An otherwise healthy White man in his 60s presented with right jaw pain, trismus, and facial swelling. Symptoms started a year before, after receiving dental implants for new lower dentures. The patient noted right upper and lower eyelid swelling most notable in the morning but denied associated fevers, chills, vision changes, dysphagia, headaches, urinary symptoms, or rashes. Physical examination revealed a 3-cm round fluctuant area lateral to the right lateral canthus, mildly tender to palpation. No overlying warmth or erythema and no lymphadenopathy. The patient's dentures appeared to be well fitting, but mouth opening was at approximately 50% of expected. Laboratory results included an erythrocyte sedimentation rate (ESR) of 20 mm/h, and normal complete blood cell count, comprehensive metabolic panel results, and lactate levels. Findings on magnetic resonance imaging (MRI) (Figure , A) were most consistent with osteomyelitis of the mandible with inflammation of surrounding soft tissues. Right temporalis muscle biopsy results for Gram stain and culture, fungal stain and culture, and acid-fast bacillus stain were unremarkable. The patient's symptoms did not improve after 7 weeks of empirical intravenous ertapenem followed by 8 weeks of oral cefuroxime and minocycline. Additional laboratory test results, including serum IgG4, SPEP, brucella AB, Q fever AB, RF, urinalysis, and microalbumin/creatinine levels, were all unremarkable. Results for p-ANCA and c-ANCA were negative. Repeated MRI findings showed progression of the inflammation and new involvement of the temporal lobe dura. Findings on positron emission tomographic computed tomography (PET-CT) scan showed nonspecific inflammatory changes to the bone, muscle, and brain meninges. A biopsy of the temporalis muscle, sphenoid wing, and dura was performed (Figure , B).
Diagnosis
B. Atypical vasculitis
DiscussionThe lack of response to a full course of antibiotics and negative culture results made actinomycosis unlikely. The final biopsy results A Axial slice of head MRI B Histologic image from biopsy of head structures