Over the years many amazing cases have been presented during the PEMPix presentation at the American Academy of Pediatrics’ annual national Conference and Exhibition during the Section on Emergency Medicine Sessions. PEMPix Classic is a new featured series on PEMBlog that will highlight some of those classic cases.

The Case

A 22 month old boy presents with a chief complaint of dental problems. History is notable for two days of teeth grinding and loss of several teeth in the process. He has a history of anemia (hemoglobin = 7.8) diagnosed five weeks prior. He is being treated with iron supplements. For the past two days he has also had tactile fevers, and has thrown up four times.

He is a former full-term infant who born in U.S. but has spent a good portion of his life living in south east Asia as well. He has a history of speech delay, and eats a limited diet of cow’s milk and oxtail soup (yes, really). The family has moved multiple times.

On examination he is febrile to 38.4 C. The parents hand you a bag with five intact teeth – roots and all. The rest of his examination is unremarkable. Labs are as follows:

  • WBC  21.1. Neutrophils 80%, Bands 5%, Lymphocytes 6%, Monocytes9%
  • CRP 5.1 mg/L = 48.6 nmol/L
  • Metabolic Panels unremarkable

What is the diagnosis?

A. Osteogenic Sarcoma
B. Acute Myeloblastic Leukemia
C. Osteomyelitis
D. Fibrous Dysplasia
E. Mandibular Tuberculosis

 

C. Osteomyelitis

This is specifically Odontogenic Garré’s Osteomyelitis a rare sequela of typical odontogenic infections. The mandible is more susceptible to osteomyelitis than the maxilla. Garré’s osteomyelitis is a chronic pediatric non-suppurative osteomyelitis with thickened periosteum & reactive bone formation. The patient was admitted for IV antibiotics, MRI and consultation with oral maxillofacial surgery. Interestingly, his MRI was delayed by an episode abdominal pain, and subsequent diagnosis of intussusception with a 2 cm bleeding hamartoma as the lead point. That hamartoma explains the aforementioned anemia.

References

Park J, Myoung H. Chronic suppurative osteomyelitis with proliferative periostitis related to a fully impacted third molar germ: a report of two cases. J Korean Assoc Oral Maxillofac Surg. 2016;42(4):215–220. doi:10.5125/jkaoms.2016.42.4.215.

Pincus DJ, Armstrong MB, Thaller SR. Osteomyelitis of the craniofacial skeleton. Semin Plast Surg. 2009;23(2):73–79. doi:10.1055/s-0029-1214159