Osteomyelitis of the Maxilla Secondary to Periorbital Cellulitisin a Neonate: A Case ReportOsteomielitis del maxilar secundaria a celulitis periorbitaria en unneonato: reporte de un casoRevista Ecuatoriana de PediatríaEditorial:Sociedad Ecuatoriana de Pediatría (Núcleo de Quito, Ecuador)Tipo de estudio:Reporte de CasoÁrea de estudio:PediatríaPáginas:45-51Codígo DOI:https://doi.org/10.52011/RevSepEc/e351URL:https://rev-sep.ec/index.php/johs/article/view/351RESUMENLa osteomielitis es la infección del tejido y médula ósea, causado principalmente por bacterias, microorganis-mos que pueden diseminarse por tres vías: hematógena, por contigüidad o directa. En la etapa neonatal esuna entidad grave y poco frecuente, que puede causar secuelas osteoarticulares permanentes, presentándoseen esta etapa de la vida con características etiopatogénicas e histológicas diferentes a las presentaciones enotros grupos etarios. Su presentación en el macizo facial es poco y puede ser secundaria a infecciones detejidos blandos de la cara. Se presenta el caso de un neonato femenino de 20 días de vida que desencadenóosteomielitis del maxilar superior secundaria a celulitis facial y periorbitaria, con determinación de Staphylo-cocus aureus en hemocultivos y secreción ocular, manejado con cobertura antibiótica de amplio espectro ymanejo quirúrgico expectante, con evolución clínica favorable, en seguimiento actual por ambulatorio.Palabras clave:Celulitis periorbitaria, osteomielitis, neonatal, infección bacteriana, celulitis.ABSTRACTOsteomyelitis is an infection of bone tissue and bone marrow, primarily caused by bacteria, which may spreadthrough three main routes: hematogenous dissemination, contiguous spread, or direct inoculation. In the neo-Jean Carlos Delgado Macías1, Miguel Ángel Hernández Cedeño1, Ambar Noemi Armijos Cevallos1,Alex Villalta Herrera2, Aurora Chávez Veliz3, Reyma Mosquera Peña3Reporte de Caso1.Resident Physician in Pediatrics, Hospital de Niños Dr. Roberto Gilbert Elizalde, Guayaquil, Ecuador.2.Resident Physician in Pediatrics, Hospital de Niños Dr. Roberto Gilbert Elizalde, Guayaquil, Ecuador.3.Resident Physician in Pediatrics, Hospital de Niños Dr. Roberto Gilbert Elizalde, Guayaquil, Ecuador.4.Attending Physician, Department of Diagnostic Imaging, Hospital de Niños Dr. Roberto Gilbert Elizalde, Guayaquil, Ecuador.5.Attending Physician, Department of Neonatology, Hospital de Niños Dr. Roberto Gilbert Elizalde, Guayaquil, Ecuador.6.Attending Physician, Department of Neonatology, Hospital de Niños Dr. Roberto Gilbert Elizalde, Guayaquil, Ecuador.Jean Carlos Delgado Macíashttps://orcid.org/0009-0007-0289-4596Miguel Ángel Hernández Cedeñohttps://orcid.org/0000-0002-2307-8981Ambar Noemi Armijos Cevalloshttps://orcid.org/0000-0002-1768-0925Alex Villalta Herrerahttps://orcid.org/0000-0001-8333-2307Auror Chávez Velizhttps://orcid.org/0009-0000-9861-6628Reyma Mosquera Peñahttps://orcid.org/0009-0008-7252-1557Correspondencia:maciasjeancarlosdelgado@gmail.comRecibido: 10/oct/2025 - Aceptado: 12/nov/2025 - Publicado: 29/dic/2025
Revista Ecuatoriana de Pediatría | ISSNe: 2737-6494Pagína 46| VOL.26 N°3 (2025)Septiembre - Diciembrenatal period, it represents a rare but severe condition with the potential to cause permanent osteoarticularsequelae. During this stage of life, osteomyelitis exhibits etiopathogenic and histological features that differ fromthose observed in other age groups. Involvement of the facial skeleton is uncommon and is usually secondaryto contiguous soft tissue infections of the face. We report the case of a 20-day-old female neonate who de-veloped osteomyelitis of the maxilla secondary to facial and periorbital cellulitis, with Staphylococcus aureusisolated from blood cultures and ocular discharge. The patient was treated with broad-spectrum antibiotictherapy and conservative surgical management, showing favorable clinical evolution and currently remainingunder outpatient follow-up.Keywords:Periorbital cellulitis; osteomyelitis; neonatal period; bacterial infection; cellulitis.Reporte de CasoIntroducciónOsteomyelitis (OM) is an infection of bonetissue and bone marrow, primarily caused bybacteria, which may spread through threemain routes: hematogenous dissemination,contiguous spread, or direct inoculation1. Inthe neonatal period, hematogenous spreadrepresents the predominant mechanism ofinfection. During the early phase of the di-sease,increasedbonevascularityoccursas a result of the inflammatory response,whereas reduced vascularity is observed inchronic cases2,5.Identifiedriskfactorsincludeprematurityand prolonged stays in critical care units,oftenassociatedwithcatheter-relatedin-fections.Inneonates,OMpresentswithetiopathogenic and histological characteris-tics that differ from those observed in olderpatients3.Maxillary osteomyelitis predominantly affectsinfants and young children and may arisefrom hematogenous dissemination or as acomplicationofadjacentstaphylococcalskin infections4. The most commonly repor-ted etiologic agents include Staphylococcusaureus, Bacteroides spp., and Streptococcusspp5. Clinical presentation is usually nonspe-cific and includes prolonged fever, irritabi-lity, edema, erythema, pain, and functionalimpairment6.The diagnosis of maxillary osteomyelitis re-lies on clinical evaluation, imaging studies,biopsy,andmicrobiologicalcultures7,withbloodculturesconsideredthegoldstan-dard for etiologic identification. Treatmentis primarily based on broad-spectrum an-tibiotictherapy8,withsurgicalinterventionreserved for selected cases.Case PresentationA 20-day-old femaleneonate,born to a23-year-old mother, fifth pregnancy, delive-red via uncomplicated vaginal delivery at39 weeks of gestation, was admitted witha 48-hour history of fever up to 38 °C, im-mediate postprandial vomiting, abdominaldistension,right-sidedperiorbitaledema,and greenish discharge from the upper ri-ght gingival region.On admission, the patient was irritable, fe-brile, and tachycardic. Physical examinationrevealed edema and erythema of the righteyelid, induration of the right cheek, yellowi-sh discharge from the right nostril, and aviolaceous mass approximately 0.5 cm indiameter in the upper right gingiva, asso-ciated with greenish discharge and whitishspots on the mucosa.Given the presentation of a febrile neonate,an initial diagnostic approach for late-on-set neonatal sepsis and periorbital cellulitiswas initiated. Blood and site cultures wereobtained. Chest radiography showed rightperihilarreinforcement,whileabdominalradiography revealed poor air distributionand mild interloop edema. Transfontanellarultrasound was normal, whereas abdominalultrasounddemonstratedhepatomegalyand splenomegaly.Laboratory evaluation showed leukocytosiswith neutrophilia (absolute neutrophil countof 15,200), reactive thrombocytosis, elevatedacute-phase reactants, and indirect hyper-bilirubinemia. Immunoglobulin and comple-ment levels were normal for age, as wereorgan function tests. Urine and cerebrospi-nal fluid cultures were negative, and echo-cardiography was unremarkable.
Revista Ecuatoriana de Pediatría | ISSNe: 2737-6494Pagína 47| VOL.26 N°3 (2025)Septiembre - DiciembreContrast-enhanced computed tomography(CT)oftheorbitsandfacialboneswasperformed (Figure 1). Ophthalmologic eva-luationrevealedanormalfundoscopicexaminationandfindingsconsistentwithrightperiorbitalcellulitis,recommendingconservativemanagementandophthal-mic antibiotic therapy. In conjunction withneonatology, the infectious diseases teammaintained ampicillin and added vancomy-cin.Maxillofacialsurgeryrecommendedgingival cleansing with Dakin’s solution andcontinuation of antibiotic therapy.Subsequentclinicaldeteriorationincludedworsening right periorbital edema with in-ability to open the eye, marked proptosis,and purulent discharge. Blood cultures andocularsecretionculturesyieldedmethici-llin-resistant Staphylococcus aureus. Leuko-cytosis and elevated inflammatory markerspersisted. Following multidisciplinary discus-sion, conservative management and anti-biotic therapy were continued.After 14 days of antibiotic treatment, clinicalimprovement of periorbital edema was no-ted, with improvement in blood counts butpersistentelevationofinflammatorymar-kers. Follow-up CT of the face and orbitswas performed (Figures 2 and 3), followedby contrast-enhanced magnetic resonanceimaging (MRI) of the right orbit (Figure 4).Based on clinical and radiological evidenceof osteomyelitis,andconsideringthepa-tient’s age and surgical risks, conservativemanagementwithcontinuedvancomycintherapyandclosemonitoringofinflam-matory markers was maintained.Figure 1.Non-contrast coronal computedtomography demonstrating mucosal thicke-ning of the right maxillary sinus and adja-Figures 2 and 3.Contrast-enhanced axialcomputedtomography showingextensionof inflammatory changes to the adjacentcanthal region (white arrows), mild protru-sion of the right globe (interzygomatic line–anterior corneal border distance: 14.3 mmon the right and 11.3 mm on the left), andmillimetric bone fragments within the extra-conal fat associated with the inflammatoryprocess (yellow arrow).Reporte de Casocent osteomeatal complex, associated withirregularity of the medial wall and floor ofthe ipsilateral orbit, as well as inflammatorychanges in the anterior third of the conti-guous extraconal fat, consistent with compli-cated sinusitis with associated osteomyelitis.
Revista Ecuatoriana de Pediatría | ISSNe: 2737-6494Pagína 48| VOL.26 N°3 (2025)Septiembre - DiciembreReporte de CasoFigure 4.Axial contrast-enhanced T1-wei-ghtedmagneticresonanceimagingde-monstrating inflammatory changes involvingthe extraconal fat and the medial canthalregions.tocontiguousspreadrelatedtotrauma,penetrating wounds, surgical procedures, orjoint replacement; and osteomyelitis secon-dary to vascular insufficiency, with the he-matogenous route being the most frequent,particularly in neonates11. Nevertheless, otherpredisposing factors have been describedin the literature, including genetic conditionssuch as sickle cell anemia and osteopetro-sis, as well as toxic and environmental fac-tors, including birth-related trauma12,13.Factors associated with maxillary osteom-yelitisincludeinfectionsoftheorofacialregion, eyes, nose, paranasal sinuses, andears, as well as alveolodental infections14,15.In the present case, the presence of a ru-dimentary tooth in the palatal region withsubsequent abscess formation representeda significant risk factor for the developmentof maxillary osteomyelitis.Clinicalpresentationduringtheneonatalperiod is highly variable and often nons-pecific, and may manifest solely as irritabi-lity, fever, or even gastrointestinal symptomssuch as diarrhea16. Purulent nasal dischargeor drainage from the canine fossa may alsobe observed17. In hematogenous acute os-teomyelitis, symptom onset typically occurswithin less than two weeks11, consistent withthe clinical course observed in our patient.Once the maxilla is involved, rapid spreadto adjacent structures may occur, includingthe orbital region, dental follicles, nasal ca-vity,andmedialmaxillarysinus.Clinically,this results in erythema and edema of theperiorbital region, usually involving the me-dial aspect, as well as cheek and periorbitalsoft tissue swelling14,15,17. In more severe cases,proptosis,chemosis,andophthalmoplegiamay develop14, findings that were consistentwith the clinical deterioration and right-eyeproptosis observed in our patient.ThemostfrequentlyisolatedpathogenacrossallagegroupsisStaphylococcusaureus, followed by Streptococcus agalac-tiae,entericgram-negativebacteria,andCandida spp., particularly in infants youn-ger than one year3. In the present case,S. aureus was isolated, in agreement withglobal literature. It is important to highlightIn view of the improvement in clinical andlaboratory findings, it was decided to com-plete30daysofantibiotictherapywithvancomycin, followed by a switch to oralclindamycin to complete a total of six wee-ks of antimicrobial treatment. After joint re-assessmentbytheneonatology,ophthal-mology, maxillofacial surgery, and infectiousdiseases teams, the patient was dischargedwith a plan for multidisciplinary outpatientfollow-up.DiscussionOsteomyelitis is an inflammatory process ofbone caused by bacterial or fungal infec-tion. Maxillary osteomyelitis in the neonatalperiod and early infancy is an exceptionallyrare condition; the first case was describedin 1847 by Jacob and Sagorin9. The inciden-ce of acute osteomyelitis (AO) is estimatedat 1 to 3 cases per 1,000 children10. Howe-ver,inour country,therearenopreciseepidemiological data regarding prevalenceor incidence, likely due to the rarity of thisclinical presentation.According to etiopathogenic classification,AO is divided into three types: hematoge-nous osteomyelitis; osteomyelitis secondary
Revista Ecuatoriana de Pediatría | ISSNe: 2737-6494Pagína 49| VOL.26 N°3 (2025)Septiembre - DiciembreReporte de Casothe increasing emergence of antimicrobialresistanceandmethicillin-resistantstrains(MRSA). In our patient, the isolated strainwas methicillin-susceptible, which representsa favorable prognostic factor.The diagnosis of maxillary osteomyelitis isprimarily clinicalandsupportedbylabo-ratoryandimagingstudies.Inflammatorymarkers such as leukocyte count and C-re-active protein (CRP) are useful for monito-ring disease progression; CRP values below20 mg/L have been associated with crite-ria for discontinuation of antibiotic therapy.However, independent predictors of MRSAinfectionhavebeendescribed,includingelevated body temperature, low hematocrit,leukocytosis, and increased CRP levels18.Computed tomography and magnetic reso-nance imaging are essential tools for asses-sing changes in tissue density, lytic lesions,and periosteal involvement associated withmaxillary osteomyelitis19. In our patient, initialimaging demonstrated increased density ofthemaxillaryandethmoidalsinusesandhypertrophy of the nasal turbinate mucosa,followed by progression to lytic lesions ofthemaxillarybone,confirmedonsubse-quent imaging studies.The treatment of maxillary osteomyelitis re-mains controversial, as there is no absoluteconsensusregardingexclusiveconservati-ve management with antibiotics versus theneed for surgical intervention. Since the firstreportedcases,treatmenthasbeengui-ded by microbiological sensitivity; penicillinhas historically been used as first-line thera-py14,16. In our patient, empirical therapy withan aminopenicillin and an aminoglycosidewas initiated to cover S. aureus and entericgram-negative bacteria. However, definitiveantimicrobial selection depends on the iso-lated pathogen, its susceptibility profile, andlocal resistance patterns; in cases of sus-pected or confirmed MRSA infection, van-comycin is the treatment of choice19.The duration of antibiotic therapy dependson the association with acute bacterial ar-thritisandthepresenceofosteomyelitis.In cases without osteomyelitis, a 10–14-daycourse of antibiotics is recommended20. Inpatients with osteomyelitis and isolation ofS. aureus, treatment should be extended to3–4 weeks, with longer courses required forresistant organisms13,21. In the present case,with methicillin-susceptible S. aureus isolatedfrom blood and maxillary secretion cultures,three weeks of vancomycin therapy werecompleted due to initial concern for MRSA,considering risk factors such as age andextensive involvement of adjacent structu-res. The patient showed favorable clinicalevolutionwithoutneurologicalcomplica-tionsandwasdischargedonorallinco-samide therapy, in accordance with inter-national guidelines for the management ofosteomyelitis21.ConclusionMaxillary osteomyelitis in the neonatal pe-riod is an uncommon condition but is asso-ciated with significant morbidity and morta-lity. Early diagnosis is often challenging dueto the nonspecific nature of initial clinicalmanifestations and the rapid progression toorbital and systemic complications. This casehighlights the importance of maintaining ahigh index of suspicion in infants with facialor periorbital cellulitis showing poor respon-se or refractory evolution to initial therapy,as well as the need for a multidisciplinaryapproach involving neonatology, infectiousdiseases, and maxillofacial surgery to opti-mizeclinicaloutcomes. Timely recognitionand early initiation of appropriate antibiotictherapy remain critical in preserving func-tion, preventing aesthetic sequelae, and im-proving overall prognosis.Author contributionsArmijos Cevallos: Preparation of the originalmanuscriptdrafts.DelgadoMacías:Con-ceptualization and manuscript writing. Her-nández Cedeño: Critical review and con-tentvalidation.VillaltaHerrera:Resourceprovision. Chávez Aurora: Study supervision.Mosquera Reyma: Study supervision.Ethical StatementThis clinical case is presented anonymously,
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