COMPLICATING WOUND HEALING E RIC R. C A R L S O N , D .M .D .; B R IA N J A C K S O N , D.D.S.
yospherulosis is an inflam matory, granulomatous lesion, often of iatrogenic origin. In 1969, McClatchie, Warambo and Bremner1reported peripheral soft tissue nodules located on the arms, legs, gluteal region and skin overlying the scapula in seven patients from Kenya, East Africa. These lesions contained spherical fungus-like structures morphologically distinct from any known patho genic fungi. The tissues showed inflamed fibromuscular connec tive tissue containing cystic spaces. The most striking material consisted of large “parent” bodies filled with smaller round “spherules” said to resemble “a bag of marbles.” Because of skeletal muscle involvement they termed this entity myospherulosis. A report from Hutt, Fernandes and Templeton2involved five patients with similar lesions in which the histologic findings were identical to those described by McClatchie. Fungal pathosis was considered but not substantiated because the structures of myospherulosis do not take any of the usual stains for fungi and could not be cultured. In 1977, Kyriakos3 presented 16 cases of myospherulosis located in the nose, middle ear and paranasal sinuses. The common features of these cases included a previous surgery during which the bony defects were packed with plain gauze, petrolatum-impregnated gauze, petrolatum-impregnated
ABSTRACT
Myospherulosis is a complication o f wound healing which results from an action between lipids and extravasated erythrocytes. A case o f myospherulosis of the mandible is reviewed with its history, histopathology and occurrence. rayon or gauze impregnated with non-sterile antibiotic ointments. Furthermore, the histopathology was identical to that of the previ ously described African cases.4 In 1978, Rosai5reported an additional case of myospherulosis of the maxillary antrum after postoperative packing with gauze impregnated with 3 percent tetracycline ointment. The spherules resembled erythrocytes. When the lesion was stained for hemoglobin, lipofuscin and peroxidase, it reacted positively, indicating that erythrocytes altered by antibiotic ointment gave myospherulosis its histological appearance. R EPO R T OF CASE
A 26-year-old Caucasian male went to the Oral and Maxillofacial Surgery Clinic at Henry Ford Hospital for treatment of pain in the left side of his face. A 1centimeter unilocular, well-
circumscribed radiolucent area was apparent on X-rays. This lesion was located at the site of tooth no. 17 which had been extracted 14 years previously. The patient reported an uncomplicated postoperative course, and was unaware of whether the impacted tooth was associated with a cyst. The patient’s remaining medical history was non-contributory. The patient appeared well developed, well nourished, in no apparent distress, and without facial asymmetry. Heart, lungs and abdomen were unremarkable. The maxillofacial complex was normal. The patient had no intraoral palpable tenderness, infection or expansion. The soft tissue overlying the lesion was compressible and hyperkeratotic. Palpation of the lesion revealed a bony defect at the superior alveolar crest proximal to tooth no. 18. A differential diagnosis of residual cyst, odontogenic keratocyst, ameloblastoma, odontogenic myxoma, myospherulosis and primary vs. metastatic malignant disease was considered. A biopsy of the intrabony lesion and overlying soft tissue indicated the lesion was well circumscribed and easily enucleated, leaving smooth, bony concavities. The cys tic cavity contained a thick, black, greasy substance that did not dissolve or disperse in normal saline or formalin. Histologic examination of the specimen resulted in a diagnosis of myoJADA, Vol. 122, May 1991
65
latum-impregnated antibiotics were used in an extraction socket, illustrating the occasional slow development of this process. SUMM ARY
Myospherulosis represents erythrocytes altered by petrolatumbased oint ments. It is not known whether the antibiotic, K :j the petrolatum or the combin Dr. Carlson is senior ation is respon staff member, sible for the Division of Oral and Maxillofacial alteration of Surgery, Henry Ford erythrocytes Hospital, 2799 W. and thus, lesion Grand Blvd., Detroit 48202-2689. Address formation. requests for reprints Extraction to Dr. Carlson. sockets should be explored surgically when a patient has radiographic changes, symptoms and a history suggestive of myospherulosis. ■
n
Intraoperative view of exploration and biopsy of left side of mandible. Black, greasy material was immediately seen on flap reflection.
spherulosis. The patient is cur rently being monitored for contin ued healing without recurrence.. The histological findings show: ■■ a mixed inflammatory infiltrate with macrophages and foreignbody-type giant cells in varying degrees, with surrounding fibrosis; ■■ cystlike spaces of varying sizes, with numerous erythrocytes of various structural alterations; membrane-bound aggregates of altered erythrocytes resembling a “bag of marbles”; ™ cellular debris, parent bodies and erythrocytes with distinctive brown-to-black hematoxylin- and eosin-stained section as the result of acid hematin formed from decomposed hemoglobin.6 D IS C U S S IO N
It is not clear whether the antibi otic7,8or the petrolatum base is primarily responsible for the development of myospherulosis. Dunlap and Barker9state that the histological changes noted in myo spherulosis are probably caused by a combination of the petrolatum
66
JADA, Vol. 122, May 1991
and antibiotics. This deduction was made by comparing the histological changes of a lesion produced by self-injection of vegetable oil and mineral oil with myospherulosis. The former did not produce the alterations in erythrocytes usually associated with lipogranulomatous lesions. Therefore the alteration of erythrocytes in myospherulosis may be caused by the combined antibiotic and petrolatum. Several representative papers6,9'10indicate a variety of clinical presentations at varying time intervals related to myospher ulosis development. Lynch’s review of six cases in 19846 identifies the development of mandibular myospherulosis two months to seven years after antibiotic ointment use. These patients had swelling, a mass and infection, although two patients were asymptomatic. The present case of myo spherulosis required 14 years for symptoms and radiographic changes to develop after petro
1. McClatchie S, Warambo MW, B rem ner AD. Myospherulosis: a previously unreported disease? Am J Clin Pathol 1969;51:699-704. 2. H utt MSR, Fernandes BJJ, Tem pleton AC. Myospherulosis (subcutaneous spherulocystic disease). Trans R Soc Trop Med Hyg 1971;65:182-8. 3. Kyriakos M. M yospherulosis of the paranasal sinuses, nose and middle ear: a possible iatrogenic disease. Am J Clin Pathol 1977;67:11830. 4. DeSchryver-Kecskemeti K, Kyriakos M. The induction of hum an m yospherulosis in experim ental animals. Am J Pathol 1977;87:33-46. 5. Rosai J. The n ature of m yospherulosis of the u p p e r respiratory tract. Am J Clin Pathol 1978;69:475-81. 6. Lynch DP, Newland JR, McClendon JL. M yospherulosis of the oral hard and soft tissues. J Oral Maxillofac Surg 1984;42:349-55. 7. Hall HD, Boldman BS, Hand CD. Prevention of dry socket w ith local application of tetracycline. J Oral Surg 1971;29;35-7. 8. Quinley JF, Roger RQ, Gores RJ. “Dry socket” after m andibular odontectom y and use of soluble tetracycline hydrochloride. Oral Surg Oral Med Oral Pathol 1960;13:38-42. 9. D unlap CL, B arker BF. M yospherulosis of the jaws. Oral Surg Oral Med Oral Pathol 1980;50:23843. 10. Bright C, Russel D, Keyes G. M yospherulosis. J Oral Maxillofac Surg 1982;40:509-12.
yospherulosis is an inflam matory, granulomatous lesion, often of iatrogenic origin. In 1969, McClatchie, Warambo and Bremner1reported peripheral soft tissue nodules located on the arms, legs, gluteal region and skin overlying the scapula in seven patients from Kenya, East Africa. These lesions contained spherical fungus-like structures morphologically distinct from any known patho genic fungi. The tissues showed inflamed fibromuscular connec tive tissue containing cystic spaces. The most striking material consisted of large “parent” bodies filled with smaller round “spherules” said to resemble “a bag of marbles.” Because of skeletal muscle involvement they termed this entity myospherulosis. A report from Hutt, Fernandes and Templeton2involved five patients with similar lesions in which the histologic findings were identical to those described by McClatchie. Fungal pathosis was considered but not substantiated because the structures of myospherulosis do not take any of the usual stains for fungi and could not be cultured. In 1977, Kyriakos3 presented 16 cases of myospherulosis located in the nose, middle ear and paranasal sinuses. The common features of these cases included a previous surgery during which the bony defects were packed with plain gauze, petrolatum-impregnated gauze, petrolatum-impregnated
ABSTRACT
Myospherulosis is a complication o f wound healing which results from an action between lipids and extravasated erythrocytes. A case o f myospherulosis of the mandible is reviewed with its history, histopathology and occurrence. rayon or gauze impregnated with non-sterile antibiotic ointments. Furthermore, the histopathology was identical to that of the previ ously described African cases.4 In 1978, Rosai5reported an additional case of myospherulosis of the maxillary antrum after postoperative packing with gauze impregnated with 3 percent tetracycline ointment. The spherules resembled erythrocytes. When the lesion was stained for hemoglobin, lipofuscin and peroxidase, it reacted positively, indicating that erythrocytes altered by antibiotic ointment gave myospherulosis its histological appearance. R EPO R T OF CASE
A 26-year-old Caucasian male went to the Oral and Maxillofacial Surgery Clinic at Henry Ford Hospital for treatment of pain in the left side of his face. A 1centimeter unilocular, well-
circumscribed radiolucent area was apparent on X-rays. This lesion was located at the site of tooth no. 17 which had been extracted 14 years previously. The patient reported an uncomplicated postoperative course, and was unaware of whether the impacted tooth was associated with a cyst. The patient’s remaining medical history was non-contributory. The patient appeared well developed, well nourished, in no apparent distress, and without facial asymmetry. Heart, lungs and abdomen were unremarkable. The maxillofacial complex was normal. The patient had no intraoral palpable tenderness, infection or expansion. The soft tissue overlying the lesion was compressible and hyperkeratotic. Palpation of the lesion revealed a bony defect at the superior alveolar crest proximal to tooth no. 18. A differential diagnosis of residual cyst, odontogenic keratocyst, ameloblastoma, odontogenic myxoma, myospherulosis and primary vs. metastatic malignant disease was considered. A biopsy of the intrabony lesion and overlying soft tissue indicated the lesion was well circumscribed and easily enucleated, leaving smooth, bony concavities. The cys tic cavity contained a thick, black, greasy substance that did not dissolve or disperse in normal saline or formalin. Histologic examination of the specimen resulted in a diagnosis of myoJADA, Vol. 122, May 1991
65
latum-impregnated antibiotics were used in an extraction socket, illustrating the occasional slow development of this process. SUMM ARY
Myospherulosis represents erythrocytes altered by petrolatumbased oint ments. It is not known whether the antibiotic, K :j the petrolatum or the combin Dr. Carlson is senior ation is respon staff member, sible for the Division of Oral and Maxillofacial alteration of Surgery, Henry Ford erythrocytes Hospital, 2799 W. and thus, lesion Grand Blvd., Detroit 48202-2689. Address formation. requests for reprints Extraction to Dr. Carlson. sockets should be explored surgically when a patient has radiographic changes, symptoms and a history suggestive of myospherulosis. ■
n
Intraoperative view of exploration and biopsy of left side of mandible. Black, greasy material was immediately seen on flap reflection.
spherulosis. The patient is cur rently being monitored for contin ued healing without recurrence.. The histological findings show: ■■ a mixed inflammatory infiltrate with macrophages and foreignbody-type giant cells in varying degrees, with surrounding fibrosis; ■■ cystlike spaces of varying sizes, with numerous erythrocytes of various structural alterations; membrane-bound aggregates of altered erythrocytes resembling a “bag of marbles”; ™ cellular debris, parent bodies and erythrocytes with distinctive brown-to-black hematoxylin- and eosin-stained section as the result of acid hematin formed from decomposed hemoglobin.6 D IS C U S S IO N
It is not clear whether the antibi otic7,8or the petrolatum base is primarily responsible for the development of myospherulosis. Dunlap and Barker9state that the histological changes noted in myo spherulosis are probably caused by a combination of the petrolatum
66
JADA, Vol. 122, May 1991
and antibiotics. This deduction was made by comparing the histological changes of a lesion produced by self-injection of vegetable oil and mineral oil with myospherulosis. The former did not produce the alterations in erythrocytes usually associated with lipogranulomatous lesions. Therefore the alteration of erythrocytes in myospherulosis may be caused by the combined antibiotic and petrolatum. Several representative papers6,9'10indicate a variety of clinical presentations at varying time intervals related to myospher ulosis development. Lynch’s review of six cases in 19846 identifies the development of mandibular myospherulosis two months to seven years after antibiotic ointment use. These patients had swelling, a mass and infection, although two patients were asymptomatic. The present case of myo spherulosis required 14 years for symptoms and radiographic changes to develop after petro
1. McClatchie S, Warambo MW, B rem ner AD. Myospherulosis: a previously unreported disease? Am J Clin Pathol 1969;51:699-704. 2. H utt MSR, Fernandes BJJ, Tem pleton AC. Myospherulosis (subcutaneous spherulocystic disease). Trans R Soc Trop Med Hyg 1971;65:182-8. 3. Kyriakos M. M yospherulosis of the paranasal sinuses, nose and middle ear: a possible iatrogenic disease. Am J Clin Pathol 1977;67:11830. 4. DeSchryver-Kecskemeti K, Kyriakos M. The induction of hum an m yospherulosis in experim ental animals. Am J Pathol 1977;87:33-46. 5. Rosai J. The n ature of m yospherulosis of the u p p e r respiratory tract. Am J Clin Pathol 1978;69:475-81. 6. Lynch DP, Newland JR, McClendon JL. M yospherulosis of the oral hard and soft tissues. J Oral Maxillofac Surg 1984;42:349-55. 7. Hall HD, Boldman BS, Hand CD. Prevention of dry socket w ith local application of tetracycline. J Oral Surg 1971;29;35-7. 8. Quinley JF, Roger RQ, Gores RJ. “Dry socket” after m andibular odontectom y and use of soluble tetracycline hydrochloride. Oral Surg Oral Med Oral Pathol 1960;13:38-42. 9. D unlap CL, B arker BF. M yospherulosis of the jaws. Oral Surg Oral Med Oral Pathol 1980;50:23843. 10. Bright C, Russel D, Keyes G. M yospherulosis. J Oral Maxillofac Surg 1982;40:509-12.
