Facial Actinomycosis Mimicking a Cutaneous Tumor

Actinomycosis is a chronic granulomatous infection that commonly occurs in the cervicofacial region. Although Actinomcyes is an element of the normal oral flora, infections of the facial skin are very rare because of the entirely endogenous habitation of the organism. The authors report a case of facial actinomycosis, which mimicked a cutaneous tumor both clinically and surgically in a 44-year-old woman with chronic renal failure and Hepatitis C viral infection. The majority of cases can be treated with long-term antibiotics. However, a treatment-resistant abscess, a fistula, or postsurgical excision of the mass formation that are infected can be treated with antibiotics as soon as possible, and recurrence of infection is prevented. The treatment should consist of conservative surgery to obtain a firm histological diagnosis and to drain any collections.

Unusual Behavior of a Posttraumatic Scar: Craniofacial Actinomycosis

Actinomycosis is a chronic suppurative granulomatous infection most commonly involving the cervicofacial region. Clinical diagnosis is usually difficult, and fine-needle aspiration cytology or imaging studies are usually unhelpful in diagnosing actinomycosis. Definitive diagnosis is based on the histopathological examination of a tissue biopsy. The authors report a case of a 32-year-old healthy man who underwent multiple surgeries over a period of 7 years to correct a posttraumatic scar on his forehead with unusual behavior. Final diagnosis was made by tissue biopsy. Scar was excised and penicillin was administered for 1 month postoperatively; after a 12-month follow-up, the wound was fully healed with minimal scarring and no recurrence.

Isolated Actinomycotic Swelling in Right Upper Cervical Region

Cervicofacial actinomycosis is today a rare disease in our country. Isolated neck swelling due to actinomycosis is extremely rare. A case of 52 year old man with an isolated neck swelling due to actinomycosis without any discharging sinus is reported here.

Two unusual presentations of cervicofacial actinomycosis and review of the literature

Cervicofacial actinomycosis is the most common clinical form of actinomycosis. This bacterial infection is rare. Diagnosis is difficult, often it is definitive only after surgical excision of the cervicofacial mass. Personal experience is reported concerning two cases of cervicoactinomycosis. Diagnosis, in both cases, has been based on histological findings, not on clinical symptoms. A review of the literature shows that mainly males are affected by this condition and, in fact, both patients described here are males. Symptoms of acute infection were absent. Both patients denied any history of oromaxillofacial trauma or recent dental extraction or oral manipulations. Imaging techniques--ultrasonography and computerized tomography--were not effective in making the diagnosis, in either of these patients. Furthermore, fine needle aspiration cytology did not provide a definitive diagnosis. Both patients underwent surgical excision of the mass. Penicillin was the drug of choice in post-operative long-term treatment (one month). In one of the two men, intravenous steroids were administered. As in several reports in the literature, the definitive diagnosis was histological and not clinical.

Actinomycosis of the larynx

Actinomycosis is a rare chronic granulomatous disease that involves the upper airway and gastrointestinal tract. Approximately 40-55% of actinomycosis comprises the cervicofacial form. It presents a challenging clinical diagnostic dilemma because of variable presentations in the head and neck. Herein, we report a rare case of actinomycosis presenting as a vocal cord nodule in a healthy 21-year-old man who was not immunocompromised and had no other known medical disease.

Cervicofacial actinomycosis: still a difficult differential diagnosis

Cervicofacial actinomycosis, a rare chronic infectious disease, is, however, an important clinical entity, due to the difficulties involved, still today, in its diagnosis. Following personal experience in a case referred to our Department, and in agreement with reports in the literature, attention is drawn to the presenting clinical manifestations, stressing that these are often confusing since they mimic those of other diseases, Moreover, many pre-operative investigations (radiological scans, incisional biopsy, fine-needle aspiration) are generally nonspecific. Finally, surgical excision of the mass is now the last essential step to make a definitive diagnosis and define the appropriate antibiotic therapy.

Fine-needle aspiration cytology in the diagnosis of cervicofacial actinomycosis: report of 15 cases

OBJECTIVES

Actinomycosis is quite an infrequent bacterial infection nowadays. However it can be considered in cases with a persistent cervicofacial disease. Although it is a bacterial infection, microbiologic cultures are frequently not diagnoses, therefore histopathologic studies and image studies are essential. Our interest is to explain our experience with cervicofacial actinomycosis; the clinical behaviour, evolution and treatment, always assisted by their elected diagnostic technique: the FNAC.

STUDY DESIGN

In the last 16 years, 15 patients have been diagnosed with cervicofacial actinomycosis by FNAC, treated by Maxillofacial, Internal Medicine and Paediatrics units. Clinical course, evolution, anatomical space situation, antibiotic treatment, and surgical treatment have been studied.

RESULTS AND CONCLUSIONS

The fine-needle aspiration cytology (FNAC) is an easy, safe and rapid method, with a high effect, that has made the final diagnosis in 15 cases in our Hospital. All the patients have had a good clinical evolution, only in one case did we need a new treatment for recidive. In all the cases treatment has been definitive. Our interest is to explain our experience in the treatment of cervicofacial actinomycosis, its clinical presentation and evolution, together with its elected method of diagnosis, FNAC.

Pediatric cervicofacial actinomycosis: a case report

Cervicofacial actinomycosis affects many soft tissue and bony structures in the head and neck, and has both granulomatous and suppurative features. Pathogenesis of actinomycosis is still unclear, but trauma provides a portal of entry for the infection. It usually presents as a diffuse swelling with multiple sinus tracts containing macroscopic colonies of the organism known as "sulphur granules." Cervicofacial actinomycosis in children is rare. This article reports a case of actinomycosis in a 10-year-old-boy overlying the left ramus of the mandible.

Cervicofacial actinomycosis: CT and MR imaging findings in seven patients

BACKGROUND AND PURPOSE

Cervicofacial actinomycosis is uncommon, but without proper treatment it causes extensive tissue destruction. Early diagnosis is critical but usually difficult with cultures or imaging. Our aim was to identify characteristic imaging features that facilitated diagnosis in seven patients with cervicofacial actinomycosis.

METHODS

We retrospectively reviewed the CT and MR findings in seven patients with pathologically proved actinomycosis. Histologic diagnosis was made by means of surgical excision or biopsy in seven patients. Culturing was performed in two patients. Enhanced CT scans (n=7) and MR images (n=2) were evaluated for the location, margin, infiltrative nature, enhancement pattern, and presence of lymphadenopathy.

RESULTS

CT and MR images showed either a well-defined (n=2) or ill-defined (n=5) mass. Involved areas included the nasal cavity (n=2), buccal space (n=1), pyriform sinus (n=1), aryepiglottic fold (n=1), oro- and hypopharynx (n=1) and tongue (n=1). Imaging confirmed the infiltrative nature, showing the tendency of the lesion to invade across tissue planes and boundaries (n=6). Moderate homogeneous contrast enhancement was seen on CT scans in six patients with several small low-attenuating foci (n=2). T1- and T2-weighted MR images showed intermediate signal intensity with moderate contrast enhancement (n=2). Reactive lymphadenopathy was associated in three patients.

CONCLUSION

Although cervicofacial actinomycosis occurs infrequently, it should be included in the differential diagnosis when images show a soft-tissue mass with inflammatory changes and an infiltrative nature in the cervicofacial area.

Atypical presentations of pediatric actinomycosis: report of a case

It is well recognized that cervicofacial actinomycosis is rare in children, especially at maxilla. Actinomycosis involving the maxilla usually is seen as a localized intraoral infection in contrast to classical cervicofacial actinomycosis. In this article, we describe an 8-year-old patient who had actinomycosis involving the bone at the left maxillary lateral incisor region. The diagnosis was based on histologic report because of location and development of the lesion with unusual history. The treatment of choice was removal of the soft and hard tissues with concomitant prolonged penicillin administration. In cases of persistent oral infection the diagnosis of actinomycosis should be actively attempted through microbiologic and histologic examination.

[A classical form of actinomycoses involving the mouth, face bones, orbit and base of the cranium in an African patient]

Osteitis due to actinomycosis is now an uncommon clinical entity in industrialized countries. This report describes a classic case of imported actinomycosis involving the buccal cavity, facial bones, orbit and skull base. For two years after the onset, various diagnoses followed by different medical as well as surgical treatments were unsuccessfully attempted first in Senegal then in Italy. Proper diagnosis was finally established in Marseille, France, on the basis of histological findings after extensive surgical biopsy. The patient was treated with high-dose intravenous penicillin G for four weeks followed by daily oral administration of amoxicillin for one year. Surgical reconstruction could not be carried out before the patient's return to Senegal. The pitfalls of diagnosis and treatment of actinomycosis are discussed.

Atypical presentations of actinomycosis

BACKGROUND

Actinomycotic infections of the cervicofacial region are uncommon. Most major medical centers report approximately one case per year. Presenting clinical manifestations are confusing because they often mimic other disease processes. Diagnosis may be difficult due to a general lack of familiarity with the disease and the fastidious nature of the organism in culture. The cervicofacial manifestations of actinomycosis are varied, and a high index of suspicion is required to make an accurate and timely diagnosis.

METHODS

Retrospective chart review with the presentation of four unusual cases of actinomycosis were performed.

RESULTS

Two patients were initially seen with dysphagia from a tongue base mass. The third patient was initially seen with a 3-week history of worsening hoarseness and stridor. Examination revealed an ulcerative lesion of the left hemilarynx and pyriform sinus. All three patients were thought to have a neoplastic process. Diagnosis was made on histologic examination of a tissue biopsy. The fourth patient was initially seen with a buccal space mass that was draining externally. Culture of the purulent drainage revealed Actinomyces. In all four cases, symptoms resolved after appropriate antimicrobial therapy.

CONCLUSIONS

Actinomycosis of the head and neck, although rare, is an important entity to the otolaryngologist. A confusing clinical presentation combined with the fastidious nature of the organism make for a difficult diagnosis. A high index of suspicion is required to make an accurate diagnosis and institute the appropriate antibiotic therapy.

Cervical actinomycosis causing spinal cord compression and multisegmental root failure: case report and review of the literature

OBJECTIVE AND IMPORTANCE

Epidural invasion and the resulting cord compression are clinical entities not usually associated with actinomycosis, and we found only 11 reported cases of cord compression caused by Actinomyces infection in the literature. Only one reported case was described as actinomycosis with epidural granuloma (14, 16), whereas in the other cases, epidural macroabscess (phlegm) formation caused the symptoms. Histopathological demonstration of the inflammatory granulation tissue and gram-positive sulfur-containing filamentous bacteria are important for the diagnosis of actinomycosis, because the clinical and microbiological studies cannot always demonstrate the causative microorganism and primary infection source.

CLINICAL PRESENTATION

In this article, a case of Actinomyces infection causing cervical cord compression is presented. Precise diagnosis was accomplished using specific histopathological studies of the surgical specimens; such a precise diagnosis cannot always be achieved using preoperative investigations and microbiological studies. The treatment modalities and the patient's outcome are also discussed.

CONCLUSION

As shown by hematoxylin and eosin stain, in contrast to the Nocardia species, Actinomyces filaments histopathologically are basophilic in nature and terminate in eosinophilic clubs as a predictive feature. The clinical and radiological findings closely resemble metastatic tumors and other infectious processes. A differential diagnosis is also emphasized in this article, along with a review of the literature.

[Cervical actinomycosis in systemic lupus erythematosus, nephrocalcinosis and distal renal tubular acidosis (type I-RTA)]

HISTORY AND CLINICAL FINDINGS

A 25-year-old woman presented with a painful soft-tissue swelling in the right neck, which made it impossible to assess the right cervical lymph nodes, while other lymph nodes were unremarkable on palpation. For 9 years she had been known to have polyarthritis. All joints were freely mobile and were without deformity or inflammatory signs. Flexion of the left elbow was slightly painful but freely mobile. There was no skin rash.

INVESTIGATIONS

Erythrocyte sedimentation rate was 44 mm/h, there was a leucocytosis of 16,000 granulocytes/ml. There was hypokalaemia (3.5 mEq/l) and a metabolic hyperchloremic acidosis with a pH of 7.27 and a urinary pH of 6.5. Antinuclear and anti-ds-DNA antibodies were raised (ANA: 3.9 multiple of cutoff point [MOC; normal: 0-1.0]; anti-ds-DNA antibodies: 4.0 [normal: 0-1.0])-Fine needle aspiration cytology from the swelling revealed erythrocytes, double-refractory horny lamellae, cellular debris and only a few inflammatory cells. Abdominal ultrasound showed nephrocalcinosis. Microbiological cultures were negative.

DIAGNOSIS, TREATMENT AND COURSE

Assuming a bacterial cause of the swelling antibiotic treatment with Phenoxymethylpenicillin (4 MU/d) was initiated. The local findings rapidly improved and the inflammatory parameters regressed to normal. 16 weeks after the initial admission the abscess recurred and biopsy now revealed actinomycetes with typical granules, confirming cervical actinomycosis. The other symptoms indicated autoimmune disease and, together with previous findings, established the additional diagnosis of lupus erythematodes, which caused the type 1 distal tubular acidosis.

CONCLUSIONS

This case illustrates the basic approach of establishing an all-encompassing diagnosis that brings together seemingly isolated findings. It is especially in systemic disease that such diagnostic strategy will frequently lead to its recognition.

Actinomycosis of the posterior triangle: a case report and review of the literature

Actinomycosis presents acutely as an abscess, or as a chronic lesion mimicking malignancy, tuberculosis, or aspergillosis. Most disease involves the mouth and its immediate site of lymphatic drainage, the anterior triangle of the neck. We present a case of actinomycosis at the apex of the posterior triangle, suspected of being a malignancy, and discuss the importance of being aware of this as a cause of neck lumps. The diagnosis is usually made late because of the difficulties in culturing the organism, or in identifying characteristic 'sulphur granules' in pus or biopsy specimens. For these reasons, the disease is underdiagnosed. When acute or chronic neck lesions prove difficult to diagnose, microscopy and prolonged anaerobic culture of pus and biopsy specimens should be performed in addition in Ziehl-Neelsen staining, tuberculosis and fungal cultures. The tests should be repeated if negative. Specific treatment requires prolonged courses of antibiotics, despite adequate surgical excision, to prevent relapse.

Actinomycosis presenting as a nasopharyngeal tumour: a case report

A case of head and meck actinomycosis presenting clinically and radiologically as a nasopharyngeal tumour is described.

Oral manifestations of infectious diseases

The oral manifestations of infectious diseases is a major topic since the prevalence rate has increased, and usually poses diagnostic and therapeutic dilemmas to the oral clinician. The clinical features of the most common and important oral infectious diseases are discussed.

Actinomycosis in fine needle aspiration cytology

Four cases of actinomycosis were diagnosed by fine needle aspiration (FNA) cytology and eight more cases were detected during a review of FNA smears reported as inflammatory. The age of these 12 cases ranged from 20 to 61 years with a median of 35 years. The male to female ratio was 3:1. The common regions of involvement were cervicofacial in seven cases (58.3%), thoracic in three (25.0%) and abdominal in two (16.7%). Four of the seven cervicofacial cases presented with intra-oral masses; the thoracic lesions were pulmonary in location, and the abdominal lesions presented as bowel masses. The possibility of actinomycosis was not considered clinically in any case. The main reason for missed cytodiagnosis in two thirds of the cases appeared to be observer error. It is suggested that when the aspiration smear from a mass is found to be an inflammatory exudate rich in neutrophils, special efforts must be made to look for this microorganism.

Pediatric cervicofacial actinomycosis

It is well recognized that cervicofacial actinomycosis is rare in children. We have summarized the cases in the English language literature and reported a recent case from our hospital. In only 10% of clinical situations is actinomycosis the primary diagnosis. Failure to consider actinomycosis in the differential diagnosis of a cervical mass may compromise the ability to make the diagnosis, given the fastidious nature of the most common pathogen, Actinomyces israelii. Indeed, the recovery rate of only 30% in some of the earlier studies of actinomycosis may have been in part due to this oversight. The correct diagnosis, however, is imperative because the treatment of actinomycosis is different from that of routine cervical adenitis in that actinomycosis requires high doses of penicillin over a prolonged time, since it is subject to relapse. Our case serves as a reminder to consider actinomycosis as the possible cause of a cervical mass, not only in adults, but in children as well.

Actinomycosis of the neck: diagnosis by fine-needle aspiration biopsy

A patient with actinomyces infection of the posterior neck was diagnosed by fine-needle aspiration biopsy. The lesion presented as a recurrent, firm, and indurated mass that was clinically diagnosed as adenitis and cellulitis and was thought to be a lymphoma 6 months after the onset of his illness. Smears and cell block sections of the aspirate showed characteristic colonies ("sulfur granules") of actinomyces. Subsequent regional lymph node biopsy revealed reactive lymphoid hyperplasia.

Intra-masseteric actinomycosis: report of a case

A case of actinomycosis arising within the masseter following extraction of a lower second molar is reported. The most likely cause was a needle tract infection from the planned administration of the local anaesthetic.

[Cervicofacial actinomycosis. A case study]

A case of cervicofacial actinomycosis, sited in the central hyoid region, is reported. The Authors have emphasized the difficulties of the diagnosis. It's very important hat the clinical diagnosis of actinomycotic infection be confirmed by a positive culture test. Actinomycosis can be suspected if multiple recurrent pustular swellings are present, associated with any trauma or teeth extractions.

Cranio-facial actinomycosis

In the National Neurosurgical Centre in the Sultanate of Oman, four patients with cranio-facial actinomycosis were seen over a 5-year period. All patients had osteomyelitis and intracranial granulomata and the diagnosis was confirmed with histopathology. In two cases the organisms were cultured. In three patients the cranial spread was by contiguity from the scalp and face while one case had the extradural granuloma following a dental extraction. With medication there was gross reduction of proptosis and intracranial lesion in one patient and in two there was marked reduction in the size of the intracranial lesion as seen on serial computerized tomographic scanning of the head (CT head). Three patients are now asymptomatic and are being followed up while one expired with subarachnoid haemorrhage. Although eradication of the disease is difficult, with adequate medication and appropriate surgical intervention, three of these patients continue to remain relatively symptom-free for long periods of time.

[Cervicofacial actinomycosis. Report of a case]

Actinomycosis is a relatively rare chronic granulomatous infection, which is characterized by the formation of abscesses which tend to form fistulas. Anatomically is classified according to the location of the lesions in cervicofacial, pulmonary and abdominal form. We present a case of cervicofacial actinomycosis and its treatment, emphasizing on the difficulty of the diagnosis of the lesion.

Cervicofacial actinomycosis in a patient treated for tonsillar carcinoma

A 50-year-old patient who underwent locoregional radiotherapy and surgery for a tonsillar carcinoma, developed osteomyelitis with Actinomyces israelii with fistulization in the treated area, during chemotherapy treatment. This rare complication is discussed.

Cervicofacial actinomycosis in pregnancy

Two cases of cervicofacial actinomycosis in pregnancy are described and the refractory nature of the condition in pregnancy is discussed.