Photo Quiz

Persistent Submandibular Abscess

 

Am Fam Physician. 2021 Jan 1;103(1):51-52.

A 23-year-old patient presented with a nonhealing wound in the submandibular area. The lesion began eight months earlier while the patient was working on a construction project in Cameroon, which involved frequent partial submersion in water.

The lesion began as a large, painful area around the angle of the left mandible (Figure 1) that was accompanied by fever, lymphadenopathy, and pain with swallowing. The abscess was drained, but no other treatment was provided because of limited resources.

FIGURE 1


FIGURE 1

Eight months later, the lesion had decreased in size but never healed. It continually drained a small amount of pus and occasionally increased in size. The patient did not recall having any bites or scratches while in Cameroon and had no symptoms of common tropical diseases. No one else in the group in Cameroon reported having a similar condition. The patient did not have current fevers, chills, tooth pain, oral lesions, swollen glands, dysphagia, night sweats, weight loss, or other symptoms.

Physical examination was unremarkable except for a soft, nonfluctuant, nontender, 2-cm, oval-shaped lesion on the left jaw (Figure 2). A small amount of granulation tissue was present. Scanty white discharge could be expressed from the lesion through a 3-mm central opening. A complete blood count was normal. Wound culture grew Prevotella denticola.

FIGURE 2


FIGURE 2

Question

Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

  • A. Actinomycosis.

  • B. Cutaneous leishmaniasis.

  • C. Mycobacterium marinum infection.

  • D. Periodontal abscess.

See the following page for discussion.

Discussion

The answer is D: periodontal abscess. Periodontal abscesses are common manifestations of untreated dental caries and periodontal disease. Periodontal infections can extend beyond their natural boundaries, causing infections in deep fascial spaces of the head and neck. If untreated, the infection can form a sinus tract to the external subcutaneous tissue.

Initially, the periodontal infection presents as pain and erythema at the site of the dental caries. Without treatment, it can progress to an abscess with edema, erythema, and pain at the remote space, such as the submandibular area, due to formation of a sinus tract that may rupture. Over time, a nonhealing

Address correspondence to Kari A. Neamand-Cheney, DO, FAAFP, at kari.a.neamandcheney.mil@mail.mil. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Patel PV, Kumar GS, Patel A. Periodontal abscess: a review. J Clin Diagn Res. 2011;5(2):404–409....

2. Centers for Disease Control and Prevention. Parasites – leishmaniasis. Accessed February 13, 2020. https://www.cdc.gov/parasites/leishmaniasis

3. Valour F, Sénéchal A, Dupieux C, et al. Actinomycosis: etiology, clinical features, diagnosis, treatment, and management. Infect Drug Resist. 2014;7:183–197.

4. Diaz JH. Skin and soft tissue infections following marine injuries and exposures in travelers. J Travel Med. 2014;21(3):207–213.

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