Actinomycosis


Article Author:
Sandeep Sharma


Article Editor:
Dominic Valentino III


Editors In Chief:
Stephen Leslie
Karim Hamawy


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
6/20/2019 12:23:21 AM

Introduction

Actinomycosis is a rare subacute to chronic infection caused by the gram-positive filamentous non-acid fast anaerobic to microaerophilic bacteria, Actinomyces. The infection is usually a granulomatous and suppurative infection. The chronic form has multiple abscesses that form sinus tracts and are associated with sulfur granules. About 70% of infections are due to either Actinomyces israelii or Actinomyces gerencseriae.

The diagnosis can be difficult, as isolation of the organism requires prolonged bacterial culture under anaerobic conditions. The infection is usually polymicrobial and very rarely spreads hematogenously. The other organisms which are usually associated with the infection are Aggregatibacter actinomycetemcomitans, Prevotella, Streptococcus, Enterobacteriaceae, Peptostreptococcus, and Staphylococcus.[1][2][3]

The bacteria infects by inhibiting host defenses and/or reducing partial pressures of oxygen.

Etiology

Actinomyces normally colonize the human mouth, urogenital tract, and gastrointestinal (GI) tract. As it is a commensal organism, it is very difficult to determine normal flora colonization versus infection.[4][5][6]

Thoracic actinomycosis may occur in patients with alcoholism and seizure disorders. Pulmonary infection usually happens from aspiration. Rarely disease can result from a human bite. Infection in the cervical and facial areas typically occurs following oral cavity surgery in patients with poor oral hygiene. Pelvic actinomycosis has been associated with the use of intrauterine devices (IUDs). Abdominal actinomycosis has been reported after any kind abdominal surgery but is most commonly seen after an appendectomy.

Epidemiology

The incidence of the disease is greater in males age 20 to 60 years. With a peak incidence in 40 to 50 years old. The male to female ratio for incidence is 3:1. The use of IUD contraceptive devices in females has increased the incidence. The infection has a higher prevalence within areas with low socioeconomic status. There is no racial predilection.[7]

Pathophysiology

Actinomyces are part of the normal flora of the human oral cavity, GI tract, and female urogenital tract. The organism is not virulent and only invades the body to cause deeper infections when there are tissue injury and a subsequent break in the normal mucosal barrier. Infection is mostly polymicrobial with as many as 5 to 10 other bacterial species present. The infection is established with the help of a companion bacteria by inhibiting host defenses, reducing oxygen tension, or by producing a toxin that facilitates the inoculation of actinomycoses.

Once mucosal barriers are breached, and infection is established, the human host responds by initiating an intense inflammatory response which is suppurative and granulomatous. The infection does not respect tissue planes and spreads contiguously. This results in draining sinus tracts, tiny yellow clumps called sulfur granules, and the result may be intense fibrosis of tissue.

Around 60% of infections are cervicofacial and described as “lumpy jaw syndrome.” The predisposing risk factors for cervicofacial infection include infection in erupting teeth, dental caries, gingivitis, and dental extraction, diabetes, alcoholism, malnutrition, and malignancy.

HIV, solid organ transplantation of lungs or kidneys, biologic agents like infliximab, and acute lymphoblastic leukemia treated with chemotherapy are other risk factors.

Pulmonary infections are primarily due to the aspiration of oral and GI secretions. Risk factors include the diseases mentioned above as well as any chronic lung disease that lead to tissue destruction and break in normal mucosal defenses such as chronic obstructive pulmonary disease (COPD), bronchiectasis, tuberculosis (TB), silicosis, among others. It can be a direct or indirect extension from a cervicofacial infection. From the lungs, Actinomyces can easily spread to mediastinum and pleura. Bronchial and laryngeal infections are rare. Vocal cord infection may mimic cancer.

The second most frequent site for Actinomyces infection is the genitourinary tract. The major risk factor is the use of the intrauterine device.

Abdominal actinomycosis is most common in the appendix, cecum, and colon. Abdominal surgery is the greatest risk factor.

Skin and soft tissue actinomycosis is rare but can happen secondary to skin injury.

Hematogenous dissemination is extremely rare.

Histopathology

Gram staining of infected tissue or purulent material is more useful and sensitive than culture, as in 50% of cases culture may be negative. The negative rate is high due to previous antibiotic therapy, polymicrobial infection where other organisms present inhibit growth, failure to maintain an anaerobic environment during transportation and/or culture, or short-term incubation.

The characteristic of the disease is the sulfur granules which are yellow. They are formed primarily by mycelial fragments with some proteinaceous polysaccharide complexes, which act as a resistance mechanism to avoid and inhibit phagocytosis. The most common microscopic finding is necrosis of yellowish sulfur granules and the filamentous gram-positive bacteria. The most appropriate specimen is a tissue biopsy of the infected site or pus. For better results, the clinician should note their suspicion for the infection to the microbiologist or pathologist. This will ensure anaerobic cultures are performed for prolonged time frames to ensure an optimal growth environment.

Immunofluorescence has poor sensitivity but high specificity and can be used to confirm the diagnosis.

History and Physical

The clinical presentation depends upon the site of infection and can vary accordingly. Taking a detailed history, which includes risk factors is important.

Cervicofacial

The most common presentation, constituting approximately 60% of infections and usually involves the tissues surrounding the maxilla and lower mandible (almost 50% of all cases). The most common presentation is a progressive, painless mass that is indurated with or without reddish or bluish discoloration of overlying skin and eventually evolves into multiple abscesses with sinus tract formation which drains yellow sulfur granules. The patient may give a history of an oral procedure or injury. Difficulty in chewing food and trismus can happen in chronic stages of infection. Lymphadenopathy is not associated with the disease process.

Genitourinary

History of IUD use is common. The symptoms mostly mimic gynecological tumors, both malignant and benign. The presentation could be with lower abdominal pain, constipation, and vaginal discharge. Fever is rare unless the disease spreads to the peritoneum.

GI

The patient might have a history of abdominal surgery, especially appendectomy, perforated viscus, or ingestion of fish bone. It can involve the esophagus, appendix, cecum, and colon, and presentation depends upon the site of infection. In esophageal disease, dysphagia is the most common symptom. At other gastrointestinal sites, infection presents with nonspecific symptoms of low-grade fever, weight loss, fatigue, nausea, vomiting, change in bowel habits, and abdominal pain with or without a palpable mass. Rarely, the liver and biliary tract are involved, in which case there may be right upper quadrant pain and jaundice.

Pulmonary

The infection can be acute to subacute, but because the diagnosis is difficult most cases are diagnosed in the chronic phase. Initially, the patients may present with very nonspecific symptoms of mild fever and weight loss. The symptoms mimic other chronic lung infections and cancer. The most common symptoms are a chronic productive cough with or without hemoptysis, shortness of breath, and chest pain. Lung parenchymal infections can cavitate forming sinus tracts which are a pathognomonic finding. If the disease process is extensive and the host is immunocompromised, the disease process can present with severe hypoxemia and florid respiratory failure with acute respiratory distress syndrome (ARDS).

Evaluation

A complete blood count (CBC) will show leukocytosis with elevated neutrophils. Nonspecific inflammatory markers such as C- reactive protein and erythrocyte sedimentation rate are elevated.[8][9][10]

The gold standard test for diagnosis is tissue biopsy culture with anaerobic pus cultures. Swabs from the infected sites should be avoided. Cultures can be falsely negative; gram-stain may demonstrate the presence of branched, beaded, gram-positive filamentous rods with sulfur granules, which helps in making a preliminary diagnosis. For examination, under the microscope, the granules should be crushed in between the 2 slides and then stained with methylene blue to identify the organism.

Serological tests do not help in making the diagnosis.

Imaging results will depend upon the site of infection and can mimic other chronic infections like nocardiosis, TB, and malignancy.

Cervicofacial

Imaging findings are nonspecific and are noncontributory in diagnosing the disease but will help in assessing the degree of soft tissue and bone involvement. Dental radiographs are helpful in assessing the apical abscesses. CT and MRI studies may show osteolysis in the chronic form of infection.

Pulmonary

The imaging for actinomycosis is nonspecific. In the acute presentation, it can look like any other pneumonia. In chronic forms, it can present as a pulmonary mass or can cavitate. In the case of a mass malignancy, Actinomycosis is an important diagnosis to consider. Especially when it cavitates, tuberculosis is an important differential diagnosis to consider. The computed tomography scan findings can vary depending upon the duration of illness and can include consolidation, cavitation, pleural effusion, lymph node enlargement, atelectasis, and ground glass opacification.

The gold standard test is a histological examination and bacterial culture of a biopsy which can be obtained with bronchoscopy (pulmonologist), a CT-guided biopsy (interventional radiologist), or video-assisted thoracoscopy surgery (VATS) performed by a thoracic surgeon. Anaerobic cultures of pleural fluid almost never grow the organism. Sputum culture will not be useful unless the patient has cavitary disease.

GI

Imaging of actinomycosis can be nonspecific; findings will depend upon the site of infection and chronicity. In chronic cases, a CT scan might show an enterocutaneous fistula with multiple abdominal abscesses. The best test is a culture of the infected site.

Genitourinary

A CT scan can show pelvic mass (6 to 7 cm) with the cystic lesion. Lymphadenopathy can be seen in 40% to 60 % of cases. A tubo-ovarian abscess is highly suggestive of infection with actinomycosis. Bladder actinomycosis can present like bladder carcinoma, with bladder thickening and hematuria.

Pus samples can be taken after removing the IUD. Colonization must be differentiated from infection. Tissue biopsy should be taken in patients presenting with pelvic masses to rule out malignancy.

Treatment / Management

Most of the cases can be managed with antibiotics; surgery can be adjunctive.[11][12]

Medical management in the form of antibiotics includes:

  • Penicillin G
  • Beta-lactams with a long course of oral amoxicillin
  • Cephalosporin

If the patient is penicillin allergic, alternatives include:

  • Clindamycin
  • Macrolides (erythromycin, clarithromycin or azithromycin)
  • Doxycycline

Combination of metronidazole and a beta-lactamase inhibitor may be tried in polymicrobial infections.

Antimicrobial susceptibility testing is not indicated due to predictable antibiogram.

The duration of therapy is usually 6 to 12 months but can be shortened if surgical resection of the infected site has been performed. Type of surgery will depend upon the site and extent of the disease, but it usually involves incision and drainage of abscesses, decompression of closed space, and excision of sinus tracts.

The response to treatment can be monitored with imaging.

Differential Diagnosis

The differential will depend upon the site of infection. It is a slow spreading infection it can mimic benign or malignant tumors, nocardiosis, and TB.

The other most important differential diagnosis to consider are the following:

  • Aspiration pneumonia
  • Appendicitis
  • Diverticulosis
  • Crohn disease
  • Lung abscess
  • Fungal pneumonia
  • Pelvic inflammatory disease
  • Brain abscess
  • Dental abscess

Prognosis

Prolonged antibiotic therapy is usually required, and the prognosis is excellent. With improved oral hygiene, availability of antibiotics, and improved surgical techniques the outcome and mortality has improved. For extensive and complicated disease, antibiotics and surgical treatment are required. In these cases, morbidity is high, and death may occur.

Pearls and Other Issues

Most patients need central catheters for prolonged intravenous (IV) antibiotics as outpatients. Repeat imaging is required to determine if the infection is resolving. The prognosis for most patients is good, but extensive scarring may be the result.

Good oral hygiene and limitation of alcohol may limit cervicofacial, pulmonary, and central nervous system (CNS) actinomycosis. In women, changing the IUD device every 5 years prevents the actinomycosis infection.

Actinomyces infection has no racial predilection and is not contagious.

Enhancing Healthcare Team Outcomes

Actinomycosis infections are not common but when they do occur, they are usually serious. The organism can infect almost any organ; thus actinomycosis is best managed by a multidisciplinary team that includes an infectious disease consult, intensivist, general surgeon, endocrinologist, and an internist. These patients need close monitoring by nurses because the infection can rapidly prove fatal in immunocompromised hosts or diabetics. Pharmacists should assist with the coordination of antibacterial treatment. The outcomes depend on the site of infection, its severity, patient immune status, and other comorbidities. In healthy people, the infection has low morbidity and mortality if treated.[13][14]


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Actinomycosis - Questions

Take a quiz of the questions on this article.

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A 54-year-old female with diabetes mellitus complains of increased facial pain, fevers, and chills. She developed an infection around her neck a few weeks ago. She thought it would go away; however, despite taking over the counter medications, the infection has now started to drain. She has been diabetic for 20 years and takes an oral hypoglycemic. Her diabetes is under good control. She denies any trauma, travel, and does not smoke. On physical exam, there is an area of infection at the base of her right neck that is draining a serosanguinous discharge. The surrounding area is red and indurated. There is no crepitus. A histological staining of the drainage shows gram-positive branching bacteria. There are black spots on the histology slide. What is the best treatment?



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In an individual with draining sinus tracts on the chest wall, what is the most likely causative agent?



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Which of the following about fungal infections is true?



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A patient has draining sinuses from the chest wall. A swab sent to the lab reveals the presence of sulfur granules, and the laboratory reports growth of an anaerobic organism. Which of the following statements about the presumed pathogen is false?



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A diabetic male is found to have a non-healing ulcer on his neck. The wound has been draining on and off for the past 2 weeks. Gram stain of the fluid reveals beaded, branched gram-positive filamentous rods. Which of the following is most probable?



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Actinomycosis usually is caused by Actinomyces israelii. Which is true about the bacterium?



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In humans, actinomycosis is usually seen as an abscess over which of the following?



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Actinomyces israelii typically causes which of the following conditions?



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Actinomyces israelii is best identified by which of the following?



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A patient presents with a draining sinus from the chest wall. Dark brown granules are seen on a frozen section. Which of the following is used to treat this condition?



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In humans, which of the following is the most common area infected with actinomyces?



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In an active actinomycotic infection of the head and neck with draining sinus, what discharge material is often a clue to the diagnosis?



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Which organism produces yellow granules in pus?



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A 40-year-old male presents with a broken jaw after a street fight a few days prior. Physical exam reveals a hard, non-tender abscess-like swelling along his jawline. Which of the following is correct regarding the causative agent of this abscess?



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A patient has drainage from his left neck and cheek area. He has been ill for a few days and noticed that his neck and cheeks were painful and swollen. Examination reveals a sinus tract. A Gram stain reveals a gram-positive filamentous bacteria. What is the most common cause?



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Which organism grows contiguously in tissues without respect for anatomic barriers?



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An immigrant from Brazil has extremely poor dental hygiene including loss of an adult tooth and a swollen face. The tooth is the focus of the current infection. There are two open ulcers on the outside of the swollen cheek. Small yellow "grains" are seen in one of the ulcers. Gram stain shows purple-staining fine filaments. What is the most likely cause?



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Where are actinomyces normally found?



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Which infection characteristically presents with "sulfur" granules?



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A 64-year old female with the diabetes mellitus complains of increased facial pain, fever, and chills. She says she developed an infection around her axilla a few weeks ago. She thought it would go away and despite taking over the counter medications, the infection has now started to drain. She says she has had diabetes for 30 years. She denies any trauma, travel, and does not smoke. On physical exam, there is an area of infection at the base of her right axilla, which is draining a serosanguineous fluid. The surrounding area is red and indurated. There is no crepitus. A sample of the discharge is sent for histological staining, and the pathologist tells reports that there are gram-positive branching bacteria. There are black spots over the histology slide. What is the treatment for this patient?



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A 66-year-old male with diabetes mellitus is seen in the clinic with a painless swelling just under the right mandible. The lesion is draining pus and the overhead skin appears reddish. His only complaint is that he has not been able to chew for the past few days. He has a long history of poor oral hygiene. His diabetes is poorly controlled and he often misses taking his metformin. Palpation reveals a nodular lesion with sinus tracts which exude pus. There is no cervical adenopathy and the patient is afebrile. A deep needle aspirate is obtained, gram-stained and shown below. For what should the specimen be tested to make a preliminary diagnosis?

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  • Image 5944 Not availableImage 5944 Not available
    Image donated by Sbhimji
Attributed To: Image donated by Sbhimji



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Actinomycosis - References

References

Ahmed S,Ali M,Adegbite N,Vaidhyanath R,Avery C, Actinomycosis of tongue: Rare presentation mimicking malignancy with literature review and imaging features. Radiology case reports. 2019 Feb     [PubMed]
Tippett E,Goyal N,Guy S,Wong J, Actinomyces spp. bloodstream and deep vein thrombus infections in people who inject drugs. Infection. 2018 Nov 8     [PubMed]
Mishra A,Prabhuraj AR,Bhat D,Nandeesh BN,Mhatre R, Intracranial Actinomycosis Presenting As A Parenchymal Mass Lesion: A Case Report And Review Of Literature. World neurosurgery. 2018 Oct 31     [PubMed]
McCann A,Alvi SA,Newman J,Kakarala K,Staecker H,Chiu A,Villwock JA, Atypical Form of Cervicofacial Actinomycosis Involving the Skull Base and Temporal Bone. The Annals of otology, rhinology, and laryngology. 2018 Oct 29     [PubMed]
Valdés-Peregrina EN,Bonifaz A,Arteaga-Sarmiento JF,Hernández-González M, [Primary intestinal actinomycosis in ilium and colon. A case report and review of the literature]. Revista espanola de patologia : publicacion oficial de la Sociedad Espanola de Anatomia Patologica y de la Sociedad Espanola de Citologia. 2018 Oct - Dec     [PubMed]
Sadeghi S,Azaïs M,Ghannoum J, Actinomycosis Presenting as Macroglossia: Case Report and Review of Literature. Head and neck pathology. 2018 Sep 22     [PubMed]
Rolfe R,Steed LL,Salgado C,Kilby JM, Actinomyces meyeri, a Common Agent of Actinomycosis. The American journal of the medical sciences. 2016 Jul     [PubMed]
Ding X,Sun G,Fei G,Zhou X,Zhou L,Wang R, Pulmonary actinomycosis diagnosed by transbronchoscopic lung biopsy: A case report and literature review. Experimental and therapeutic medicine. 2018 Sep     [PubMed]
Lim JA,Wong PS,Leong KN,Wong KL,Chow TS, Masking and misleading: concomitant actinomycosis and B-cell lymphoma - a case report and review of literature. Scottish medical journal. 2018 Aug 30     [PubMed]
Rousseau C,Piroth L,Pernin V,Cassuto E,Etienne I,Jeribi A,Kamar N,Pouteil-Noble C,Mousson C, Actinomycosis: An infrequent disease in renal transplant recipients? Transplant infectious disease : an official journal of the Transplantation Society. 2018 Jul 28     [PubMed]
Steininger C,Willinger B, Resistance patterns in clinical isolates of pathogenic Actinomyces species. The Journal of antimicrobial chemotherapy. 2016 Feb     [PubMed]
Nelson AL,Sulak P, IUD patient selection and practice guidelines. Dialogues in contraception. 1998 Spring     [PubMed]
Ravindra N,Sadashiva N,Mahadevan A,Bhat DI,Saini J, Central Nervous System Actinomycosis-A Clinicoradiologic and Histopathologic Analysis. World neurosurgery. 2018 Aug     [PubMed]
Hwang CS,Lee H,Hong MP,Kim JH,Kim KS, Brain abscess caused by chronic invasive actinomycosis in the nasopharynx: A case report and literature review. Medicine. 2018 Apr     [PubMed]

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