Actinomycosis

Notes

## Basic introduction:

  • This is a rare chronic disease
  • It is caused by Actinomyces spp., which is an anaerobic Gram-positive bacteria
  • The common species of Actinomyces include:
  • Actinomyces israelii (the most prevalent species)
  • Actinomyces viscosus
  • Actinomyces meyer
  • Actinomyces naeslundii
  • Actinomyces odontolyticus
  • Actinomyces gerencseriae
  • This bacterium generally colonizes the mouth, GIT, and GUT

## Statistics:

  • The sensitivity of culture of Actinomyces spp.is 50%c
  • It is more prevalent in males than in females (with a 3:1 ratio)e
  • Prevalence in Cleveland (USA) in 1970’s was 1 case per 300,000 persons

## Risk factors for Actinomycosis:

  • Poor oral hygiene
  • Alcoholism
  • Chronic lung disease e.g.
  • Emphysema
  • Chronic bronchitis
  • Bronchiectasis,
  • Pulmonary tuberculosis
  • Immune suppression
  • HIV/AIDS
  • Corticosteroids
  • Infliximab treatment
  • Lung and renal transplantation
  • Acute leukemia during chemotherapy
Symptoms
  • Cervicofacial Actinomycosis that is characterized by a slowly progressive painless indurated mass that leads to multiple abscesses with draining sinus tracts on the skin surface or oral mucosa affecting:
  • Upper or lower mandible (majority of cases)
  • Cheek
  • Chin
  • Submaxillary ramus and angle
  • Pelvic Actinomycosis
  • Pulmonary Actinomycosis
  • Actinomycosis that affects bones
  • Actinomycosis that mimic the malignancy process
Diagnosis
  • Bacterial cultures (in anaerobic conditions)
  • Microscopy:
  • Necrosis with yellowish sulfur granules (constituted by conglomeration of bacteria trapped in biofilm)d
  • Filamentous Gram-positive fungal-like micro-organisms
Differential
  • Aspergillosis
  • Abscess
  • Abdominal
  • Brain
  • Liver
  • Bisphosphonate-related necrosis
  • Cancer:
  • Colon
  • Lung
  • Ovarian
  • Oviduct
  • Uterine
  • Gastric adenocarcinoma
  • Crohn's disease
  • Diverticulitis
  • Erysipelas
  • Leishmaniasis
  • Nocardiosis
  • Osteomyelitis
  • Pelvic inflammatory disease
  • Pneumonia
  • Ulcerative colitis
Prevention
  • Reduction of alcohol abuse
  • Improvement of dental hygiene
  • Changing IUDs every 5 years
Reference

a. Valour, F., Sénéchal, A., Dupieux, C., Karsenty, J., Lustig, S., Breton, P., ... & Chidiac, C. (2014). Actinomycosis: etiology, clinical features, diagnosis, treatment, and management. Infect Drug Resist, 7(7), 183-197.

b. Schaal, K. P., & Lee, H. J. (1992). Actinomycete infections in humans—a review. Gene, 115(1), 201-211.

c. Brown, J. R. (1973). Human actinomycosis: a study of 181 subjects. Human pathology, 4(3), 319-330.

d. Heffner, J. E. "Pleuropulmonary manifestations of actinomycosis and nocardiosis." In Seminars in respiratory infections, vol. 3, no. 4, pp. 352-361. 1988.

d. Bennhoff, D. F. (1984). Actinomycosis: diagnostic and therapeutic considerations and a review of 32 cases. The Laryngoscope, 94(9), 1198-1217.

Management
  • Duration of treatment:
  • Treatment is normally done for a prolonged period of time (6 -12 months)
  • This prolonged treatment is necessary to allow the drug penetration in abscess and in infected tissues
  • Duration of treatment is reduced to at least 3 months after successful surgical resection of infected tissues
  • Antimicrobial therapy in order of preference include:
  • -Benzyl penicillin Initial IV high doses of penicillin G of up to 24 MIU/day
  • -Amoxycillin Initial IV high doses of up to 200 mg/kg/day
  • -Tetracycline
  • -Macrolides 
  • -Clindamycin
  • Surgical intervention
  • -Drainage of voluminous abscesses
  • -Marsupialization of chronic sinus tracts
  • -Excision of recalcitrant fibrotic lesion
  • -Debridement of necrotic bone tissue in case of osteomyelitis
  • -Dental avulsions
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