eMedicine Specialties > Ophthalmology > Infectious Disease

Actinomycosis

Manolette R Roque, MD, MBA, President and CEO, Service Chief of Ocular Immunology and Uveitis, Refractive Surgery, EYE REPUBLIC Ophthalmology Clinic; General Manager, Ophthalmic Consultants Philippines; Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, Asian Hospital and Medical Center; Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, St. Luke's Medical Center Global City; Senior Eye Surgeon, The LASIK Surgery Clinic
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

Updated: Oct 13, 2008

Introduction

Background

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 teeth.^3,4,5,6

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 trauma.⁷ 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 eye.²⁰

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 israelii.²²

Orbital actinomycosis

Painful ophthalmoplegia resulting from orbital actinomycosis has been reported.^{23,24,25,26,27}

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
  • Symptoms^8,9
    • 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.
• Canaliculitis^8,9
  • 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

• Infectious
  • Actinomyces species
  • See Background.

Differential Diagnoses

Other Problems to Be Considered

Propionibacterium propionicus canaliculitis
Candida species canaliculitis

Workup

Laboratory Studies

• Canalicular discharge and canaliculiths
  • Gram stain/Giemsa stain
  • Cultures and sensitivities (ie, blood agar, Sabouraud, anaerobic)
  • Special stains (ie, calcofluor white)
• Anterior chamber (aqueous fluid) aspirate
  • Gram stain/Giemsa stain
  • Cultures and sensitivities (ie, blood agar, Sabouraud, anaerobic)
• Vitreous samples
  • Gram stain/Giemsa stain
  • Cultures and sensitivities (ie, blood agar, Sabouraud, anaerobic)
  • Polymerase chain reaction
  • rRNA sequence analysis

Imaging Studies

• Distension dacryocystography: Contrast material is used to visualize the anatomic details of the lacrimal drainage system.
• Scanning electron microscopy
• High-resolution ultrasound (transducer frequency of 20 MHz): The 20-MHz scanner images may reveal pathological findings that are invisible during a slit lamp examination. Ultrasonic images of chronic canaliculitis show ectasia of the canaliculus and sulfur grains measuring 1-2 mm in diameter.^28,29,30,31
• Brain and orbital CT scan may be of use in cases of painful ophthalmoplegia.

Other Tests

• Probing may be performed with a lacrimal probe to check for a diverticulum and remaining casts.

Procedures

• Canaliculitis
  • A 2-snip punctoplasty may be performed under anesthesia.
  • Curettage may also be helpful in removing any adherent casts from the canaliculus.
  • Subsequent lacrimal irrigation with 2 MU of penicillin in 20 mL of sterile water may be helpful.
• Endophthalmitis: A diagnostic and therapeutic, 3-port, pars plana vitrectomy may be performed in cases where a diagnosis has not been achieved.

Histologic Findings

Histologic examination of the canaliculiths demonstrated that they consisted of solid casts of Actinomycetes with typical branching and filamentous structures. The organisms were found by using a Gram stain on the histopathologic preparations and by using a scanning electron microscopy.

Electron microscopic results of an actinomycosis of the lacrimal canaliculus were presented in 1980. The interior of the actinomycotic conglomerate showed no evidence of a cellular defense reaction, but, in the loosely woven outer network of hyphae, a massive granulocytic reaction was observed to be present. After phagocytosis, the structure of the actinomycotic microorganisms within the granulocytes was not significantly damaged. Within the tissue of the lacrimal canaliculus, adjacent to the actinomycotic conglomerate, an increased number of plasma cells were observed to be present; however, no organisms were present.

Treatment

Medical Care

• Keratitis: Actinomycetes are usually susceptible to penicillins and cephalosporins.^32,33,34,35 The treatment of keratoactinomycosis used to be excision of necrotic tissue, followed by cauterization. However, good results have been obtained by subconjunctival penicillin coadministered with systemic iodides. Alternatively, topical sulfacetamide or penicillin can be used.
• Canaliculitis: Actinomycetes are usually susceptible to penicillins and cephalosporins. Postoperatively, patients may be treated with topical cefazolin for 1 month. Adjunctive hyperbaric oxygen therapy for actinomycotic lacrimal canaliculitis has been reported.³⁶
• Endophthalmitis: Intraocular, periocular, topical, and systemic therapy.

Surgical Care

• Keratitis: All reported cases of keratoactinomycosis responded to therapy, which included intraocular, topical, and systemic antibiotics, as well as pars plana vitrectomy and partial iridectomy. Urgent keratoplasty for a corneal infection by Actinomyces species was reported in a 41-year-old man.
• Canaliculitis: Failure to resolve canaliculitis by using topical treatment requires surgical exploration of the canalicular system and removal of any casts.^8,15 Extensive surgery is not always required. A 2-snip punctoplasty, cast removal, curettage, probing, and adjunctive antibiotic therapy usually result in resolution of the canaliculitis. Cultivation of the surgically obtained dacryoliths and secretion enables reliable proof of Actinomyces and allows for an appropriate therapy for canaliculitis. Even though Actinomyces is sensitive to penicillin, cure of canaliculitis does not occur until all the concretions and the granulations that are present in the canaliculus are meticulously removed.
• Endophthalmitis: A diagnostic and therapeutic, 3-port, pars plana vitrectomy may be performed in cases where a diagnosis has not been achieved.²¹

Consultations

An external disease and cornea specialist may provide care for the anterior segment.

An oculoplastics consult may be required for eyelid and orbital involvement.

A posterior segment surgeon is necessary for endophthalmitis.

Medication

Actinomyces organisms are usually susceptible to penicillins and cephalosporins. Good results have been obtained by subconjunctival penicillin coadministered with systemic iodides. Alternatively, topical sulfacetamide or penicillin can be used.

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Penicillin G (Pfizerpen)

Exerts bactericidal action against penicillin-susceptible microorganisms during the stage of active multiplication. Acts by inhibiting biosynthesis of cell wall mucopeptide, rendering the cell wall osmotically unstable. Not active against penicillinase-producing bacteria, which include many strains of staphylococci

Dosing

Adult

Topical: 100,000-333,000 U/mL in topical
Subconjunctival: 0.5-1.0 million U/mL
Intravitreal injection: 2,000 U / 0.1 mL intravitreal injection, and probenecid 0.5 g PO qid (possible retinal toxicity)
Oral: 400,000 U PO qid (rarely used; poor stomach absorption)
IV: 2-6 million U IV q4h and probenecid 0.5 g PO qid
IM: Depends on formulation

Pediatric

Topical: 10,000-20,000 U/mL
IV: 50,000 U/kg/d IV divided bid/tid

Interactions

Probenecid can increase effects; coadministration of tetracyclines can decrease effects

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in impaired renal function

Cefazolin (Ancef, Kefzol, Zolicef)

First-generation cephalosporin with excellent activity against gram-positive cocci, including penicillinase-producing Staphylococcus aureus, penicillinase-producing Staphylococcus epidermidis, group A beta-hemolytic streptococci (Streptococcus pyogenes), group B streptococci (Streptococcus agalactiae), and Streptococcus pneumoniae. Ineffective against Bacteroides fragilis and only weak activity against gram-negative organisms.

Dosing

Adult

Topical: 133 mg/mL
Subconjunctival: 100 mg/mL
Intravitreal injection: 2.25 mg / 0.1 mL intravitreal injection, and probenecid 0.5 g PO qid
IV/IM: 500-1,000 mg IV/IM q6h

Pediatric

25-100 mg/kg/d IV/IM divided q6-8h depending on severity of infection; not to exceed 6 g/d

Interactions

Probenecid can increase effects of penicillin; coadministration of tetracyclines can decrease effects of penicillin

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Prolonged use may result in overgrowth of nonsusceptible organisms; caution in GI disease, particularly colitis

Antiparasitic agents

Parasite biochemical pathways are sufficiently different from the human host to allow selective interference by chemotherapeutic agents in relatively small doses.

Sulfacetamide sodium 10% (Sulamyd, Bleph-10)

N-acetyl-substituted derivative; at 30% solution, topical sulfacetamide has pH of 7.4 and has good tissue penetration.

Dosing

Adult

Solution: Instill 1-3 gtt in affected eye q2-3h, while awake, with less frequent administration at night
Ointment: Apply 0.5-inch ribbon into the conjunctival sac 1-4 times/d

Pediatric

<2 months: Not established
>2 months: Administer as in adults

Interactions

Effects of sulfonylurea hypoglycemic agents, hydantoin anticonvulsants, and oral anticoagulants increase when administered concurrently with sulfacetamide sodium; PABA antagonizes effects of sulfonamides; PABA esters (eg, procaine) may inhibit antibacterial effect of these agents; trimethoprim enhances effects of sulfacetamide

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in severely dry eye; ointment may retard corneal epithelial healing; if inflammation or pain persists >48 h or becomes aggravated, reevaluate therapy; adverse effects include local irritation, brow ache, blurred vision, transient burning and stinging, and sensitivity reactions (rare cases of Stevens-Johnson syndrome and exfoliative dermatitis have been reported); GI upset and bone marrow depression have been described

Follow-up

Further Outpatient Care

• Patients should receive follow-up care as needed.

Inpatient & Outpatient Medications

• Postoperatively, patients may be treated with topical cefazolin for 1 month.

Prognosis

• Prognosis is excellent once the organism is positively identified and appropriately treated.

Patient Education

• Patients should be advised to wear protective eye gear when working with vegetable matter.

Miscellaneous

Medicolegal Pitfalls

• Failure to properly identify the organism with subsequent appropriate medical and surgical management may lead to a persistent epiphora; intermittent, mucopurulent discharge; and a localized, tumorlike swelling on the involved site.

Multimedia

Media file 1: Canaliculitis of the left lower lid. Courtesy of Peter Rubin, MD, Director, Eye Plastics Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School.

Media file 2: Canaliculitis of the right upper lid. Courtesy of Peter Rubin, MD, Director, Eye Plastics Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School.

Media file 3: A pediatric patient with canaliculitis. Courtesy of Peter Rubin, MD, Director, Eye Plastics Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School.

Media file 4: A patient presenting with pseudocanaliculitis secondary to a chalazion. Courtesy of Peter Rubin, MD, Director, Eye Plastics Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School.

Media file 5: A patient presenting with pseudocanaliculitis secondary to a chalazion. Courtesy of Peter Rubin, MD, Director, Eye Plastics Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School.

Media file 6: Actinomyces israelii (non–spore-forming, gram-positive bacilli). Courtesy of Medical Education Information Center, Department of Pathology and Laboratory Medicine, The University of Texas-Houston Medical School.

Media file 7: Actinomyces israelii. (The image is labeled.)

Media file 8: Actinomycosis.

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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

Contributor Information and Disclosures

Author

Manolette R Roque, MD, MBA, President and CEO, Service Chief of Ocular Immunology and Uveitis, Refractive Surgery, EYE REPUBLIC Ophthalmology Clinic; General Manager, Ophthalmic Consultants Philippines; Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, Asian Hospital and Medical Center; Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, St. Luke's Medical Center Global City; Senior Eye Surgeon, The LASIK Surgery Clinic
Manolette R Roque, MD, MBA 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 and Director of Fellowship Training Program in Ophthalmic Plastic and Reconstructive Surgery for Countries Served by the Aloha Medical Mission, University of Hawaii John A Burns School of Medicine
Jorge G Camara, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, and American Society of Ophthalmic Plastic and Reconstructive Surgery
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.

The authors and editors of eMedicine gratefully acknowledge the assistance of Ryan I Huffman, MD, with the literature review and referencing for this article.

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

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