Pediatric cervicofacial actinomycosis presenting with mandibular osteomyelitis: a diagnostic and therapeutic challenge and literature review

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Abstract
Background. Actinomycotic osteomyelitis is a rare, chronic infection caused by Actinomyces species, anaerobic bacteria normally found in the oral flora. Mandibular involvement is uncommon and may mimic malignancies, complicating diagnosis. Case Presentation. A 15-year-old previously healthy male presented with painful neck swelling and trismus. Examination revealed a firm mass at the angle of the mandible. Imaging suggested osteomyelitis but raised concern for malignancy. Surgical drainage was performed, and histopathology confirmed actinomycotic infection. The patient initially received empirical intravenous vancomycin, cefotaxime, and metronidazole. Due to persistent fever and elevated inflammatory markers, the regimen was switched to teicoplanin plus piperacillin/tazobactam. Therapy was subsequently escalated to meropenem due to recurrent fever and based on magnetic resonance imaging findings suggestive of osteomyelitis, then vancomycin was replaced with teicoplanin because of vancomycin-associated nephrotoxicity. Following clinical improvement, the patient was discharged on oral amoxicillin/clavulanate to complete a total of six weeks of therapy. Discussion. Pediatric mandibular actinomycotic osteomyelitis is extremely rare. Its indolent course often mimics tumors or granulomatous disease. In this case, delayed diagnosis and nonspecific imaging findings led to initial misinterpretation. Surgical intervention played a key role in diagnosis and treatment. Early recognition and combined medical-surgical management are crucial to avoid complications. This case highlights the importance of considering infectious causes in mandibular masses and underscores the diagnostic challenges associated with them.

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