Pathology · patient case question
What is Patient A's diagnosis?
Patient case: Two periosteal reactions
Patient: Two patients
Chief Complaint: A: “The bottom of his jaw is hard and swollen.” B: “This part of my palate has swollen up over three months.”
Background: A, 11-year-old male: firm, painless swelling at the lower border of the mandible. Tooth #30 has gross caries and does not respond to cold. Afebrile, no lymphadenopathy, inflammatory markers normal. B, 58-year-old male: progressive expansion of the anterior maxilla with loosening teeth.
Findings: A: successive parallel layers of new bone laid down on the periosteal surface of the lower border — an ONION-SKIN appearance. B: a mixed radiolucent-radiopaque expansile lesion of the anterior maxilla with a SUNBURST periosteal pattern and SYMMETRICAL WIDENING of the periodontal ligament spaces of the involved teeth. Biopsy shows a malignant CARTILAGINOUS matrix.
Show answer and explanation
Correct answer: D. Chronic osteomyelitis with proliferative periostitis (Garré)
- A. Ewing sarcoma is the genuine mimic and deserves to be known, because it can also produce onion-skin periostitis. It is distinguished by PAIN, fever, raised inflammatory markers and a permeative, destructive lesion — none of which is present here, and all of which the stem deliberately excludes.
- B. Osteosarcoma also produces a periosteal reaction, but the classic pattern is SUNBURST or spiculated rather than layered, and it is accompanied by symmetrical widening of the periodontal ligament space. It also occurs in an older age group and would not be explained by a carious non-vital molar.
- C. Fibrous dysplasia produces ground-glass bone blending imperceptibly into normal bone, with no periosteal layering and no associated non-vital tooth.
- D. CORRECT. CHRONIC OSTEOMYELITIS WITH PROLIFERATIVE PERIOSTITIS, historically GARRÉ osteomyelitis, is a disease of CHILDREN AND YOUNG ADULTS, almost always at the LOWER BORDER OF THE MANDIBLE, driven by a low-grade infection — typically a carious non-vital first molar, exactly as here, or a pericoronitis. The periosteum responds by laying down successive parallel layers of new bone, producing the ONION-SKIN appearance. The management point is the important one: treat the SOURCE. Extract or root treat the offending tooth and the periosteal bone remodels over months without any need for surgery on the swelling itself.
Note: The lesson generalises: a periosteal reaction is a pattern, not a diagnosis. ONION-SKIN in a child with a carious tooth → proliferative periostitis. ONION-SKIN with pain and fever → exclude Ewing sarcoma. SUNBURST with widened PDL spaces → osteosarcoma until proven otherwise.