Opportunistic Osteomyelitis in the Jaws of Children on Immunosuppressive Chemotherapy

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Abstract
Four children with an osteomyelitic process in the jaw bones while on cytotoxic chemotherapy were treated by radical surgery and antimicrobial chemotherapy. Symptoms (local swelling and pain in the jaw, necrotic gingivitis, and spontaneous loss of teeth) appeared 3 weeks, 4 weeks, and 8 months after diagnosis of leukemia, and 8 days posttransplant in a patient with severe aplastic anemia. Three had the process in the mandible and one in the maxilla. Specific diagnoses of Aspergillus flavus, Saccharomyces cerevisiae, and Actinomyces species were obtained histologically from surgical samples. Treatment was radical surgery to remove all infected and necrotic tissue: removal of a substantial part of the mandible and loss of seven to eight permanent teeth in those with mandibular lesions. Actinomycosis was treated with penicillin for 2 years. The patients with fungal lesions received amphotericin B for 2, 5, and 6 months, with adjuvant itraconazole, fluconazole, or 5-fluorocytosine for 9-12 months. Anti-cancer chemotherapy was continued. All the bony lesions healed. The patient with acute myeloid leukemia died in relapse 1 year postdiagnosis; her aspergillus osteomyelitis had been inactive for 8 months. The other three patients are alive and well 1.9, 2.1, and 1.9 years after termination of antimicrobial therapy. We emphasize the necessity of specific diagnosis from appropriate surgical samples and conclude that in patients undergoing chemotherapy bony lesions caused by opportunistic microorganisms may be curable with aggressive surgery and prolonged medication.