Actinomycosis - Clinicals, Diagnosis, and Management

Infectious diseases

Clinicals - History

Fact Explanation
Swelling of the jaw 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. The infection may spread to the mandibular bone and result in periostitis or osteomyelitis. Swelling of the jaw
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. The infection may spread to the mandibular bone and result in periostitis or osteomyelitis.
Difficulty in swallowing and trismus Due to the involvement of muscles of mastication. Trismus is present early in the course of illness. Difficulty in swallowing and trismus
Due to the involvement of muscles of mastication. Trismus is present early in the course of illness.
Cough and hemoptysis Due to thoracic actinomycosis. Shortness of breath and chest pain are other complains of thoracic involvement. Cough and hemoptysis
Due to thoracic actinomycosis. Shortness of breath and chest pain are other complains of thoracic involvement.
Fever Commonly seen in thoracic actinomycosis. Fever
Commonly seen in thoracic actinomycosis.
Constitutional symptoms These include weight loss, fatigue, nausea, vomiting and anorexia. Constitutional symptoms
These include weight loss, fatigue, nausea, vomiting and anorexia.
Change in bowel habits Seen in abdominal actinomycosis. Change in bowel habits
Seen in abdominal actinomycosis.
Symptoms of pelvic actinomycosis Females complain of discomfort or pain in the lower abdomen menorrhagia and vaginal discharge. Symptoms of pelvic actinomycosis
Females complain of discomfort or pain in the lower abdomen menorrhagia and vaginal discharge.
Symptoms of central nervous system involvement 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. Symptoms of central nervous system involvement
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.
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. Actinomycosis is commonly seen in men for which the exact cause is unknown. 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. Actinomycosis is commonly seen in men for which the exact cause is unknown.

Clinicals - Examination

Fact Explanation
Fever This is a common examination finding especially in thoracic actinomycosis. Fever
This is a common examination finding especially in thoracic actinomycosis.
Cervico-facial involvement There are multiple small tender nodules which may fluctuate with the development of abscesses. These nodules become non-tender and woody hard in later disease. These are called “sulfur granules”. Cervico-facial involvement
There are multiple small tender nodules which may fluctuate with the development of abscesses. These nodules become non-tender and woody hard in later disease. These are called “sulfur granules”.
Intra-abdominal mass 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. Intra-abdominal mass
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.
Pelvic mass Tubo-ovarian mass is palpated in pelvic actinomycosis. Pelvic mass
Tubo-ovarian mass is palpated in pelvic actinomycosis.
Cutaneous sinuses Depending on the site of the primary lesion sinuses can be seen around the jaw, thorax or over the abdominal skin. Cutaneous sinuses
Depending on the site of the primary lesion sinuses can be seen around the jaw, thorax or over the abdominal skin.
Signs of central nervous system involvement Examination of the optic fundus will show papilledema. Chronic meningitis may produce neck stiffness. Signs of central nervous system involvement
Examination of the optic fundus will show papilledema. Chronic meningitis may produce neck stiffness.
Signs of infective endocarditis Patients rarely can have Roth spots, splinter hemorrhages, Osler nodes, Janeway lesions, hepatosplenomegaly and changing murmurs. Signs of infective endocarditis
Patients rarely can have Roth spots, splinter hemorrhages, Osler nodes, Janeway lesions, hepatosplenomegaly and changing murmurs.

Investigations - Diagnosis

Fact Explanation
Full blood count Mild anemia and leukocytosis is commonly seen. Full blood count
Mild anemia and leukocytosis is commonly seen.
Erythrocyte sedimentation rate (ESR) Elevated due to inflammation. Erythrocyte sedimentation rate (ESR)
Elevated due to inflammation.
C-reactive protein (CRP) Elevated due to inflammation. C-reactive protein (CRP)
Elevated due to inflammation.
Liver function test Alkaline phosphatase levels are elevated in hepatic involvement. Liver function test
Alkaline phosphatase levels are elevated in hepatic involvement.
Gram stain Specimens obtained from the sinuses, needle aspirations or biopsy of the lesions show beaded, branched, gram-positive filamentous rods. Gram stain
Specimens obtained from the sinuses, needle aspirations or biopsy of the lesions show beaded, branched, gram-positive filamentous rods.
Culture 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. Culture
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.
Polymerase chain reaction (PCR) Detects the organism’s genome and enable accurate diagnosis. Polymerase chain reaction (PCR)
Detects the organism’s genome and enable accurate diagnosis.
Immunofluorescence Allows detection of antigen and or antibodies. Immunofluorescence
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. 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.
X-ray film of the abdomen In hepatic involvement abscesses are seen. X-ray film of the abdomen
In hepatic involvement abscesses are seen.
CT scan of the chest CT shows infiltrative mass with focal areas of decreased attenuation with contrast enhancement. 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. Fine-needle aspiration and/or biopsy
CT or Ultrasound guided aspiration or biopsy allows collection of high quality specimen for the diagnosis.
Bronchoscopy In thoracic actinomycosis bronchoscopy is used to obtain a sample of bronchoalveolar lavage fluid. This sample can be used to isolate the organism. Bronchoscopy
In thoracic actinomycosis bronchoscopy is used to obtain a sample of bronchoalveolar lavage fluid. This sample can be used to isolate the organism.

Investigations - Management

Fact Explanation
Chest X-ray The resolution of the initial lesion is monitored with chest X-ray films to evaluate the response to treatment. Chest X-ray
The resolution of the initial lesion is monitored with chest X-ray films to evaluate the response to treatment.
CT scanning and MRI Used in assessment of response to treatment. With successful treatment resolution of the initial brain abscesses is seen. CT scanning and MRI
Used in assessment of response to treatment. With successful treatment resolution of the initial brain abscesses is seen.

Management - Supportive

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. 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. Treatment of infective endocarditis
Drug of choice is penicillin which is given in high doses.

Management - Specific

Fact Explanation
Antimicrobial therapy Penicillin G is the drug of choice. 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. Osteomyelitis complicating actinomycosis may require ertapenem as the antibiotic treatment. Hepatic involvement is treated with penicillin, tetracycline, or clindamycin. Antimicrobial therapy
Penicillin G is the drug of choice. 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. Osteomyelitis complicating actinomycosis may require ertapenem as the antibiotic treatment. Hepatic involvement is treated with penicillin, tetracycline, or clindamycin.
Surgery 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. Surgery
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.

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