Actinomycosis

BASIC INFORMATIONActinomycosis is a chronic bacterial infection characterized by the formation of painful abscesses, soft tissue infiltration, and draining sinuses.SYNONYMSActinomyces infectionEPIDEMIOLOGY & DEMOGRAPHICS Actinomycosis is worldwide in distribution. Commonly found as normal flora of the oral cavity, pharynx, tracheobronchial tree, gastrointestinal tract, and female urogenital tract. Incidence 1:300,000. Males infected more often than females 3:1.Can occur at any age but commonly seen in midlife.

Incidence has decreased since the 1950s and is attributed to better oral hygiene and antibiotics.PHYSICAL FINDINGS & CLINICAL PRESENTATIONActinomycosis can affect any organ and characteristically manifests as: Cervicofacial disease (most common site):1. Occurs in the setting of poor dental hygiene, recent dental surgery, or minor oral trauma2. Painful soft tissue swelling commonly seen at the angle of the mandible3. Fever, chills, and weight loss4. Trismus5. Soft tissue facial infection with sinus tract or fistula formation Thoracic disease:1. Can involve the lungs, pleura, mediastinum, or chest wall.2. Presumed secondary to aspiration of Actinomyces organisms in patients with poor oral hygiene.3. Fever, cough, weight loss, and pleuritic chest pains are common symptoms.4. Signs of pneumonia or pleural effusion may be present.5. With extension beyond the lungs to mediastinal structures and the chest wall, signs and symptoms of pericarditis, empyema, chest wall sinus drainage, andtracheoesophageal fistula can all occur. Abdominal disease:1. Occurs most commonly after appendectomy, perforated bowel, diverticulitis, or surgery to the gastrointestinal tract.2. Lesions develop most commonly in the ileocecal valve, causing abdominal pain, fever, weight loss, and a palpable mass.3. Extension may occur to the liver, causing jaundice and abscess formation.4. Sinus tracts to the abdominal wall can occur. Pelvic disease:1. Commonly occurs by extension from abdominal disease of the ileocecal valve to the right adnexa (80% of cases).2. Endometritis.ETIOLOGY Actinomycosis is most commonly caused by Actinomyces israelii. Other causes are A. naeslundii, A. odontolyticus, A. viscosus, A. meyeri, and A. gerencseriae. Actinomyces are gram-positive, non-spore-forming, anaerobic or microaerophilic rods. Actinomycosis infections are polymicrobial, usually associated with Streptococcous, Bacteroides, Eikenella corrodens, Enterococcus, and Fusobacterium. Infects individuals only after entry into disrupted mucosa or tissue injury.DIAGNOSISIsolating the bacteria in the proper clinical setting makes the diagnosis of actinomycosis.DIFFERENTIAL DIAGNOSISNocardiosis, botryomycosis, chromomycosis, intestinal tuberculosis, ameboma, Crohns disease, colon cancer, and other causes of acute, subacute, or chronic infections of the lung, abdomen, hepatic, GI, GU, musculoskeletal, and CNS system.WORKUPThe workup includes obtaining specimens either by aspirating abscesses, excising sinus tracts, or tissue biopsies.LABORATORY TESTS Isolating sulfur granules from tissue specimens or draining sinuses confirm the diagnosis of actinomycosis.1. Sulfur granules are nests of Actinomyces species. Sulfur granules may be macroscopic or microscopic.2. Sulfur granules are crushed and stained for identification of Actinomcyes organisms and may take up to 3 wk to grow in culture media.TREATMENTNONPHARMACOLOGIC THERAPY Incision and drainage of abscesses Excision of sinus tractACUTE GENERAL Rx Penicillin 10 to 20 million units per day in 4 divided doses for 4 to 6 wk. In penicillin-allergic patients, erythromycin, tetracycline, clindamycin, or cephalosporins (depending on the type of penicillin allergy) are reasonable alternatives. Chloramphenicol 50 to 60 mg/kg/day has been used for CNS actinomycosis.CHRONIC Rx Following 4 to 6 wk IV penicillin, oral penicillin V 500 mg PO qid for 6 to 12 mo. Treatment of associated microorganisms is not needed.DISPOSITION Clinical actinomycosis, if not treated, spreads to contiguous tissues and structures ignoring tissue planes. Hematogenous spread, although possible, is rare. Actinomycosis is very sensitive to antibiotics but requires chronic long-term treatment to prevent relapse.REFERRALIf the diagnosis of actinomycosis is suspected, consultation with an infectious disease specialist is suggested. General surgical consultation for excision of sinus tracts and abscess incision and drainage is recommended.http://encyclopedia.lubopitko-bg.com/Actinomycosis.html Actinomycosis

Submitted by amh10 on 23 February, 2007 - 00:25

Background: Actinomycosis is most commonly caused by the gram-positive bacillus higher bacterium Actinomyces israelii.

Form delicate filaments (often called hyphae or mycelia as per the structures formed by the true fungi) and aerial filaments which may branch, fragment into spores, or become pigmented.

Actinomyces actually means "ray fungus" in Greek.

Actinomyces are true bacteria due to the lack of mitochondria and a nuclear membrane, reproduction by cell fission and susceptibility to penicillin but not to antifungal chemotherapeutic agents.

The frequency of oral cavity colonization with Actinomyces is nearly 100% by 2 years of age.

It is also often cultured from the gastrointestinal tract, bronchi, and female genital tract.

Infection may occur in individuals of all ages. The peak incidence of actinomycosis is reported to be in the mid-decades, with cases in individuals younger than 10 and older than 60 years being less frequent.

A pivotal step in the pathogenesis of actinomycosis is disruption of the mucosal barrier. Oral and cervicofacial disease is frequently associated with dental procedures, trauma, oral surgery, and head and neck radiotherapy or oncologic surgical procedures. Likewise, pulmonary infections often arise in the setting of aspiration, and abdominal infection is usually preceded by conditions that result in loss of mucosal integrity, such as gastrointestinal surgery, diverticulitis, appendicitis, or foreign bodies (e.g., fish bones). Recognition of factors that enable bacterial entry into deep tissues, however, may be absent. The lack of such a history should not prevent consideration of this disease when the clinical circumstance is appropriate.

An acute inflammatory phase manifested by a painful, cellulitic reaction is occasionally observed with oral-cervicofacial disease or with soft tissue infection elsewhere in the body. The chronic phase of this disease is more often seen. Classic disease is characterized as a densely fibrotic lesion that undergoes slow, contiguous spread and ignores tissue planes. Lesions usually appear as either single or multiple indurated swellings. As the lesion matures, it becomes soft and fluctuant and suppurates centrally. The fibrous walls of the mass have been characteristically described as "wooden" and, in the absence of suppuration, have been frequently confused with neoplasms. This extensive fibrosis, which is one of the hallmarks of this disease, may be minimal, especially in pulmonary and central nervous system lesions. Given time, sinus tracts will often extend from the abscess to either the skin or adjacent organs or bone, depending on the location of the lesion. Sinus tracts can spontaneously close and then re-form. Overlying skin may assume a red to bluish hue.

Hematogenous dissemination can occur from these local sites and occasionally be fulminant, although in the antibiotic era this clinical syndrome has become rare Microscopically, lesions have an outer zone of granulation, consisting of collagen fibers and fibroblasts. There is a central purulent loculation that contains neutrophils that surround the sulfur granules present. Granules are conglomerations of organisms and are virtually diagnostic of this disease. One to six may be present per loculation, and they range from microscopic to macroscopic in size As many as 50 loculations may be present per lesion, and these loculations are separated by granulation tissue or foamy macrophages and may undergo coalescence. Lymphocytes and plasma cells are usually present, and eosinophils were seen in 15% of abscesses. Multinucleated giant cells were occasionally seen, primarily in pulmonary lesions, but they have also been described in disease elsewhere. The association of pelvic actinomycosis with IUCDs suggests that at least this foreign body contributes to pathogenesis. Associations with actinomycosis and foreign material elsewhere are less strong. Several reports describe periapical actinomycosis associated with root canal fillings mandibular osteomyelitis associated with wire used in the treatment of a fracture, and infection of the tongue in the presence of a foreign body. Actinomyces infecting prosthetic joints, through presumed hematogenous spread, is rare but reported. Whether aspirated or ingested foreign bodies contribute to pathogenesis via mucosal disruption, or facilitate the growth and survival of Actinomyces, or both, is unclear.

Clinical Features: Oral cervicofacial disease:

Thoracic

Abdominal

Pelvic (IUCD)

CNS

Musculoskeletal

Disseminated disease

Diagnosis: Obtain suitable samples from sterile sites if possible.

Because these organisms are normal inhabitants of the oral cavity and female genital tract, the identification of organisms alone, in the absence of sulphur granules or an appropriate clinical syndrome, from sputum, bronchial washings, and cervicovaginal secretions is of little significance.

The single most helpful diagnostic maneuver for actinomycosis is to demonstrate grains (sulfur granules) in pus or histologic section of a surgical specimen.

If branching bacteria are seen on staining of the grain and the infection did not originate in subcutaneous tissue, then the diagnosis is established.

When Nocardia is the causative agent of mycetoma, granules are formed. On Gram stain the branching gram-positive bacilli are indistinguishable from Actinomyces, but they may be stained by a Fite modified acid-fast stain, whereas Actinomyces is not.

Selective media: NaCl, 5% horse blood, added MTZ 10mg/L & nalidixic acid 30mg/L. Positive control Actiomyces israelli, negative is Bacteroides fragilis.

Colonial morphology ("molar tooth")

"sun-ray" appearance occurs on crushing bacilli which release the sulphur granules between a slide):

Treatment: Penicillin

Erythromycin

Tetracycline

Clindamycin

AMH

http://microblog.me.uk/185

What Is Actinomycosis? What Causes Actinomycosis?

Editor's ChoiceMain Category: Infectious Diseases / Bacteria / VirusesArticle Date: 08 May 2012 - 0:00 PST

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Actinomycosis is a rare type of infectious bacterial disease. Unlike other infections, actinomycosis is able to move gradually and infiltrate the body's tissue, causing swelling and inflammation. Eventually there is tissue damage and scaring, pus-filled abscesses appear in the mouth, lungs, or gastrointestinal tract. Small holes leaking pus form in the affected tissue.

Actinomycosis is caused by a species of bacteria known as actinomyces, which live harmlessly in the lining of the mouth, throat, digestive system and womens vagina. If the tissue-lining becomes damaged by injury or disease, the bacteria can penetrate deeper into the body - the actinomyces bacteria then thrive deep inside human tissue.

This bacterial disease is very rare in humans, but more common in farm animals. In cattle it is called lumpy jaw

According to Medilexicon's medical dictionary: actinomycosis is:

"A disease primarily of cattle and humans caused by the bacterium Actinomyces bovis in cattle and by A. israelii and Arachnia propionica in humans. These actinomycetes are part of the normal bacterial flora of the mouth and pharynx, but when introduced into tissue they may produce chronic destructive abscesses or granulomas that eventually discharge a viscid pus containing minute yellowish granules (sulfur granules).

In humans, the disease commonly affects the cervicofacial area, abdomen, or thorax; in cattle, the lesion is commonly found in the mandible."

What are the different types of actinomycosis?

Oral cervicofacial actinomycosis: The infection develops inside the tissue of the neck, jaw or mouth. Most cases are a complication of dental problems, poor oral hygiene, gum disease, dental abscess, tonsillitis, dental or jaw surgery. This is the most common type of actinomycosis and accounts for an estimated half of all cases.

Thoracic actinomycosis: The infection develops inside the lungs or connected airways. Most cases of thoracic actinomycosis are caused by people accidentally ingesting contaminated material into their lungs.

Abdominal actinomycosis: The infection develops inside the stomach. It can occur when something tears the wall of the intestine, allowing the bacterium to penetrate into deep tissue. This can happen after accidentally swallowing an object (a fish or chicken bone) containing actinomyces bacteria. Also, it can develop as a complication following removal of the appendix or bowel or abdominal surgery.

Pelvic actinomycosis: The infection develops inside the pelvis. The actinomyces bacteria spread from the female genitals into the pelvis. This type of infection is associated with the long-term use of the intrauterine device (IUD) type of contraceptive. Although very unlikely, the IUD may damage the womb lining over time, allowing bacteria to penetrate into deep tissue.

Actinomycosis of Maxilla. The disease spread to opposite side; finally implicated base of skull, and proved fatal. Treated by radium. (Mr. D. P. D. Wilkie's case.)What are the signs and symptoms of actinomycosis?

A sign is something everyone can see, such as a rash or swelling, while a symptom is something only the patient experiences and describes to a doctor, nurse, family member or friend, such as a headache, dizziness or anxiety.

Abscesses grow larger as the disease progresses. In severe cases, narrow passages called sinus tracts can form on the surface of the skin. They may break open and leak large amounts of pus. The signs and symptoms vary according to the affected area.

The signs and symptoms of oral cervicofacial actinomycosis may include: Fever of 38C (100.4F).

Swollen lumps on cheek or neck. They gradually increase in size and number. Lumps are tender and later become painless and hard.

Reddish or bluish colored skin over the lumps.

Jaw muscles may also be affected, making chewing difficult.

Narrow passages (called sinus tracts) can form on the surface of the skin leaking pus.

The signs and symptoms of thoracic actinomycosis may include: Fever of 38C (100.4F).

Weight loss.

Fatigue.

Poor appetite.

Shortness of breath.

Chest pain.

Dry cough, or a cough that produces phlegm.

Drops of blood when coughing or blood-stained phlegm.

Sinus tracts forming on the surface of the chest.

The signs and symptoms of abdominal actinomycosis may include: Mild fever, no higher than 38C (100.4F).

Weight loss.

Fatigue.

Constipation or diarrhea.

Stomach pain.

Nausea.

Vomiting.

Noticeable bulge or lump in the lower abdomen.

Appearance of sinus tracts on the surface of the abdomen.

The signs and symptoms of pelvic actinomycosis may include: Mild fever.

Lower abdominal pain.

Abnormal vaginal bleeding.

Unusual vaginal discharge.

Loss of appetite.

Fatigue.

Noticeable bulge or lump in the pelvis.

How is actinomycosis diagnosed?

In the earlier stage, this bacterial infection is difficult to diagnose because it can be can be confused with other conditions. Often, a correct diagnosis is made after taking and examining a sample (biopsy).

It is more easily diagnosed in its later stages, after its hallmark sinus tracts have appeared in the surface of the skin.

What are the treatment options for actinomycosis?

The patient will be put on a long-term course of antibiotics - this is the only way to eliminate the infection completely.

Antibiotic injections are initially recommended, followed by a course of antibiotic tablets.

Penicillin is very effective in treating some types of bacterial infections. In cases of penicillin allergy, alternative antibiotics can be used.

Some patients may take several months before they respond properly to treatment.

In severe cases, surgery may be required to repair tissue damage or to drain the pus from abscesses that have formed deep inside the body.

Abscesses can spread easily from one part of the body to another. Complications may occur when the disease extends from the original site of the infection to other organs.

Dental hygiene

Oral actinomycosis, the most common form, usually occurs because of poor dental hygiene. Prevention can be achieved by practicing good dental hygiene, i.e. brushing teeth twice a day, flossing and using a mouthwash that contains fluoride once a day, attending regular dental check-ups, and limiting sweet food.

http://www.medicalnewstoday.com/articles/245144.php

Actinomycosis (lumpy jaw) is caused by a bacteria introduced to face tissues by trauma, surgery or infection. Long term treatment with antibiotics is often required.

Also known as: Lumpy jawDefinition

Actinomycosis is a long-term (chronic) bacterial infection that commonly affects the face and neck.

Causes, incidence, and risk factors

Actinomycosis is usually caused by an anaerobic bacteria called Actinomyces israelii, which is a common and normally not disease-causing (nonpathogenic) organism found in the nose and throat.

Because of the bacteria's normal location in the nose and throat, actinomycosis most commonly appears in the face and neck. However, the infection can sometimes occur in the chest (pulmonary actinomycosis), abdomen, pelvis, or other areas of the body. The infection is not contagious.

Symptoms occur when the bacteria enters the facial tissues after trauma, surgery, or infection. A common triggering causes is dental abscess or oral surgery. The infection has also been seen in certain women who have had an intrauterine device (IUD) to prevent pregnancy.

Once in the tissue, it forms an abscess, producing a hard, red to reddish-purple lump, often on the jaw, from which comes the condition's common name, "lumpy jaw."

Eventually, the abscess breaks through the skin surface to produce a draining sinus tract.

Symptoms

Draining sores in the skin, especially on the chest wall from lung infection with Actinomyces Fever

Minimal or no pain

Swelling or a hard, red to reddish-purple lump on the face or upper neck

Weight loss

See also: Neck lumpsSigns and tests

Culture of the tissue or fluid shows Actinomyces species.

Examination of drained fluid under a microscope shows "sulfur granules" in the fluid. They are yellowish granules made of clumped organisms.

Examination under a microscope shows the Actinomyces species of bacteria.

Treatment

Treatment of actinomycosis usually requires antibiotics for several months to a year. Surgical drainage or removal of the lesion may be needed. If the condition is related to an IUD, the device must be removed.

Expectations (prognosis)

With treatment, you should recover fully.

Complications

Meningitis can rarely develop from this infection.

Calling your health care provider

Call your health care provider if you develop any of the symptoms of this disorder. Beginning treatment promptly helps quicken the recovery.

Prevention

Good oral hygiene and regular dentist visits may help prevent some forms of actinomycosis.

References

Brook I. Actinomycosis. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 350.

http://www.scripps.org/articles/2204-actinomycosis