You are on page 1of 4

MEDICAL INTELLIGENCE

11.
12.
13.
14.
15.

16.

lar endothelium in lymphoid tissue. A reexamination. J.
Exp. Med., 136:568-588, 1972.
Ghadially, F. N.: Ultrastructural Pathology of the Cell. Boston,
Butterworth Pnblishers, Inc., 1975, pp. 154-155.
Sobel, H., and Geller, J.: Experimental thyroiditis in guinea
pig. II. Electron microscopy, Am. J. Pathol., 46:149-163,
1965.
Heimann, P.: Uhrastrncture of human thyroid: a study of
normal thyroid, untreated and treated diffuse toxic goitre.
Acta Endocrinol. (Suppl.), 110:1-102, 1966.
N~ve, P., and Dnmont,J. E.: Time sequence of uhrastructural
changes in the stimulated dog thyroid. Z. Zellforsch.,
103:61-74, 1970.
Kalderon, A. E., Bogaars, H. A., and Diamond, I.: Uhrastrncrural alterations of the follicular basement membrane in
Hashimoto's thyroiditis. Report of eight cases with basement
deposits. Am. J. Med., 55:485--491, 1973.
Kalderon, A. E., Bogaars, H. A., Jolly, G., and Diamond, I.:
Electron dense deposits in the follicular basal lamina of
obese strain chickens with spontaneous hereditary autoimmtme thyroidifis. An electron microscope study. Lab. Invest., 37:487--496, 1977.

17. Kalderon, A. W., and Bogaars, H. A.: Immune complex
deposits in Graves' disease and Hashimoto's thyroiditis. Am.
J. Med., 63:729-734, 1977.
18. Weigle, W. O., and Nakamura, R. M.: Perpetuation of autoimmune thyroiditis and production of secondary renal lesions
following periodic injections of aqueous preparations of
ahered thyroglobulin. Clin. Exp. Immunol., 4:645-657,
1969.
19. Trump, B. F., McDowell, E. M., Glavin, F., Barrett, L. A.,
Becci, P. J., Schurch, W., Kaiser, H. E,, and Harris, C. C.:
The respirator)' epithelium. IIl. Ilistogenesis of epidermoid
metaplasia and carcinoma in situ in the human. J. Natl.
Cancer Inst., 61:563-575, 1978.
20. Becci, P.J., McDowell, E. M., and Trump, B. F.: The respirator)" epithelium. IV. Histogenesis of epidermoid metaplasia
and carcinoma in situ in the hamster. J. Natl. Cancer Inst.,
61:577-586, 1978.
Department of Pathology
University of Maryland School of Medicine
10 South Pine Street
Bahimore, Maryland 21201 (Dr. Shamsuddin)

Medical Intelligence
OSTEOMYELITIS OF A BONE GRAFT OF
THE MANDIBLE WITH ACANTHAMOEBA
CASTELLANil INFECTION
DENNIS BOgOCHOVITZ, M.B., B.Ctt., F.F. PA~rH. (S.A.),*
A. J o H n ~IARTINEZ, M.D.,I"
A,xn GARY T. PATrERSOY, D.M.D.~:

Abstract
An ameloblastoma of the right side of the mandible was
resected in a 32 year old prediabetic female. An iliac crest autograft
became infected and a seqnestrum was removed seven weeks later.
Pathologic examination of this tissue demonstrated a mixed infection, including Acantbamoeba casteIlanii. This is the first
recorded instance of h~vasion of bone by a free living ameba.
Despite the ubiquity of free living amebae in the
environment, they are rarely observed in h u m a n infection.~. 2 In recent }'ears, however, it Ires become a p p a r e n t
that there are two genera that may be pathogenic to man
and ustmlly fatally so? 5 T h e first to be recognized was
Naegleria, which is a free living ameba f o u n d in heated
swimming pools a n d m a n - m a d e lakes? This organism infects man via the olfactory neuroepithelium, causing fatal
meningoencephalitis. T h e r e have been over 150 r e p o r t e d
cases, ustmlly occurring in otherwise h e a h h y individtmls
who acquire tltg infection while swimming in unchlorinated
o r poorly chlorinated m a n - m a d e swimining facilities. T h e
other type that infects man is Acantimmoeba o f wliich th[~re
are a n u m b e r o f species. A c a n t h a m o e b a spp. have been
Accepted for publication August 30, 1979.
*Clinical Assistant Professor, Department of Pathology,
University of Pittsburgh School of Medicine. Assistant Pathologist,
Montefiore Hospital, lfittsburgh, l'ennsylvania.
tPrafessor, Department of l'athology, University of Pittsburgh
School of Medicine. Neuropathologist, Presbyterian-University
llospital of Pittsburgh, Pittsburgh, Pennsylvania.
:~Resident, Department of Oral and Maxillofacial Surgery,
University of Pittsburgh School of Medicine and PresbyterianUniversity ttospital of Pittsburgh, Pittsburgh, Pennsylvania.

isolated from the air, from the nasal passages and orop h a r y n x in normal individuals, from a purulent ear discharge, a n d from corneal tllcers. 614 In a recent review o f
the literature only few instances o f h u m a n infections d u e to
A c a n t h a m o e b a spp. worldwide were f o u n d ? ' z5-22 A quite
different epidemiology was suggested in that this infection
was found to occur probably as an opportunistic infection
in the compromised host. T h e primary focus o f infection
also differs, being skin, conjtmctiva, a n d probably u p p e r
respiratory tract with subsequent dissemination a n d encephalitis with a fatal outcome. These patients may be
healthy, but they include diabetic patients with skin nlcers,
alcoholic patients with cirrhosis o f the liver, and patients
taking steroids and broad spectrttnt antibiotics or receiving
radiotherapy.
Bone is not a tissue receptive to invasion by amebae in
g e n e r a l :~ I n 1954 Bell et al. z4 r e p o r t e d a much quoted case
o f a patient with amebic colitis, amebic liver abscess, and
subsequent chronic osteomyelitis o f the right scapula. Entamoeba histolytica was observed in the colon and jn tlie liver
abscess. Despite preoperative examination of the d r a i n i n g
sinus attd pathologic examination o f the scapulectomy
pecimens, amebae were not found. This case must thus be
considered unproven. In 1892 Dr. Sinmn Flexner z5 reported a patient, "a Virginian male aged 62 with an abscess on
the floor o f the mouth." T h e pus was drained from this
abscess and revealed u n d e r l y i n g necrotic bone; it "was
particularly offensive, suggesting fecal inatter." On direct
microscopy it showed "a large nuntber and variety o f
bacteria" and "mixed with the, pus c e l l s , . . , larger cells
possessing the power o f altering their forms . . . . and recognized as amoebae." With c o m m e n d a b l e catttion (anti some
foresight?) Dr. Flexner suggested tlmt these amebae were
o f an "allied species i'f not identical" to that described in
amebic dysentery. We have been unable to find an}" oilier
d o c u m e n t e d example o f amebic infection with bone invoh'ement.
This r e p o r t concerns a 32 }'ear old female in wltom an
ameloblastoma was resected from the right side o f the
mandible. A n autograft from the right iliac crest was used
to fill the defect. Acute suppurative osteomyelitis o f the

HUMAN PATHOLOGY - - VOLUME 12, NUMBER 6 June 1981

573

T h e physical examination revealed a grossly obese white female with a unilateral right m a n d i b u l a r facial swelling.0 cm.HUMAN PATHOLOGY--VOLUME 12. Acanthamoeba castellanii was observed and cultured. T h e patient was taken to surgery a n d a right submandibular incision (extraoral approach) was used to remove the lesion en bloc with the related teeth. and the skin was closed.5 cm. Examination o f the graft site revealed a large sequestrum o f necrotic bone. T h e tissue was sectioned and stained with hematoxylin and eosin. the intermaxillary wires were in place. Streptococcus viridans).000 units o f aqueous penicillin G intramuscularly.5 by 1. o r an imntunologically altered host all play a role in this p h e n o m enon. with a normal differential. T h e trophozoites are large. T h e cellulitis failcd to resolve after one week and she was readmitted. 2~"~r T h e trophozoites were identified as Acanthamoeba castellanii. erythrocytes. Microscopy shows necrotic bone with necrotic marrow spaces. 2 x 10 ~ units intravenously every f o u r hours. T h e amebae a p p e a r to be acting in the role o f scavengers and can be seen apparently engaging in phagocytosis o f both cocci and bacilli attd also erythrocytes. and the BrownBrenn modification o f the G r a m stain. T h e white cell count was 7200 per cu. It is possible that an alteration in bacterial flora. Roentgenographic examination revealed a radiolucency that was well circumscribed and was associated with an impacted third molar tooth. and the entire area was d e b r i d e d a n d irrigated with betadine solution (povidoneiodine 1 p e r cent). Free living amebae have r6cently been recognized as oral commensals albeit o f a transient nature. S. T h e s e include bacteria o f many genera (Neisseria spp. who c u h n r e d Acanthamoeba castellanii from that broth. bacteria. A Panorex r o e n t g e n o g r a m indicated an intact bone graft. local tissue danmge. T h e patient received Kellin elixir. Willaert o f the Veterans Administration Hospital in Gainesville. In ninny o f the spaces acnte inflammatory exudate is seen in association with large groups of bacterial colonies (Fig. Florida. which exhibited a feculent smelling. a punch biopsy demonstrated ameloblastoma. T h e thyoglycollate broth was retrieved from the Bacteriology Laboratory and sent to Dr. Actinomyces israelii is an example. June 1981 graft.. 2). and an autogenous bone graft from the right s u p e r i o r iliac crest was taken a n d positioned with interosseous wire fixation. Examination o f the removed specimen revealed gram positive cocci and g r a m positive and gram negative bacilli.0 by 0. T b e skin overlying the lesion and the related mucosa were both intact. was instituted and betadine mouthwash was used four times a day. T h e oral examination revealed an expansile firm mass extending front the first m a n d i b u l a r right bicuspid area (mental foramen) to the gonial angle o f the the ascending ramus. the communicating intraoralextraoral fistulous tract was closed. the patient's m o t h e r had maturity onset diabetes. I). 500 mg. who p e r f o r m e d indirect immunoflnorescence for Acanthamoeba spp. Enterobacter aerogenes and light microaerophilic Streptococcus pyogenes were cult u r e d from the area. Postoperatively she did well and was discharged on the fifth hospital day. periodic acid--Schiff. T h e postoperative recovery was uneventfld and she was discharged afebrile on the eleventh postoperative clay. She was afebrile. Tissue sections were submitted to Dr. and the oral mucosa was pink with dehiscence overlying the m a n d i b u l a r graft site. NaegleHa fowleH.. U n d e r general anesthesia the wound was o p e n e d extraorally. with 500 nag. Most d o not invade the tissues o f the mouth. and occasionall}' a leukocyte. a n d Entamoeba histolytica. Atlanta. Sntall groups o f trophozoites are identified in clusters and intimately associated with some bacterial colonies (Fig. T h e nucleus is single and central or slightly eccentric a n d shows a thick nuclear membrane. T h e patient revealed no symptoms except that the teeth in that area displayed mobility. Georgia. orally four times daily. the periosteum was rcpositioncd a r o u n d the r e m a i n i n g portion o f the 574 T h e specimen was a roughly rectangular portion o f bone 5. ram. It was white-yellow with focal areas o f h e m o r r h a g e . for 10 days as a routine part o f this procedure. E. T h e mucosa was closcd. this is the first r e c o r d e d example of invasion o f the . T h e mucosa was closed. Nowhere do the trophozoites a p p e a r in direct contact with the host bone but a p p e a r r a t h e r to be intimately associated with the bacterial colonies present (Fig. A dense large central p o l y m o r p h o u s karyosome is a distinguishing feature. It is not known what factors p r o m o t e excystation o r w h e t h e r indeed this occurs in the oral cavity o f the normal host.. thick p u r u l e n t material. A h h o u g h major oral surgery o f the type experienced by this patient is a frequent event in m o d e r n medical practice. T h e patient was placed into intermaxillary fixation and given clear liquid feedings with multiple vitamin supplements. Some o f these can be seen to contain vacuoles in which phagocytized debris is seen. N U M B E R 6. chromatin free Imlo. representing about one-half o f the autograft.2 x 10 ~ units o f procaine penicillin G a n d 6000. PATHOLOGY CASE R E P O R T T h e patient was a mildly obese. 4. Penicillin V orally four times daily for 10 days.0 by 2.0 by 1. and this is separated from the nuclear m e m b r a n e by a relatively clear. T h e patient r e m a i n e d asymptomatic for five weeks following discharge. 1). Center for Disease Control. T h e rest o f the general physical examination was noncontributory. ~ DISCUSSION T h e oral cavity is the site o f many microbial commensals. T h e latter is replete in vacuoles o f various sizes and shapes containing cell debris. 32 }'ear old Caucasian female who was admitted in J a n u a r y 1979 for treatment of an expansile mass in the right m a n d i b u l a r area. Grocott silver methenamine. T h e specimen was fixed in 10 p e r cent b n f f e r e d fornmlin and decalcified in nitric acid with aerosol. T h e scquestrtnn was removed. She was given 1. Each exhibits a well defined ectoplasm enveloping the granular endoplasm. measuring a p p r o x i m a t e l y 20 to 40/x in diameter. A thin purulent exudate covered many areas o f the foul smelling tissue. trichrome. In rare instances. commensals may act as opportunists and invade the tissue. T h e periosteum was closed a r o u n d the graft and the wountl closed. On examination she was afebrile. G. T h e right s n b m a n d i b u l a r area showed diffuse cellulitis with an external fistula. 7~~ The}" are carried by air or dust into the u p p e r respirator}' tract and mouth in the form o~r cysts. however. It had been present a n d slowly enlarging for two years. Penicillin G. graft developed and a sequestrum was removed d u r i n g the d e b r i d e m e n t procedure. T h e r e was a questionable history o f diabetes mellitns controlled by diet alone. at which time she presented to the emergency room with acute right snbnmndibular cellulitis without intraoral or extraoral fenestration. Visvesvara.

Oil immersion. It appears to have engulfed many bacteria and a red cell (arrow).nmerslon. (ttematoxylin and eosin stain. In the inset.MEDICAL ' INTELLIGENCE / IP Figure 1. Photonlicrograph demonstrating morphology of Acanthanloeba spp. (Hematoxylin and eosin stain. bacterial colonies. Note the large dense kar)'osome and the clear |~erikaryosomal halo typical of this genus. and Acanthamoeba trophozoites (arrowhead). Oil i. at higher magnification.X 1680. l'hotomicrograpll demonstrating a necrotic bone marrow space with leukocytes (arrow).) I~ Figure 2. the Acanthamoeba trophozoite iqdicated is demoqstrated in more detail.) 575 . x 1680. lnset. x400.

. Acknowledgments T h e authors gratefully acknowledge the contributions of Dr. 8.: Amoebic infection of the eye. S. Lancet.: Granuloma of brain probably due to Endolimax williamsi (lodamoeba butschlii).. O.Jones. one good example recently the subject of an excellent review being tbat ofSenatia marcescens. 22. Culbertson. Director of Laboratories.. 14.. 35:195-202. 225-255. J. U. Culbertson. Hehvig. H. G. 19. Presbyterian-University Hospital... Pathology Department Mmltifiore 1tospital 3t59 FiIHt Avenue Pittsburgh. E. Soc. and then superinfection by the Acanthamoeba. C. 7l:201-203. S. with infection. In Sonanaers. A. T. J.. R. 1972. 88:468--473. J.J. W. S. Agents Chemother. Jager. Ophthal. G. R. S. McGiII. resulted in a breakdown in their relationslfip and in tissue invasion. K.: Hartmannella (Acanthamoeba): experirnental chronic. P. P. and Overton. J. Dr. 29. and MeG. W. 24. (Berl.. However. 13.. Nelson.... However. 79:174-179.)... and Feldman. O. S. P. 2. Hines. 25 T h e authors wish to tbank Linda Shab for photgraphic work and Gustine Lewis for secretarial assistance.: Metabolic Degenerative and Inflammatory Diseases of Bone and Joints. Visvesvara.: Acanthamoeba polyphaga keratitis and Acanthamoeba uveitls associated with fatal meningoencephalitis. Med. J. 28. Magath. and Levitt. Hoffmann. and Tolls. B. Jakovlzevich.. B. in a patient in whom a number o f host resistance factors were impaired. Abraham. Clin. Trans. Willaert. 1978... V. Am.: A case of primary amebic meningoencephalitis.. Am. W. Garcia. A. 1976. Clin. and Dechant.. necrotic infected oral tissue). E. often necrotic tissue. It. R..: Serratia marcescens.: Brain abscesses caused by free-living amoeba probably of the genus Hartmannella in a patient with Hodgkin's disease. a diligent search for these organisms in possible sites o f invasion should be made in biopsy material from sites that have been reported as primary ports of entry (ear discharges. Sotelo-Avila. 1966. W. 1977. and X~. Possible factors that play a role may be an alteration of the bacterial flora. Total scapulectomy. D. Ann. L. D. Anderson. Bhaga~'andeen. Pathol. dos Santos. Charles G Thomas.. M. N. Kingston. It is also possible that there has been a recent change in the Acanthamoeba population. E. 1979. Jones. Am. G. Med. Pathol. 1978. and Martinez. 25. Bull.. Antimicrobiol... J. 2:15371540.: Amebaein an abscessofthejaw. B. l. J. 26. Diagnosis and Chemotherapy. Clin. Acta Ncuropathol. Bull.. Pathol. C.: Pathogenic Acanthamoeba (Hartmannella). t6 This too cannot be the entire explanation. Garda-Tamayo. J. Am.: Amebic meningoencephalitides.. D. despite tbe ubiquity o f free living ameba. Martlnez.. Protozool. G. P. (Editors): Pathology of Tropical and Extraordinary Disease. Clin. Robert E. J. G. and. W. and Conner. J. M. 3:104-106. Willaert and Dr. witb superinfection by Acanthamoeba castellanii. T h e r e must be man)' diabetic patients wbo have harbored Acanthamoeba cysts transiently in the oral cavity and. Engl. Kernohan. R.. E. Armed Forces Med. A. J. L..: A case of hartmanellid amebic meningoencephalltis in Zambia. Nagington. 12. Willaert. and Schloss. 1975. operated on this pattent and kindly consented to our report. F. 1977. (Praha). Tiffs allowed the proliferation o f gram negative bacilli and gram positive cocci. D.Johns Hopkins ttosp. D. Int. Wang. wound and bone graft by Acanthamoeba.: Isolation of amoeba from the air. corneal infections. 1967. 1969. G.. One such factor is the altered immunologic competence of the host. Philadelphia. now. Biol. S. T. P. Ringsted. and Sk6cil.. G. G. P.. C. A. L. and Balamuth. Arch. 1978.. McGarry. G. 7. L.: Primary amebic encephalitis. 1979. D. D. Takano-Mor6n. C. 1976. Ophtbalmol. the possibility is raised that free living amebae. Lancet. T h e patient is a prediabetic and Acanthamoeba infection has been reported in diabetics. V. where they may be overlooked as degenerated bistiocytes. C. E. and Stevens.: Occurrence of Acanthamoebae in tissue cultures inoculated wittt human pharyngeal swab. and Ede.. Lawande. and Stature. H.. Wang. J. pp. 27.: Amebiasis: Pathology. Med. C.. 31:717-720.. probably related to the broad spectrum antibiotic used. SUMMARY We present a case of osteomyelitis of a mandibular bone graft. 576 June 1981 3. 1971. C. Watson.. Playfair. W. G. Only careful examination of suspect tissnes in susceptible patients will allow early detection o f such a phenomenon. have become more aggressive. 37:183-191.. New York. 2:27-36. acting in concert on the patient and the parasite. T h e conclusion is that all the foregoing factors. J. D. Ann. Illinois. and Rosen. Trop.. 1892. 66:723-730.. Med. 11.. R. J. Visvesvara...: Meningoencephalitis and brain abscess due to a free-livlng amoeba. Ensminger. 16. 1971.: Meningoencephalitis due toAcanthamoeba sp. Trop. L.: Isolation of Limax amoebae from the nasal mucosa of man... S. 5:1740-1748. Microbiol. B.. and Healy. George C. J. Naik. A. 10. Director of Oral and Maxillofacial Surgery. 23. 1953.. Med. Boshek. 27:29-38. Kenney. C. V. 24:545-547. J. 30. Stefani. J.. Dr.: The micro-Kolmer complement fixation test in routine screening for soil ameba infection. Dis. 6. 8:5-10. PathoL. Simon Flexner. A. J. A. granulomatous brain infections produced by new isolates of low virulence. Suk. and Feldman. Springfield. Willaert. 9. U. and Visvesvara. 1961.. 1954. Martlnez. Bell..: Isolation of Hartmannella species frmn human throats. Culbertson. F. Clin. Robert. H.. Steele. S. 277:1174-1179. References 1. L. N. (Editors): Pathology Annual. B. G.. resulting in a more aggressive variety or race of Acanthamoeba. 18. J. P. Pathol. Fofia Parasitol.. Jager.: Recovery of a hartmanelloid amoeba from a purulent ear discharge. P. E.: Probable Acanthamoeba meningoencephalitis in a Korean child. S. 68:818. C. S. Path.. 70:576-580.. S. Light and electron microscopy and immunohistologic studies. S. A. Pennsylvania 15213 (Dr.: Primary amebic meningoencephalitis.. Yu. R. especially m severely damaged. Clin.: pathogenesls and clinicopathological study. 300:887-893.: Comparative studies on related free-living and pathogenic amebae with special reference to Acanthamoeba. ttyg. R. Presbyterian-University Hospital. J. 20:97-103.. ti. indeed. B. V. 1975. C. N.. 17. John I. 317-324. and Rorke.. pp. 2:1343-1345... In this respect it is critical for the morphologist to be cognizant o f the appearance of the trophozoites. 1976. W.S. Serbus. Am. E. In Binford.. Duma. E. and Egler. and Robinson. 1961. tlistorical perspective and clinical review.: Retrospective identification of Acanthamoeba culbertsoni in a case of amoebic meningoencephalitis. W. 1960. 1973..: Recovery of soil amoebas from nasal passages of children during tile dusty t tartmattan period in Zaria. 20. C. Jaffe. W. 1978. anti Johnstone..C. 1973.. V.HUMAN PATHOLOGY--VOLUME 12. Lung. H.. J. 21. J.arhurst. Pathol. B.. G. T.J. C~rva. patients such as ours routinely receive antibiotics in the postoperative period so that other factors must sttare the responsibility. ttealth Lab. Pathol. G. H. Carter... It. and Cover.. 62:373-375. 95:221-232. 1972. K. Stevens. Sotereanos. B. have undergone oral surgery complicated by bacterial infection...: Indirect identification of Acanthamoeba causing meningoencephalitis. AppletonCentury-Crofts. NUMBER 6. Sci. 22:245-256. 1:50-53. Lea & Feblger. Med. 1974. Borochovitz) . Lee. This occurs in microbes in general. J. W. R. Lengy. Vol. Flexner. Lunseth. V. M. 5. L.. Armed Forces Institute of Pathology. Int.J. J. 15. and Stature. B. H... Stamm. Engl.. and Willaert. skin ulcers. J. Washington. which from being a curiosity has evolved over the )'ears to become a serious opportunistic pathogen? ~ In view of the uniformly fatal outcome of Acanthamoeba infection once systematized. J. probably fromAcanthamoeba. 1975.: Amoebic keratitis: a clinicopathological case report. Am. J. Visvesvara. G. 46:305-314. 63:483--492. N. B. 4. like other free living organisms in tbe past. Brit.. kindly drew our attention to the report in 1892 of Dr.