.

    Here’s a review article from JAAD:
    Cutaneous manifestations of chronic granulomatous disease. A report of four cases and review of the literature. Dohil M - J Am Acad Dermatol - 01-JUN-1997; 36(6 Pt 1): 899-907"

  5. Munqithe M JabirNovember 27, 2012

    I appreciate these valuable views .. and will inform for any new advances .. i will see the girl tomorrow

  6. I agree with the diagnosis of acanthosis nigricans.
    Acanthosis nigricans can be associated with endocrinopathy especially with insulin resistance diabetes and thyroiditis.

    I would check her fasting glucose level, thyroid function tests and thyroid antibodies. If any of this is abnormal, I will try to optimise the underlying endocrine abnormality.
    Usually advise patient on weight loss and diet control. I am not sure if topical creams help but can try topical tretinoin.

    I would probably not use acetretin in this young patient as long term side effects of acetretinoin eg musculo-skeletal problems such as hyperostosis and calcification of the ligaments.

  7. Ana BrasileiroDecember 11, 2012

    Although is not the most common presentation (and also because I don't know how it looked like before), have you considered cutaneous leishmaniasis? That would be an explanation for the response to rifampicin.


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