Mandibular TB presenting as squamous cell carcinoma: a case
A 46-year-old male presented with a history of a large non-healing ulcer of the lower left alveolar region of the mandible. He denied any relevant systemic medical condition but appeared malnourished. Socially, he disclosed a historic smoking habit, stopping 10 years previously, and a decrease of alcoholic intake from over 30 units/week to 10 units/week.

Extra-orally, he presented with palpable level Ib, II and V lymph nodes. Intra-oral examination revealed an approximately 2 cm × 1 cm ulcerated mass with rolled edges of the alveolar region of his left mandible and associated neurosensory disturbance of the mandibular branch of the trigeminal nerve causing lower lip paraesthesia. He also presented with a neglected dentition, and severe generalised periodontitis.

A dental panoramic tomography (DPT) image demonstrated an osteolytic lesion of the left body of the mandible measuring approximately 2cm. Cone beam computed tomography (CBCT) confirmed focal destruction extending from the lower left incisor to the lower left molar region with destruction of the lamina dura and part of the inferior alveolar nerve canal wall, as well as extensive destruction of the buccal cortex and erosion through the lingual cortex of the mandible.

CT of the chest excluded metastasis. Magnetic resonance imaging (MRI) demonstrated the soft tissue extension, thus providing a working diagnosis of left mandibular SCC with bony destruction and necrotic lymphadenopathy along the ipsilateral level I and II neck nodes.

An urgent incisional biopsy under local anaesthetic revealed necrotising granulomatous inflammation. Although acid-fast bacilli were not identified on the Ziehl-Neelsen stain, the modified Ziehl-Neelsen stain (Wade-Fite) confirmed diagnosis to be consistent with tuberculosis.

His treatment involved local surgical debridement without grafting under local anaesthetic, as well as anti-tubercular therapy. He commenced a six-month course, comprising two months intensive therapy with Isoniazid, Rifampicin and Pyrazinamide and maintenance therapy of four months with Rifampicin and Isoniazid.

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