eMedicine Specialties > Ophthalmology > Infectious Disease

Actinomycosis

Author: Manolette R Roque, MD, MBA, DPBO, FPAO, President and CEO, Chief of Service, Ocular Immunology and Uveitis, Consulting Staff, Cornea and Refractive Surgery, Eye Republic Ophthalmology Clinic; General Manager, Ophthalmic Consultants Philippines Co; Consulting Staff, CME Liaison, Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, Asian Hospital and Medical Center
Coauthor(s): Barbara L Roque, MD, Full Partner, Ophthalmic Consultants Philippines Co, Chief of Service, Pediatric Ophthalmology and Strabismus, Consulting Staff, Orbit and Eye Plastics, Eye Republic Ophthalmology Clinic; C Stephen Foster, MD, FACS, FACR, FAAO, Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institution
Contributor Information and Disclosures

Updated: Oct 13, 2008

Introduction

Background

The bacterial order Actinomycetales comprises 3 families: Actinomycetaceae, Mycobacteriaceae, and Streptomycetaceae. The genus Actinomyces, a member of the family Actinomycetaceae, grows as a fragile branching filament that tends to fragment into bacillary and coccoid forms producing chains of either conidia or arthrospores1,2

Actinomyces israelii species is a gram-positive, cast-forming, non–acid-fast, non–spore-forming anaerobic bacillus that is difficult to isolate and identify. Its filamentous growth and mycelialike colonies have a striking resemblance to fungi. They are soil organisms, often found in decaying organic matter (eg, wet hay, straw). It is primarily a commensal microbe found in normal oral cavities, in tonsillar crypts, in dental plaques, and in carious teeth3,4,5,6

Pathophysiology

Keratitis

Most reported cases of Actinomyces keratitis (keratoactinomycosis) are caused by A israelii. It is characterized by a dry ulceration with central necrosis, surrounded by a gutter of demarcation, usually accompanied by iritis and hypopyon. In severe cases, descemetocele and perforation may occur.

A primary corneal ulcer attributable to Actinomyces species is rare and usually follows corneal trauma7 A rare case of keratoactinomycosis developing in the absence of any known ocular trauma was reported in Kuala Lumpur. 

See related CME at Update on Contact Lens-Related Microbial Keratitis.

Canaliculitis

Primary chronic canaliculitis is an uncommon problem caused by A israelii (Streptothrix).

McKellar presented a 10-year-old girl with a 6-month history of intermittent conjunctivitis and discharge from her pouted left lower punctum. Topical treatment with chloramphenicol/polymyxin sulphate failed despite a diagnosis of probable A israelii infection confirmed by microbiology. Surgical exploration revealed a canalicular diverticulum and 3 canaliculiths demonstrating solid casts of Actinomycetes on histologic examination. A therapeutic triad of punctoplasty, cast removal, and adjunctive topical cefazolin resulted in resolution.8,9,10,11,12,13,14,15,16,17,18,19

Other ocular involvement

Actinomycetes have been described as causative organisms in conjunctivitis, blepharitis, dacryocystitis, postsurgical endophthalmitis, and infected porous orbital implant. Cervico-facial actinomycosis has also been reported.

Endophthalmitis

Acute postoperative endophthalmitis caused by Actinomyces neuii after uncomplicated phacoemulsification with posterior chamber intraocular lens implant in a 58-year-old male has been reported. On postoperative day 6, he presented with pain, redness, and decreased visual acuity. Chronic endophthalmitis by Actinomyces neuii subspecies anitratus after uneventful phacoemulsification with implantation of a foldable posterior chamber intraocular lens in a 75-year-old man has been reported as well. Four weeks after surgery, anterior chamber and vitreous cellular debris developed in this eye20

Endophthalmitis, attributable to Actinomyces viscosus, developed in a 78-year-old man after cataract surgery. Postoperative endophthalmitis with this organism is a rare occurrence. Inflammation was characterized by anterior segment and vitreous cellular debris in cases of chronic postoperative endophthalmitis associated with Actinomyces species.21

Endogenous endophthalmitis has been reported with Actinomyces israelii22

Orbital actinomycosis

Painful ophthalmoplegia resulting from orbital actinomycosis has been reported23,24,25,26,27

Frequency

United States

Primary chronic canaliculitis is an uncommon problem that can be overlooked; however, it may account for approximately 2% of all tearing problems. Actinomycosis may form in up to 2% of all lacrimal disease. Its occurrence is probably much less in other areas.

International

Actinomycosis occurs worldwide, with a likelihood for higher prevalence rates in areas with low socioeconomic status.

Race

No racial predilection exists.

Sex

No sexual predisposition exists.

Age

Actinomycosis can affect people of all ages. No age predisposition exists.

Clinical

History

  • Keratitis
    • Symptoms
      • Progressive visual haze
      • Increasing ocular pain
      • Photophobia
      • Constant watering
      • Redness
    • Past ocular history
      • Corneal trauma, especially when contaminated by vegetable matter
      • Ongoing, nonresponsive treatment
    • Personal history - Outdoor laborer
  • Canaliculitis
    • Symptoms8,9
      • Chronic or recurrent conjunctivitis
      • Chronic mucopurulent discharge
      • Epiphora
      • Ocular surface irritation
      • Medial eyelid and canthal pain
      • Pouting punctum
      • Failure to resolve despite topical treatment
    • Past ocular history and medical history - Similar to keratitis
  • Endophthalmitis
    • Symptoms
      • Blurring of vision
      • Floaters
      • Ocular pain
      • Redness
      • Tearing
    • Past ocular history
      • Uneventful phacoemulsification with implantation of a foldable posterior chamber intraocular lens
    • Personal history
      • Elderly
      • Debilitated

Physical

  • Keratitis
    • Gross observations
      • Some conjunctival congestion
      • Gray-white corneal lesion
    • Slit lamp findings
      • A dry ulceration with central necrosis, surrounded by a gutter of demarcation, usually accompanied by iritis, and hypopyon may be present.
      • Gray-white satellite stromal infiltrates adjacent to advancing edges may be present.
      • In severe cases, descemetocele and perforation may occur.
  • Canaliculitis8,9
    • Gross observations
      • Chronic discharge, swollen and pouted punctum
      • A pouted punctum is clinically diagnostic, although it occurs in less than 50% of all patients who are affected.
      • Typically, the discharge is particulate and contains concretions.
      • The plica may be swollen and congested, and canalicular swelling and overlying lid erythema are often present.
      • The lower lid is more commonly affected, and the lacrimal sac and the duct are usually not involved.
    • Slit lamp findings
      • Pouted punctum
      • Plica may be swollen and congested.
      • Particulate canalicular discharge with or without concretions
  • Endophthalmitis
    • Gross observations
      • Conjunctival injection
      • Elevated tear meniscus
    • Slit lamp findings
      • Anterior chamber cells and flare
      • Hypopyon
      • Vitreous debris

Causes

More on Actinomycosis

Overview: Actinomycosis
Differential Diagnoses & Workup: Actinomycosis
Treatment & Medication: Actinomycosis
Follow-up: Actinomycosis
Multimedia: Actinomycosis
References
Further Reading
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References

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Further Reading

Polenakovik H. Actinomycosis. eMedicine Journal [serial online]. April 14, 2006; Available at: http://www.emedicine.com/Med/topic31.htm.

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Keywords

actinomycosis, Actinomycetales, Actinomycetaceae, Actinomycetes, Actinomyces, Actinomyces israelii, A israelii, keratoactinomycosis, keratitis, canaliculitis, anaerobic bacillus, Actinomyces gerencseriae, Actinomyces naeslundii, Actinomyces odontolyticus, Actinomyces viscosus, Actinomyces turicensis, Actinomyces meyeri, Propionibacterium propionicus, Actinobacillus actinomycetemcomitans, Prevotella, Fusobacterium, Bacteroides, Staphylococcus, Streptococcus, Enterobacteriaceae, actinophytosis

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Contributor Information and Disclosures

Author

Manolette R Roque, MD, MBA, DPBO, FPAO, President and CEO, Chief of Service, Ocular Immunology and Uveitis, Consulting Staff, Cornea and Refractive Surgery, Eye Republic Ophthalmology Clinic; General Manager, Ophthalmic Consultants Philippines Co; Consulting Staff, CME Liaison, Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, Asian Hospital and Medical Center
Manolette R Roque, MD, MBA, DPBO, FPAO is a member of the following medical societies: American Academy of Ophthalmic Executives, American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, American Society of Ophthalmic Administrators, American Uveitis Society, International Ocular Inflammation Society, Philippine Medical Association, Philippine Ocular Inflammation Society, and Philippine Society of Cataract and Refractive Surgery
Disclosure: Nothing to disclose.

Coauthor(s)

Barbara L Roque, MD, Full Partner, Ophthalmic Consultants Philippines Co, Chief of Service, Pediatric Ophthalmology and Strabismus, Consulting Staff, Orbit and Eye Plastics, Eye Republic Ophthalmology Clinic
Disclosure: Nothing to disclose.

C Stephen Foster, MD, FACS, FACR, FAAO, Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institution
C Stephen Foster, MD, FACS, FACR, FAAO is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Association of Immunologists, American College of Rheumatology, American College of Surgeons, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, American Uveitis Society, Association for Research in Vision and Ophthalmology, Massachusetts Medical Society, Royal Society of Medicine, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Jorge G Camara, MD, Professor of Ophthalmology, Department of Surgery, University of Hawaii John A Burns School of Medicine; Chairman, Department of Ophthalmology and Otorhinolaryngology, Director of Fellowship Training Program, St Francis Medical Center
Jorge G Camara, MD is a member of the following medical societies: American Academy of Ophthalmology and American Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Mark T Duffy, MD, PhD, Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Medical Director, Advanced Cosmetic Solutions, A BayCare Clinic
Mark T Duffy, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Sigma Xi, and Society for Neuroscience
Disclosure: Allergan - Botox Cosmetic Consulting fee Consulting; Quest medical - lacrimal balloons Honoraria Speaking and teaching; Ortho-Neutrogenia Consulting fee Consulting

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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