Actinomyces maxillary necrosis in a patient with SLE

Abstract

BACKGROUNDPatients with SLE are more susceptible to infections with several pathophysiology factors. Jaw osteomyelitis is a rare condition and can be precipitated by dental infection, sinusitis, trauma or radiation. Actinomyces is a gram-positive anaerobic bacillus that resides in the normal microbiota of teeth, oropharynx, gastrointestinal tract and female genitals. Osteomyelitis of the maxilla by Actinomyces is an infrequent infection of poorly understood pathogenesis that affects both immunosuppressed and immunocompetent individuals. The authors report a case of maxilla osteomyelitis caused by Actinomyces in a patient with lupus nephritis being treated with pulse therapy regimen. CASE REPORTA 43-year-old female patient, diagnosed with SLE in December 2019. She was hospitalized in February 2020 due to class IV lupus glomerulonephritis and started on combined pulse therapy with methylprednisolone and cyclophosphamide. Fifteen days after the second pulse therapy cycle, she performed a tooth extraction on her own and presented dentoalveolar abscess, dental pain, fever and paresthesia on the face, requiring intravenous antibiotic therapy. After the condition resolved, she was submitted to the third cycle of pulse therapy. The patient evolved with softening of the teeth of the upper arch, sought dental care and underwent extraction of four units. A computed tomography scan of the face was performed showing osteomyelitis of the maxilla and osteonecrosis of the operated alveolar region. The patient underwent surgical debridement with material collection for histopathological analysis, which showed the presence of Actinomyces. Supported by the infectious disease team, she started on amoxicillin indefinitely and pulse therapy regimen was suspended. CONCLUSIONActinomyces maxillary osteomyelitis is an entity of uncertain pathophysiology. Female patients with poor oral hygiene, dental manipulation and infection, with a history of alcoholism, malnutrition, diabetes mellitus and immunosuppression, as in this case, are the most likely to develop it.