Actinomycosis: a 24 year experience

A de-escalated treatment strategy in the management of paediatric cervicofacial actinomycosis

Actinomycosis is a rare invasive bacterial disease that is characterised by granulomatous inflammation often mistaken as malignancy. Traditionally, this has been managed with prolonged courses of antibiotics with durations up to 6-12 months. Surgical intervention as an adjuvant treatment has been shown to reduce the length of antibiotic treatment significantly to 4 weeks. We report a case of cervicofacial actinomycosis in a 12-year-old girl who was adequately treated with an 11-day course of antibiotics without surgical intervention and shows no signs of recurrence at 6 months post-treatment.

Cervicofacial actinomycosis following third molar removal: case-series and review

Actinomycosis is an opportunistic infection caused by bacteria of the Actinomyces spp., commonly A. israelii. These are non-pathogenic commensals in the mouth, gut, and female genital tract. An infection may arise following trauma or surgery, such as tooth extraction. More than half of cases of actinomycosis occur in the perimandibular area and are termed cervicofacial actinomycosis. Initially, the infection develops as a painful, rapidly progressive swelling. The lesion may then indurate and is often painless while the overlying skin discolors red to purple-blue. Prolonged treatment with antibiotics and surgery are often required for resolution, unless treatment is promptly started. However, diagnosis may be delayed or missed because of difficult bacterial culturing and frequent confusion with malignancy and other infections. This case study describes six patients who developed cervicofacial actinomycosis following third molar extraction. The purpose of this study is to inform clinicians on this stubborn and deceitful disease entity and to highlight the importance of clinical recognition for quick resolution with minimal morbidity.

Oral Mucosal Infections: Insights into Specimen Collection and Medication Management

Oral mucosal infections appear as localized or generalized lesions. Symptoms range from almost unnoticeable lesions to severe pain. Systemic disease, age, immunocompromised condition, and medication use are common causes. Local causes include dentures, poor oral hygiene, traumatized epithelium, ulcerations, dentures, implants, oral piercing, and reduced salivary secretion. Oral mucosal infections are underdiagnosed and microbiological diagnosis should be more frequently used. Candidiasis is most frequently diagnosed. Clinical appearances are not always clear and are varied, creating a diagnostic challenge. Thorough understanding of clinical appearance and updated information on diagnostic and therapeutic management are essential for successful patient outcome.

Microbial succession in an inflated lunar/Mars analog habitat during a 30-day human occupation

BACKGROUND

For potential future human missions to the Moon or Mars and sustained presence in the International Space Station, a safe enclosed habitat environment for astronauts is required. Potential microbial contamination of closed habitats presents a risk for crewmembers due to reduced human immune response during long-term confinement. To make future habitat designs safer for crewmembers, lessons learned from characterizing analogous habitats is very critical. One of the key issues is that how human presence influences the accumulation of microorganisms in the closed habitat.

RESULTS

Molecular technologies, along with traditional microbiological methods, were utilized to catalog microbial succession during a 30-day human occupation of a simulated inflatable lunar/Mars habitat. Surface samples were collected at different time points to capture the complete spectrum of viable and potential opportunistic pathogenic bacterial population. Traditional cultivation, propidium monoazide (PMA)-quantitative polymerase chain reaction (qPCR), and adenosine triphosphate (ATP) assays were employed to estimate the cultivable, viable, and metabolically active microbial population, respectively. Next-generation sequencing was used to elucidate the microbial dynamics and community profiles at different locations of the habitat during varying time points. Statistical analyses confirm that occupation time has a strong influence on bacterial community profiles. The Day 0 samples (before human occupation) have a very different microbial diversity compared to the later three time points. Members of Proteobacteria (esp. Oxalobacteraceae and Caulobacteraceae) and Firmicutes (esp. Bacillaceae) were most abundant before human occupation (Day 0), while other members of Firmicutes (Clostridiales) and Actinobacteria (esp. Corynebacteriaceae) were abundant during the 30-day occupation. Treatment of samples with PMA (a DNA-intercalating dye for selective detection of viable microbial population) had a significant effect on the microbial diversity compared to non-PMA-treated samples.

CONCLUSIONS

Statistical analyses revealed a significant difference in community structure of samples over time, particularly of the bacteriomes existing before human occupation of the habitat (Day 0 sampling) and after occupation (Day 13, Day 20, and Day 30 samplings). Actinobacteria (mainly Corynebacteriaceae) and Firmicutes (mainly Clostridiales Incertae Sedis XI and Staphylococcaceae) were shown to increase over the occupation time period. The results of this study revealed a strong relationship between human presence and succession of microbial diversity in a closed habitat. Consequently, it is necessary to develop methods and tools for effective maintenance of a closed system to enable safe human habitation in enclosed environments on Earth and beyond.

Primary gastric actinomycosis: report of a case diagnosed in a gastroscopic biopsy

Background

Primary gastric actinomycosis is extremely rare, the appendix and ileocecal region being the most commonly involved sites in abdominopelvic actinomycosis. Herein, we report a case of primary gastric actinomycosis. The diagnosis was made on microscopic evaluation of gastroscopic biopsy specimens. To the best of our knowledge, this is the third case to be reported in the literature, in which the diagnosis was made in a gastroscopic biopsy rather than a resection specimen.

Case presentation

An 87-year-old Saudi male on medication for cardiomyopathy, premature ventricular contractions, renal impairment, hypertension, and dyslipidemia, presented to the emergency department with acute diffuse abdominal pain, abdominal distension, constipation and vomiting for two days, with no history of fever, abdominal surgery or trauma. The patient was admitted to the hospital with an impression of gastric outlet obstruction. Based on radiologic and gastroscopic findings, a non-infectious etiology was suspected, possibly adenocarcinoma or lymphoma. Gastroscopic biopsies showed an actively inflamed, focally ulcerated atrophic fundic mucosa along with fragments of a fibrinopurulent exudate containing brownish, iron negative pigment and abundant filamentous bacteria, morphologically consistent with Actinomyces.

Conclusion

Althuogh extremely rare, primary gastric actinomycosis should be considered in the differential diagnosis of radiologic and gastroscopic diffuse gastric wall thickening and submucosal tumor-like or infiltrative lesions, particularly in patients with history of abdominal surgery or trauma, or those receiving extensive medication. A high level of suspicion is required by the pathologist to achieve diagnosis in gastroscopic biopsies. Subtle changes such as the presence of a pigmented inflammatory exudate should alert the pathologist to perform appropriate special stains to reveal the causative organism.

Short‐Term Treatment of Actinomycosis: Two Cases and a Review

Recommendations for prolonged penicillin treatment of actinomycosis date from the early antibiotic era, when patients often presented with neglected, advanced disease and received interrupted therapy at suboptimal dosages. This report describes cases of esophageal and of cervicofacial actinomycosis treated successfully with short-term antibiotic therapy and reviews the literature. Many patients are cured with <6 months of antibiotic therapy. If short-term antibiotic treatment is attempted, the clinical and radiological response should be closely monitored. Cervicofacial actinomycosis is especially responsive to brief courses of antibiotic treatment.

Relative biological effectiveness and tolerance dose of fission neutrons in canine skin for a potential combination of neutron capture therapy and fast-neutron therapy

To investigate the potential efficacy of fission neutrons from a fast-neutron reactor for the treatment of radioresistant tumors, the relative biological effectiveness (RBE) and tolerance dose of fission neutrons in canine skin were determined. The forelimbs of 34 healthy mongrel dogs received a single dose of fission neutrons (5.6, 6.8, 8.2, 9.6 or 11 Gy) or 137Cs gamma rays (10, 15, 20, 25 or 30 Gy). Based on observations of radiodermatitis for each radiation, the single-fraction RBE of fission neutrons in the sixth month was calculated as approximately 3. The tolerance doses of fission neutrons and gamma rays, defined as the highest doses giving no moist desquamation on the irradiated skin in the recovery phase, were estimated as 7.6 Gy and 20 Gy, respectively. The tolerance dose of 7.6 Gy of fission neutrons included 5.0 Gy of fast neutrons possessing high anti-tumor effects and 1.4 x 10(12) n/cm2 of thermal neutrons, which could be applicable to neutron capture therapy (NCT). The combination of fast-neutron therapy and NCT using a fast-neutron reactor might be useful for the treatment of radioresistant tumors.

Rare presentation of actinomycosis as an abdominal mass: report of a case

PURPOSE

The purpose of this article was to report an unusual presentation of abdominal actinomycosis masquerading as a tumor.

METHODS

The patient was a 54-year-old male who presented with vague abdominal discomfort and a palpable left lower quadrant mass defined on CT scan. Multiple intraoperative core biopsies were nondiagnostic, and he underwent en bloc resection of the mass and adjacent organs for a presumed tumor.

RESULTS

Examination of tissue from deep within the excised specimen revealed sulfur granules diagnostic for actinomycosis.

CONCLUSION

Abdominal actinomycosis is an extremely rare infection that can mimic multiple disease processes and requires accurate diagnosis for successful therapy. This novel presentation and a review of the literature are reported.

Pelvic Actinomycosis Presenting as Malignant Large Bowel Obstruction: A Case Report and a Review of the Literature

Actinomycosis is an infrequent chronic infectious disease. In most cases the diagnosis is made postoperatively because of its unusual clinical presentation. Moreover, abdominal actinomycosis may mimic cancer, inflammatory bowel disease, or diverticulitis. Delay in diagnosis leading to inadequate management and unnecessary procedures has been reported. We report the case of a 49-year-old woman with large bowel obstruction secondary to extensive pelvic actinomycosis involving the rectosigmoid and cecum. She required emergency surgery, which involved both resection and colostomy. A review of the literature on abdominal actinomycosis during the last 50 years is also reported. Rarely has emergency surgery been described in this condition. Although the incidence of actinomycosis has decreased, the abdominal-pelvic form has been increasing over the past 10 years secondary to increased prolonged use of the intrauterine device. As the clinical spectrum of actinomycosis has dramatically changed, so have the therapeutic considerations. Aggressive surgical management in advanced cases with multiorganic involvement seems to have reemerged in recent years. Consideration of actinomycosis in a woman with prolonged use of an intrauterine device and symptoms of bowel obstruction could help to improve the preoperative diagnosis and management of this rare disease.

Thoracic actinomycosis

OBJECTIVE

Thoracic actinomycosis is a disease that is difficult to diagnose because its appearance varies from similarities with bronchogenic carcinoma to pneumonitis-like tuberculosis infections. Therefore the majority of patients undergo operations for diagnosis. We had seven patients with thoracic actinomycosis which were not diagnosed before operation.

METHODS

Between July 1990 and November 1997, seven patients with thoracic actinomycosis were diagnosed after thoracotomy in our centre. They all had non-specific symptoms and radiographic findings, so we failed to diagnose the disease during preoperative examinations. Therefore they all underwent thoracotomy for diagnosis. Four patients were operated because of suspicion of malignancy, two patients were operated because of pulmonary infiltration and abscess formation and one patient because of undiagnosed pulmonary infiltration. Lobectomy was performed in five of them because of destroyed lobes, and wedge resection was performed in two patients. In two patients the disease was diagnosed by fresh smears obtained from specimens in the course of operation and confirmed histopathologically and in the others histopathologically in the postoperative period.

RESULTS

Three major complications, acute renal failure, empyema and persistent air leakage developed in three cases after the operations. Bronchopleural fistula was found in only one of them and the patient died because of uncontrolled infection and sepsis on the 26th postoperative day. All of the other six cases are still alive. We did not observe any other problem in their long-term follow-up. All patients regularly took 20 million units/day of intravenous crystalline penicillin G when they were in the hospital. After that, antibiotic treatment was completed up to 2 months with procaine penicillin.

CONCLUSIONS

Sometimes diagnosis of the actinomycosis of the lung is very difficult although it is an infection. In that case thoracotomy is needed for the diagnosis and sometimes for the treatment. In some cases because of the irreversible parenchymal change resective surgery may be needed. Actinomyces israelii infections should be suspected of in chronic infiltrative, nodular, cavitary process and tumour-like mass lesions besides other most probable causes. After diagnosed, it is treated using penicillin chemotherapy at least for 2 months.

Pelvic actinomycosis presenting with a rectal stricture: report of a case

We present herein the case of a patient with actinomycosis involving the pelvic cavity, who presented with a rectal stricture. It is rare for this type of actinomycosis to be accurately diagnosed preoperatively, but a precise diagnosis, made using needle biopsy guided by computed tomography allowed for successful treatment by resection of the granulation tissue surrounding the rectal stricture through a transsacral approach.

Thoracic actinomycosis

Actinomycotic infection is uncommon and primary actinomycosis of the lung and chest wall has been less frequently reported. This disease may present as chronic debilitating illness with radiographic manifestation simulating lung tumor, pulmonary infiltrating lesion, or chronic suppuration. From 1984 to 1990, we experienced 17 cases of thoracic actinomycosis. There were nine patients who presented with a clinical picture of a suppurative lesions and the remaining eight were suspected of having primary lung tumor initially. In no case was an accurate diagnosis made at the time of hospital admission. Final diagnosis was based on aspiration (n = 3), anaerobic sputum culture (n = 1), bronchoscopic biopsy specimens (n = 4), and histologic examination of the resected tissue in the remaining 9 patients who received surgical excision. Among the 17 patients, 8 were treated medically and the other 9 received surgical intervention followed by antibiotic treatment. Regarding the surgically treated patients, suspected malignancy is the most common indication for operation (seven of nine). However, both medically and surgically treated patients achieved good clinical results, and the postoperative courses were uneventful. We would like to remind physicians of this unusual entity and review our own experience with particular emphasis on the clinical diagnosis and management of this unique disease.

Pericarditis, pneumonia and brain abscess due to a combined Actinomyces--Actinobacillus actinomycetemcomitans infection

A patient is described in whom there developed a pulmonary infiltrate and constrictive pericarditis caused by a combined Actinomyces and Actinobacillus actinomycetemcomitans infection, presumably originating from his poor dentition. The diagnosis was only made following repeated thoracotomy. After surgery, long-term treatment with antibiotics led to complete clinical recovery. None the less, some months later he was found to have a brain abscess which resolved during a further course of antibiotics. The variable clinical picture of actinomycosis is discussed, as well as the role of other bacteria frequently associated with actinomycotic infection, in particular Actinobacillus actinomycetemcomitans. The therapeutic implications are described.

Actinomycosis of the thigh presenting as a soft-tissue neoplasm

A 14-year-old boy presented with a mass measuring 6 cm x 9 cm, proximal to the patella on the anterior aspect of the knee. Magnetic resonance imaging revealed a 6 x 8 x 4 cm smoothly marginated slightly heterogeneous ellipsoidal mass which displaced musculature, the adjacent cutaneous fat and the quadriceps tendon. At surgery, the mass was noted not to penetrate the superficial surface of the quadriceps tendon and was full of slimy fluid. Histological examination revealed multiple basophilic lobulated granules with homogeneous centres and eosinophilic peripheral clubbed projections. The organisms grown anaerobically were identified as Actinomyces species. The anatomical site of the lesion is very unusual for actinomycosis and the exact route of infection in this patient remains unclear.

Actinomycotic liver abscess. Case report and literature review

A 28-year-old male with hepatic actinomycosis presented with several months of anorexia, weight loss, fever, night sweats, and mild right upper quadrant abdominal tenderness. Despite normal liver function tests, hepatic involvement was demonstrated by imaging studies. A liver biopsy and ultrasound-guided aspirate were, however, unrewarding. Laparotomy was, therefore, necessary to establish a definitive diagnosis. The patients was then successfully treated with intravenous penicillin followed by oral clindamycin. This case is presented to illustrate the diagnostic difficulties that may be encountered in such patients with hepatic actinomycosis.

Primary perianal actinomycosis over a thirty year period

A 50-year-old Japanese man had had abscesses and draining fistulas in the perianal region. These lesions recurred, despite surgical treatment such as incision and drainage over a 30 year period. "Sulfur granules" were found in the pus from the abscess and Actinomyces israelii was cultured. Ampicillin-cloxacillin treatment lead to healing. The patient died 4 months later with a hepatoma and multiple metastases.

Actinomycosis of the prostate

We report a case of actinomycosis of the prostate with symptoms of acute prostatitis. Laparotomy was required to establish an etiological diagnosis. Long-term therapy with erythromycin resulted in a clinical cure.

Actinomycotic osteomyelitis of the facial bones and mandible

Actinomyces israelii is a part of the human oral flora and thus is more commensal than pathogenic. Oral trauma, accidental or purposeful, can precipitate its introduction into the soft tissues, to which infection is usually confined. The case presented is one in which, over a span of two decades (1956 to 1977), the extraction of a mandibular tooth resulted in a chronic actinomycotic osteomyelitis, destroying first the mandible, then both maxillae, and then the right zygoma, with decreased vision and proptosis despite repeated medical and surgical intervention. Adequate treatment required removal of the sequestrum and excision of all infected granulation tissue, scars, and involucra until healthy bone was exposed. Intravenous penicillin was administered for 2 weeks, followed by a 6-month course of oral penicillin. The patient was followed for 4 years and remained disease free.

Hepatic actinomycosis presenting as repeated cholestatic reactions

A patient with hepatic actinomycosis caused by Actinomyces odontolyticus is presented. The clinical course was characterized by 2 yr of episodic abdominal pains and fever together with marked acute elevations of serum alkaline phosphatase. The diagnosis escaped extensive laboratory studies, 2 liver biopsies and 1 laparotomy and was finally verified at a second laparotomy by histology and a positive culture. Histopathology showed multiple small abscesses. No primary focus of infection was found. Treatment with doxycycline was successful.

Actinomycosis: the disease and its treatment

A case of pulmonary actinomycosis is described in a patient who presented with fever, weight loss, and a painful mass on his lower anterior left rib cage. Gram-stain and culture and sensitivity tests performed on the fluid drawn of the chest wall mass revealed Actinomyces israelii as the infecting organism. The patient was successfully treated with long-term penicillin therapy. A review of this rare bacterial disease is presented, emphasizing its treatment and its similarities and differences to other bacterial and fungal diseases.

Tuberculosis of the breast

Sixteen cases of tuberculosis of the breast are presented. The clinical features were a firm mass or a recurring abscess of the breast, sometimes associated with discharging sinuses. Diagnosis relied on histological appearance, acid-fast bacilli being present in only 3 specimens and positive cultures obtained in 4 patients. Local excision of the mass and chemotherapy proved effective treatment.

Actinomycosis of the head and neck

Actinomycosis has been known to involve virtually every anatomic site in the body; those infections involving the head and neck will be reviewed. Actinomycosis of the head and neck has many presentations; it may disguise itself as a tumor or present as a draining abscess which has failed to reveal an infectious agent as its etiology. With more recent attention directed toward the detection of anaerobic organisms especially in the cervicofacial region, this diagnosis is being made more frequently. In this review, a discussion of the bacteriology of Actinomyces, including a review of its taxonomy, morphology, growth requirements, and biochemistry, will be presented. Recommendations are made to clinicians and laboratory personnel who handle such specimens in order that they might obtain maximum information. In addition, infections which mimic or accompany actinomycosis will be reviewed. The diagnosis and management of this infection, including the physical exam, X-ray and laboratory tests, and collection and handling of specimens, as well as the surgical and antibiotic therapy will be discussed in depth. The variety of clinical presentations with their differential diagnosis is used to illustrate the complexity of this disease.

Abdominal actinomycosis: A complication of colonic perforation

Actinomycosis is a chronic, suppurative, mycotic infection, which tends to form abscesses and fistulas. The organism is a saprophyte of the human mouth. When a break in the normal contiguity of the gastrointestinal tract occurs, the organism may gain access to the surrounding tissues and become almost impossible to eradicate without surgical extirpation and administration of a long course of antibiotics. The diagnosis of actinomycosis should be considered for any patient in whom persistent or unusual enterocutaneous fistulas develop, when there is a recent history of perforated viscus or surgical intervention involving the gastrointestinal tract, such as appendectomy. The diagnosis is confirmed by the presence of "sulfur granules" in the fistulous tracts.

Actinomycosis: masquerader in the head and neck

The diagnosis of cervicofacial actinomycosis is usually not simple, but may be essential for adequate treatment. Cases seen in a Head and Neck Service illustrate some of the many guises under which actinomycosis may be concealed, and a review of recent literature confirms its propensity to be a masquerader. A combination of techniques is necessary to diagnose, and both surgical and medical approaches are needed to treat this often distressingly persistent affliction.

Pericarditis with effusion casued by Actinomyces israelii

Actinomyces israelii is a rare cause of pericarditis. Infection spreads to pericardium from an intrathoracic focus. Branching gram-positive filaments are seen on microscopic examination of clinical specimens. Cultures should be performed under anaerobic conditions. Both surgical drainage and antibiotics (penicillin) are required for treatment. Nocardiosis may resemble actinomycosis in many respects.

Cervicofacial actinomycosis

Cervicofacial actinomycosis is a disease that is currently encountered as a pseudotumor entity or cold abscess. The frequent use of antibiotics in treatment of masses in the cervicofacial region may either delay its appearance or disguise the diagnosis. The surgeon must be highly suspicious when making the diagnosis since precautions in handling the biopsy specimens are necessary. Treatment consists of incision biopsy and drainage or aspiration to establish the diagnosis, followed by prolonged penicillin therapy. In those patients allergic to penicillin, clindamycin should be the initial drug of choice. Either medication must be administered for a prolonged period of time, even after the disease is clinically controlled.