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To the Editor: Pott puffy tumor (PPT) is an anterior extension of a frontal sinus infection that results in frontal bone osteomyelitis and subperiosteal abscess. Since the advent of antibiotics, PPT has been rarely reported and most cases have been described in children and adolescents. We report a case of PPT associated with use of intranasal methamphetamine hydrochloride.

Report of a Case
A 34-year-old woman presented with fever, chills, photophobia, and neck pain for 9 days. Nine months previously, she had developed swelling on her forehead that gradually enlarged over 5 days and then spontaneously drained purulent material. Over several weeks, a fistula developed at the site of the forehead swelling, and was accompanied by intermittent bloody, purulent drainage for approximately 9 months. The patient had no other contributory medical illnesses. However, she had used intranasal and inhaled methamphetamine weekly for 15 years and reported continued intranasal use immediately prior to the development of the forehead lesion. She reported no history of intravenous or other drug use.

Physical examination revealed a sinocutaneous fistula in the midline of the forehead with seropurulent drainage but no local erythema or tenderness. The patient had nuchal rigidity, but findings of the neurologic examination were within normal limits. The remainder of the physical examination was noncontributory. The white blood cell count was 15.3 x 10⁹/L (77 neutrophils and 9 bands). Examination of cerebrospinal fluid, obtained by lumbar puncture, revealed a white blood cell count of 0.5 x 10⁹/L (91% neutrophils, 2% lymphocytes), glucose level of 63 mg/dL (3.5 mmol/L), and a total protein level of 81 mg/dL. A Gram stain showed no organisms and the cerebrospinal fluid cultures and blood cultures were sterile. Computed tomographic scan of the head showed complete opacification of all sinuses with a 1-cm connection between the anterior frontal sinus and the skin. There were no epidural fluid collections or underlying brain parenchymal lesions.

The patient was treated with intravenous clindamycin and ceftriaxone sodium, and oral ciprofloxacin for osteomyelitis with presumed bacterial meningitis secondary to a contiguous focus of infection. On day 5 of her hospital stay, she underwent endoscopic sinus surgery. A second surgical procedure for debridement of the infected frontal bone, ablation of the frontal sinus, and repair of the frontal sinocutaneous fistula was also performed. Aerobic and anaerobic cultures of the purulent drainage from the maxillary sinuses grew Streptococcus milleri and Candida albicans. At the end of 2 weeks, antibiotics were changed to intravenous cefazolin and oral metronidazole and this therapy was continued for 4 additional weeks at home. No further complications occurred at 2 months. The patient was then lost to follow-up.

Comment
Osteomyelitis of the frontal bone is most commonly caused by trauma and frontal sinusitis.¹ We propose that the use of intranasal methamphetamine by this patient contributed to chronic sinus inflammation, which led to the frontal bone osteomyelitis and subperiosteal abscess. Noskin and Kalish² have implicated the use of intranasal cocaine as a cause of chronic sinusitis associated with PPT in a 34-year-old man. The sympathomimetic effects of methamphetamine cause vasoconstriction of the mucosal vessels that may result in ischemic injury to the sinus mucosa, and thereby could provide an environment conducive to bacterial growth. We propose that PPT is a potential complication of methamphetamine use.

Peyman Banooni, MD; Leland S. Rickman, MD; David M. Ward, MD
University of California, San Diego

1. Koch SE, Wintroub BU. Pott's puffy tumor: a clinical marker for osteomyelitis of the skull. Arch Dermatol. 1985;121:548-549. FULL TEXT | PUBMED 2. Noskin GA, Kalish SB. Pott's puffy tumor: a complication of intranasal cocaine abuse. Rev Infect Dis. 1991;13:606-608. ISI | PUBMED

Letters Section Editors: Phil B. Fontanarosa, MD, Deputy Editor; Stephen J. Lurie, MD, PhD, Fishbein Fellow.

JAMA. 2000;283:1293.

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