History

Fact Explanation
Swelling of the jaw[1,2,3] Mostly involve the submandibular or perimandibular region. The overlying skin shows bluish discoloration. Initially multiple small lumps develop and later they begin to discharge as sinuses develop. [2]The infection may spread to the mandibular bone and result in periostitis or osteomyelitis. [3]
Difficulty in swallowing and trismus [2] Due to the involvement of muscles of mastication. Trismus is present early in the course of illness. [2]
Cough and hemoptysis Due to thoracic actinomycosis. Shortness of breath and chest pain are other complains of thoracic involvement.[3]
Fever Commonly seen in thoracic actinomycosis. [3]
Constitutional symptoms These include weight loss, fatigue, nausea, vomiting and anorexia. [3]
Change in bowel habits Seen in abdominal actinomycosis. [4]
Symptoms of pelvic actinomycosis [1,2] Females complain of discomfort or pain in the lower abdomen menorrhagia and vaginal discharge. [4]
Symptoms of central nervous system involvement [1] Actinomycosis result in brain abscess and chronic meningitis. Brain abscess results in increased intra-cranial pressure and patients complain of early morning headache with associated nausea and vomiting. Some may have focal seizures and hemiparesis. [3]
Risk factors Cervico-facial actinomycosis develops due to poor oral hygiene, recent dental manipulation or trauma, neoplasm and radiotherapy. Thoracic actinomycosis can develop secondary to aspiration. History of abdominal surgery, mesenteric vascular insufficiency, or ingestion of foreign bodies are risk factors for the development of abdominal disease. Presence of an intra-uterine contraceptive disease is a risk factor in females for the development of pelvic actinomycosis. Patients with compromised immune status are also at risk. [2,3] Actinomycosis is commonly seen in men for which the exact cause is unknown.
References
  1. LAWRENCE A. C., MILLIE M. L., JOEL H. Actinomyces Odontolyticus Bacteremia. Centers of disease control and prevention. [online] December 2003: 9 (12) [viewed 4 May2014] Available from: http://wwwnc.cdc.gov/eid/article/9/12/02-0646_article.htm
  2. MICHAEL M. MCNEIL, KLAUS P. SCHAAL. Actinomyces species (Actinomycoses) [online] [viewed 4 May2014] Available from: http://antimicrobe.org/new/b73.asp
  3. BROOK, ITZHAK. Actinomycosis: Diagnosis and Management. Southern Medical Journal. [online] October 2008: 101 (10) 1019-1023. [viewed 4 May2014] Available from: doi: 10.1097/SMJ.0b013e3181864c1f
  4. ANTONIO PRIVITERA, CHARANJIT SINGH MILKHU, VIVEK DATTA, MANUEL RODRIGUEZ-JUSTO, ALASTAIR WINDSOR, AND CHARLES RICHARD COHEN. Actinomycosis of the sigmoid colon: A case report. World J Gastrointest Surg. [online] Nov 30, 2009; 1(1): 62–64. [viewed 4 May2014] Available from: doi: 10.4240/wjgs.v1.i1.62

Examination

Fact Explanation
Fever This is a common examination finding especially in thoracic actinomycosis. [4]
Cervico-facial involvement There are multiple small tender nodules which may fluctuate with the development of abscesses. [3]These nodules become non-tender and woody hard in later disease. These are called “sulfur granules”. [2,4]
Intra-abdominal mass [3] Firm to hard intra-abdominal mass is palpable which is often attached to an underlying structure. The mass is commonly located in either left or right lower quadrants. [4]
Pelvic mass Tubo-ovarian mass is palpated in pelvic actinomycosis. [4]
Cutaneous sinuses Depending on the site of the primary lesion sinuses can be seen around the jaw, thorax or over the abdominal skin. [3,4]
Signs of central nervous system involvement Examination of the optic fundus will show papilledema. Chronic meningitis may produce neck stiffness. [5]
Signs of infective endocarditis [1] Patients rarely can have Roth spots, splinter hemorrhages, Osler nodes, Janeway lesions, hepatosplenomegaly and changing murmurs.
References
  1. COHEN E, BISHARA J, MEDALION B, SAGIE A, GARTY M. Infective endocarditis due to Actinomyces neuii. Scand J Infect Dis. [online] 2007;39(2):180-3. [viewed 4 May2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17366042
  2. BOWDEN GHW. ed: Baron S. Medical Microbiology. 4th ed. Galveston. University of Texas Medical Branch. Available from: http://www.ncbi.nlm.nih.gov/books/NBK8385/
  3. MICHAEL M. MCNEIL, KLAUS P. SCHAAL. Actinomyces species (Actinomycoses) [online] [viewed 4 May2014] Available from: http://antimicrobe.org/new/b73.asp
  4. BROOK, ITZHAK. Actinomycosis: Diagnosis and Management. Southern Medical Journal. [online] October 2008: 101 (10) 1019-1023. [viewed 4 May2014] Available from: doi: 10.1097/SMJ.0b013e3181864c1f
  5. HYUNG-YONG HAM, SHIN JUNG, TAE-YOUNG JUNG, SUK-HEE HEO. Cerebral Actinomycosis : Unusual Clinical and Radiological Findings of an Abscess. J Korean Neurosurg Soc. [online] Aug 2011; 50(2): 147–150. [viewed 4 May2014] Available from: doi: 10.3340/jkns.2011.50.2.147

Differential Diagnoses

Fact Explanation
Intra-abdominal mass Abdominal actinomycosis should be considered a possible differential diagnosis in patients presenting with intra-abdominal masses. These include adnexal tumors, colonic carcinoma, and appendicular abscess. [2]
Inflammatory bowel disease Chron’s disease and ulcerative colitis should be considered a possible differential diagnosis in abdominal actinomycosis. [4]
Blastomycosis Patients with Blastomycosis presents with non-specific symptoms like fever, chills, cough, muscle aches, joint pain, and chest pain. Severe disease may involve skin and bone as well. [3]
Brain Abscess Patients with brain abscess have symptoms of increased intracranial pressure.
Lung Abscess Chest X-ray will show evidence of cavitation and a fluid level.
Malignant neoplasms [1] Malignancy in the uterus, oral cavity, bowel, lymphomas, and lung cancer are differential diagnoses.
Pelvic Inflammatory Disease Females with intra uterine contraceptive disease are also at high risk of developing pelvic inflammatory disease. They present with fever, vaginal discharge and pelvic pain.
Pneumonia Thoracic actinomycosis may mimic aspiration pneumonia and bacterial, fungal or viral pneumonia. [1]
Tuberculosis Skin involvement in tuberculosis with scrofula may mimic a sinus in actinomycosis. [1]
References
  1. BROOK, ITZHAK. Actinomycosis: Diagnosis and Management. Southern Medical Journal. [online] October 2008: 101 (10) 1019-1023. [viewed 4 May2014] Available from: doi: 10.1097/SMJ.0b013e3181864c1f
  2. ANTONIO PRIVITERA, CHARANJIT SINGH MILKHU, VIVEK DATTA, MANUEL RODRIGUEZ-JUSTO, ALASTAIR WINDSOR, AND CHARLES RICHARD COHEN. Actinomycosis of the sigmoid colon: A case report. World J Gastrointest Surg. [online] Nov 30, 2009; 1(1): 62–64. [viewed 4 May2014] Available from: doi: 10.4240/wjgs.v1.i1.62
  3. Fungal Diseases. Centers for Disease Control and Prevention. [online] [viewed 4 May2014] Available from: http://www.cdc.gov/fungal/diseases/blastomycosis/symptoms.html
  4. ERDAL KARAGULLE, HALE TURAN, GOKHAN MORAY. Abdominal actinomycosis mimicking acute appendicitis. Can J Surg. [online] Oct 2008; 51(5): E109–E110. [viewed 4 May2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2556537/

Investigations - for Diagnosis

Fact Explanation
Full blood count Mild anemia and leukocytosis is commonly seen. [3,5]
Erythrocyte sedimentation rate (ESR) Elevated due to inflammation. [4,5]
C-reactive protein (CRP) Elevated due to inflammation.
Liver function test Alkaline phosphatase levels are elevated in hepatic involvement. [5]
Gram stain [2] Specimens obtained from the sinuses, needle aspirations or biopsy of the lesions show beaded, branched, gram-positive filamentous rods.
Culture [1,2] Actinomycosis grows in anaerobic culture medias. Presence of sulfur granules makes the diagnosis more likely but the definitive diagnosis cannot be made solely on that. [2]
Polymerase chain reaction (PCR) Detects the organism’s genome and enable accurate diagnosis. [6]
Immunofluorescence [2,7] Allows detection of antigen and or antibodies.
Chest X-ray Shows poorly defined mass or pneumonitis. Sometimes cavitary lesions are seen. The expanding mass may cause erosion of the ribs and the sternum. Chronic consolidation, pleural effusion and rib periostitis are a frequently encountered triad of radiological signs. [2]
X-ray film of the abdomen In hepatic involvement abscesses are seen. [5]
CT scan of the chest CT shows infiltrative mass with focal areas of decreased attenuation with contrast enhancement.
Fine-needle aspiration and/or biopsy CT or Ultrasound guided aspiration or biopsy allows collection of high quality specimen for the diagnosis. [8]
Bronchoscopy In thoracic actinomycosis bronchoscopy is used to obtain a sample of bronchoalveolar lavage fluid. This sample can be used to isolate the organism. [2]
References
  1. JOSE LUIS GÓMEZ-GARCES, ALMUDENA BURILLO, YOLANDA GIL. Soft Tissue Infections Caused by Actinomyces neuii, a Rare Pathogen. J Clin Microbiol. [online] Apr 2010; 48(4): 1508–1509. [viewed 4 May2014] Available from: doi: 10.1128/JCM.02139-09
  2. MICHAEL M. MCNEIL, KLAUS P. SCHAAL. Actinomyces species (Actinomycoses) [online] [viewed 4 May2014] Available from: http://antimicrobe.org/new/b73.asp
  3. ANTONIO PRIVITERA, CHARANJIT SINGH MILKHU, VIVEK DATTA, MANUEL RODRIGUEZ-JUSTO, ALASTAIR WINDSOR, AND CHARLES RICHARD COHEN. Actinomycosis of the sigmoid colon: A case report. World J Gastrointest Surg. [online] Nov 30, 2009; 1(1): 62–64. [viewed 4 May2014] Available from: doi: 10.4240/wjgs.v1.i1.62
  4. WAGENLEHNER F.M., MOHREN B., NABER K.G., MÄNNL H.F. Abdominal actinomycosis. Clin Microbiol Infect [online] 2003;9: 881-5.[viewed 4 May2014] Available from: DOI: 10.1046/j.1469-0691.2003.00653.x
  5. KYUENG-WHAN MIN, SEUNG SAM PAIK, HULIN HAN, KI-SEOK JANG. Hepatobiliary and Pancreatic: Hepatic actinomycosis. Journal of Gastroenterology and Hepatology [online] April 2012: 27 (4), 844. [viewed 4 May2014] Available from: DOI: 10.1111/j.1440-1746.2012.07087.x
  6. KEYURI B PATEL, GURUDUTT GUPTA, MENKA SHAH, PURVESH PATEL. Pulmonary actinomycosis in fine needle aspiration cytology. [online] 2009: [viewed 4 May2014] Available from: DOI: 10.4103/0970-9371.55233
  7. LESLIE DE, GARLAND SM. Comparison of immunofluorescence and culture for the detection of Actinomyces israelii in wearers of intra-uterine contraceptive devices. J Med Microbiol. [online] 1991 Oct;35(4):224-8. [viewed 4 May2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/1941993
  8. CUSTAL-TEIXIDOR M, TRULL-GIMBERNAT JM, GARIJO-LÓPEZ G, VALLDOSERA-ROSELLO M. Fine-needle aspiration cytology in the diagnosis of cervicofacial actinomycosis: report of 15 cases. Med Oral Patol Oral Cir Bucal. [online] 2004 Nov-Dec;9(5):467-70; 464-7. [viewed 4 May2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15580126

Investigations - Followup

Fact Explanation
Chest X-ray The resolution of the initial lesion is monitored with chest X-ray films to evaluate the response to treatment. [1,2]
CT scanning and MRI Used in assessment of response to treatment. With successful treatment resolution of the initial brain abscesses is seen. [1]
References
  1. MICHAEL M. MCNEIL, KLAUS P. SCHAAL. Actinomyces species (Actinomycoses) [online] [viewed 4 May2014] Available from: http://antimicrobe.org/new/b73.asp
  2. JAE-UK SONG, HYE YUN PARK, WON-JUNG KOH. Treatment of thoracic actinomycosis: A retrospective analysis of 40 patients. Ann Thorac Med. [online] 2010 Apr-Jun; 5(2): 80–85. [viewed 4 May2014] Available from: doi: 10.4103/1817-1737.62470

Management - General Measures

Fact Explanation
Education Patients should be advised to maintain good oral hygiene. Intra-uterine contraceptive devices should be used with keeping the possibility of actinomycosis in mind.
Treatment of infective endocarditis Drug of choice is penicillin which is given in high doses.
References
  1. MICHAEL M. MCNEIL, KLAUS P. SCHAAL. Actinomyces species (Actinomycoses) [online] [viewed 4 May2014] Available from: http://antimicrobe.org/new/b73.asp

Management - Specific Treatments

Fact Explanation
Antimicrobial therapy Penicillin G is the drug of choice. [2] Tetracyclines, erythromycin, clindamycin, and imipenem are alternative first line drugs for patients with penicillin allergy. Penicillin G is given in larger doses (150,000--200,000 U/kg/day or 10--20 million units per day in divided doses for adults) for a longer period of time. (4 to 6 weeks) This should be followed by oral penicillin (2--4 g per day) for 6 to 12 months or longer in order to prevent relapses. Amoxicillin and clavulanic acid combination is preferred in cervicofacial and thoraco-abdominal actinomycoses. Central nervous system involvement and disseminated actinomycosis may require antibiotic treatment for many months. [1] Osteomyelitis complicating actinomycosis may require ertapenem as the antibiotic treatment. [3] Hepatic involvement is treated with penicillin, tetracycline, or clindamycin. [4]
Surgery [1] Surgery is beneficial if initial antibiotic therapy fails; key procedures include incision and drainage of abscesses and closed-space infections, and excision of any sinus tracts. [1]
References
  1. MICHAEL M. MCNEIL, KLAUS P. SCHAAL. Actinomyces species (Actinomycoses) [online] [viewed 4 May2014] Available from: http://antimicrobe.org/new/b73.asp
  2. BROOK, ITZHAK. Actinomycosis: Diagnosis and Management. Southern Medical Journal. [online] October 2008: 101 (10) 1019-1023. [viewed 4 May2014] Available from: doi: 10.1097/SMJ.0b013e3181864c1f
  3. MILLER H.S., PAUL W.H., DUANE W.N., BILL LEBAR, SEAN P.E., DAVID M.A. Mandibular Actinomyces osteomyelitis complicating florid cemento-osseous dysplasia: case report. BMC Oral Health [online] 2011, 11:21 [viewed 4 May2014] Available from: doi:10.1186/1472-6831-11-21
  4. THOMAS LALL, THOMAS M.S., PAUL V. Isolated hepatic actinomycosis: a case report. Journal of Medical Case Reports [online] 2010, 4:45. [viewed 4 May2014] Available from: doi:10.1186/1752-1947-4-45