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50 Years Ago in The Journal of Pediatrics: Curious Cases of Cutaneous Fistulas from Mucosal Sites of Trauma and Infection
Journal article   Open access   Peer reviewed

50 Years Ago in The Journal of Pediatrics: Curious Cases of Cutaneous Fistulas from Mucosal Sites of Trauma and Infection

Sarah S. Long
The Journal of pediatrics, v 234, pp 26-26
01 Jul 2021
DOI: https://doi.org/10.1016/j.jpeds.2021.03.041
PMID: 34172163
url
https://doi.org/10.1016/j.jpeds.2021.03.041View
Published, Version of Record (VoR)Maybe Open Access (Publisher Bronze),  Open

Abstract

Life Sciences & Biomedicine Science & Technology Pediatrics
Arden G. Christen, DDS, MSD, the Base Dental Surgeon at Zaragoza Air Base in Spain, reported 2 cases of cutaneous fistulas (one to the face and the other to the neck) from dental origins to alert pediatricians to these frequently misdiagnosed infections. When purulent drainage is seen near a gumline or the patient has a toothache, consideration of a dental source of infection is obvious. Tooth or gum trauma, dental caries, periapical abscess, or rarely maxillary or mandibular osteomyelitis are the initiating events. When oral commensal microbial flora, especially anaerobic bacteria, and especially Actinomyces species, get stuck in a wrong place infection ensues, becomes purulent, and expands along fascial plains in search of egress, creating a fistulous tract that can end mucosally, cutaneously, or sometimes intracranially. This usually occurs without rubor, dolor, or tumor at the dental site. Actinomyces, abetted by its microaerophilic colleague Aggregatibacter actinomycetemcomitans, can take on the pathologic personality of traveling from the primary sites of infection in the mouth, lung, or gastrointestinal tract (where they are contiguous commensals) along fascial plains or burrowing through bones in a bizarre odyssey to make their appearance distantly as a purplish dermal nodule (eg, from a primary focus in the lung to the thigh, from a maxillary tooth to the face infraorbitally [as in one of Christen's cases], or from the gastrointestinal tract through the diaphragm and lung to the lower back). We infectious diseases subspecialists all have our own remarkable cases. During this writer's fellowship, Dr Bennett Lorber from Temple Hospital presented his memorable case of a seamstress who habitually held pins in her mouth while travelling on Philadelphia streetcars. Unbeknownst to her a lurch must have led to her swallowing a pin that ended up in her appendix—the story unravelling only after development of a cutaneous fistula tracking back to the pin. Usually, intervention at the source site cures the problem. Absent a source, a long course (eg, 1 year) of penicillin orally usually is curative. Surgical removal of the fistulous tract is not necessary. In the rare case of chronic osteomyelitis of the maxilla or mandible, aggressive surgical debridement can be necessary to prevent relapses.

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