Actinomycosis 

  • Author: Jason F Okulicz, MD; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Aug 2, 2011
 

Background

Actinomycosis is a subacute-to-chronic bacterial infection caused by filamentous, gram-positive, non–acid-fast, anaerobic-to-microaerophilic bacteria. It is characterized by contiguous spread, suppurative and granulomatous inflammation, and formation of multiple abscesses and sinus tracts that may discharge sulfur granules. The most common clinical forms of actinomycosis are cervicofacial (ie, lumpy jaw), thoracic, and abdominal. In women, pelvic actinomycosis is possible.

For additional information on actinomycosis, see the articles Actinomycosis (dermatology focus), Actinomycosis (pediatrics focus), and Actinomycosis (ophthalmology focus).

Next

Pathophysiology

Actinomycetes are prominent among the normal flora of the oral cavity but less prominent in the lower gastrointestinal tract and female genital tract. Because these microorganisms are not virulent, they require a break in the integrity of the mucous membranes and the presence of devitalized tissue to invade deeper body structures and to cause human illness.

Furthermore, actinomycosis is generally a polymicrobial infection, with isolates numbering as many as 5-10 bacterial species. Establishment of human infection may require the presence of such companion bacteria, which participate in the production of infection by elaborating a toxin or enzyme or by inhibiting host defenses. These companion bacteria appear to act as copathogens that enhance the relatively low invasiveness of actinomycetes. Specifically, they may be responsible for the early manifestations of actinomycosis and for treatment failures.

Once infection is established, the host mounts an intense inflammatory response (ie, suppurative, granulomatous), and fibrosis may then follow. Infection typically spreads contiguously, frequently ignoring tissue planes and invading surrounding tissues or organs. Ultimately, the infection produces draining sinus tracts. Hematogenous dissemination to distant organs may occur in any stage of actinomycosis, whereas lymphatic dissemination is unusual.

Cervicofacial actinomycosis

Cervicofacial actinomycosis is the most common type of the infection, comprising 50-70% of reported cases. This infection typically occurs following oral surgery or in patients with poor dental hygiene. Cervicofacial actinomycosis is characterized in the initial stages by soft-tissue swelling of the perimandibular area. Direct spread into the adjacent tissues occurs over time, along with development of fistulas (sinus tracts) that discharge purulent material containing granules with a yellow sulfurlike appearance (termed sulfur granules). Invasion of the cranium or the bloodstream may occur if the disease is left untreated.

Thoracic actinomycosis

Thoracic actinomycosis accounts for 15-20% of cases. Aspiration of oropharyngeal secretions containing actinomycetes is the usual mechanism of infection. Occasionally, thoracic actinomycosis results from the introduction of organisms via esophageal perforation, by direct spread from an actinomycotic process of the neck or abdomen, or via hematogenous spread from a distant lesion. Thoracic actinomycosis commonly presents as a pulmonary infiltrate or mass, which, if left untreated, can spread to involve the pleura, pericardium, and chest wall, ultimately leading to the formation of sinuses that discharge sulfur granules.

Actinomycosis of the abdomen and pelvis

Actinomycosis of the abdomen and pelvis accounts for 10-20% of reported cases. Typically, these patients have a history of recent or remote bowel surgery (eg, perforated acute appendicitis, perforated colonic diverticulitis following trauma to the abdomen) or ingestion of foreign bodies (eg, chicken or fish bones), during which actinomycetes are introduced into the deep tissues. The ileocecal region is involved most frequently, and the disease typically presents as a slowly growing tumor. Diagnosis is usually established postoperatively, following exploratory laparotomy for a suspected malignancy. Involvement of any abdominal organ, including the abdominal wall, can occur by direct spread, with eventual formation of draining sinuses. Pelvic actinomycosis most commonly ascends from the uterus in association with intrauterine contraceptive devices (IUCDs). In such cases, an IUCD has been in place for an average of 8 years.

Previous
Next

Epidemiology

Frequency

United States

Actinomycosis is rare. During the 1970s, the reported annual incidence of actinomycosis in the Cleveland area was 1 case per 300,000 persons. Improved dental hygiene and widespread use of antibiotics for various infections have probably contributed to the declining incidence of this disease.

International

Actinomycosis occurs worldwide, with likely higher prevalence rates in areas with low socioeconomic status and poor dental hygiene.

Mortality/Morbidity

The availability of antibiotics has greatly improved the prognosis of all forms of actinomycosis. At present, cure rates are high, and neither deformity nor death is common.

Race

Actinomycosis has no racial predilection.

Sex

For unknown reasons, actinomycosis is more common in men than in women (male-to-female ratio, 3:1), with the exception of pelvic actinomycosis.

Age

Actinomycosis can affect people of all ages, but most cases are reported in young to middle-aged adults (aged 20-50 y).

Previous
Proceed to Clinical Presentation
 
 
Contributor Information and Disclosures
Author

Jason F Okulicz, MD  Assistant Professor of Medicine, Uniformed Services University of the Health Sciences; Staff, Infectious Disease Service, Brooke Army Medical Center

Jason F Okulicz, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Coauthor(s)

Hari Polenakovik, MD  Assistant Professor of Medicine, Wright State University, Boonshoft School of Medicine

Hari Polenakovik, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Society for Microbiology, European Society of Clinical Microbiology and Infectious Diseases, Infectious Diseases Society of America, and Society for Healthcare Epidemiology of America

Disclosure: Nothing to disclose.

Sylvia Polenakovik, MD  Clinical Instructor, Internist, Department of Internal Medicine, Wayne Hospital, Wright State University, Boonshoft School of Medicine

Sylvia Polenakovik, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine and American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Daniel R Lucey, MD, MPH  Chief, Fellowship Program Director, Department of Internal Medicine, Division of Infectious Diseases, Washington Hospital Center; Professor, Department of Internal Medicine, Uniformed Services University of the Health Sciences

Daniel R Lucey, MD, MPH is a member of the following medical societies: Alpha Omega Alpha and American College of Physicians

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Joseph F John Jr, MD, FACP, FIDSA, FSHEA  Clinical Professor of Medicine, Molecular Genetics and Microbiology, Medical University of South Carolina College of Medicine; Associate Chief of Staff for Education, Ralph H Johnson Veterans Affairs Medical Center

Disclosure: Nothing to disclose.

Eleftherios Mylonakis, MD  Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital

Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

References

  1. Hall V. Actinomyces--gathering evidence of human colonization and infection. Anaerobe. Feb 2008;14(1):1-7. [Medline].

  2. Ruggiero SL, Mehrotra B, Rosenberg TJ, Engroff SL. Osteonecrosis of the jaws associated with the use of bisphosphonates: a review of 63 cases. J Oral Maxillofac Surg. May 2004;62(5):527-34. [Medline].

  3. Markiewicz MR, Margarone JE 3rd, Campbell JH, Aguirre A. Bisphosphonate-associated osteonecrosis of the jaws: a review of current knowledge. J Am Dent Assoc. Dec 2005;136(12):1669-74. [Medline].

  4. Hansen T, Kunkel M, Weber A, James Kirkpatrick C. Osteonecrosis of the jaws in patients treated with bisphosphonates - histomorphologic analysis in comparison with infected osteoradionecrosis. J Oral Pathol Med. Mar 2006;35(3):155-60. [Medline].

  5. Westhoff C. IUDs and colonization or infection with Actinomyces. Contraception. Jun 2007;75(6 Suppl):S48-50. [Medline].

  6. Sung HY, Lee IS, Kim SI, Jung SE, Kim SW, Kim SY. Clinical Features of Abdominal Actinomycosis: A 15-year Experience of A Single Institute. J Korean Med Sci. Jul 2011;26(7):932-7. [Medline].

  7. Sudhakar SS, Ross JJ. Short-term treatment of actinomycosis: two cases and a review. Clin Infect Dis. Feb 1 2004;38(3):444-7. [Medline].

  8. Macfarlane DJ, Tucker LG, Kemp RJ. Treatment of recalcitrant actinomycosis with ciprofloxacin. J Infect. Sep 1993;27(2):177-80. [Medline].

  9. Ferreira Dde F, Amado J, Neves S, Taveira N, Carvalho A, Nogueira R. Treatment of pulmonary actinomycosis with levofloxacin. J Bras Pneumol. Apr 2008;34(4):245-8. [Medline].

  10. Apotheloz C, Regamey C. Disseminated infection due to Actinomyces meyeri: case report and review. Clin Infect Dis. Apr 1996;22(4):621-5. [Medline].

  11. Arend SM, Oosterhof H, van Dissel JT. Actinomyces and the intrauterine device. Arch Intern Med. Jun 8 1998;158(11):1270. [Medline].

  12. Belmont MJ, Behar PM, Wax MK. Atypical presentations of actinomycosis. Head Neck. May 1999;21(3):264-8. [Medline].

  13. Brown JR. Human actinomycosis. A study of 181 subjects. Hum Pathol. Sep 1973;4(3):319-30. [Medline].

  14. Cayley J, Fotherby K, Guillebaud J, et al. Recommendations for clinical practice: actinomyces like organisms and intrauterine contraceptives. The Clinical and Scientific Committee. Br J Fam Plann. Jan 1998;23(4):137-8. [Medline].

  15. Chaudhry SI, Greenspan JS. Actinomycosis in HIV infection: a review of a rare complication. Int J STD AIDS. Jun 2000;11(6):349-55. [Medline].

  16. Choi J, Koh WJ, Kim TS, et al. Optimal duration of IV and oral antibiotics in the treatment of thoracic actinomycosis. Chest. Oct 2005;128(4):2211-7. [Medline].

  17. Chouabe S, Perdu D, Deslee G, et al. Endobronchial actinomycosis associated with foreign body: four cases and a review of the literature. Chest. Jun 2002;121(6):2069-72. [Medline].

  18. Cintron JR, Del Pino A, Duarte B, Wood D. Abdominal actinomycosis. Dis Colon Rectum. Jan 1996;39(1):105-8. [Medline].

  19. Clarridge JE, Zhang Q. Genotypic diversity of clinical Actinomyces species: phenotype, source, and disease correlation among genospecies. J Clin Microbiol. Sep 2002;40(9):3442-8. [Medline].

  20. Colmegna I, Rodriguez-Barradas M, Rauch R, Clarridge J, Young EJ. Disseminated Actinomyces meyeri infection resembling lung cancer with brain metastases. Am J Med Sci. Sep 2003;326(3):152-5. [Medline].

  21. Curi MM, Dib LL, Kowalski LP, et al. Opportunistic actinomycosis in osteoradionecrosis of the jaws in patients affected by head and neck cancer: incidence and clinical significance. Oral Oncol. May 2000;36(3):294-9. [Medline].

  22. de Montpreville VT, Nashashibi N, Dulmet EM. Actinomycosis and other bronchopulmonary infections with bacterial granules. Ann Diagn Pathol. Apr 1999;3(2):67-74. [Medline].

  23. Endo S, Murayama F, Yamaguchi T, et al. Surgical considerations for pulmonary actinomycosis. Ann Thorac Surg. Jul 2002;74(1):185-90. [Medline].

  24. Felekouras E, Menenakos C, Griniatsos J, et al. Liver resection in cases of isolated hepatic actinomycosis: case report and review of the literature. Scand J Infect Dis. 2004;36(6-7):535-8. [Medline].

  25. Fife TD, Finegold SM, Grennan T. Pericardial actinomycosis: case report and review. Rev Infect Dis. Jan-Feb 1991;13(1):120-6. [Medline].

  26. Hamid D, Baldauf JJ, Cuenin C, Ritter J. Treatment strategy for pelvic actinomycosis: case report and review of the literature. Eur J Obstet Gynecol Reprod Biol. Apr 2000;89(2):197-200. [Medline].

  27. Hansen T, Kunkel M, Kirkpatrick CJ, Weber A. Actinomyces in infected osteoradionecrosis--underestimated?. Hum Pathol. Jan 2006;37(1):61-7. [Medline].

  28. Hsieh MJ, Liu HP, Chang JP, Chang CH. Thoracic actinomycosis. Chest. Aug 1993;104(2):366-70. [Medline].

  29. Huang KL, Beutler SM, Wang C. Endocarditis due to Actinomyces meyeri. Clin Infect Dis. Oct 1998;27(4):909-10. [Medline].

  30. Kim JC, Ahn BY, Kim HC, et al. Efficiency of combined colonoscopy and computed tomography for diagnosis of colonic actinomycosis: a retrospective evaluation of eight consecutive patients. Int J Colorectal Dis. Aug 2000;15(4):236-42. [Medline].

  31. Kim TS, Han J, Koh WJ, et al. Thoracic Actinomycosis: CT Features with Histopathologic Correlation. AJR Am J Roentgenol. Jan 2006;186(1):225-31. [Medline].

  32. Kuijper EJ, Wiggerts HO, Jonker GJ, et al. Disseminated actinomycosis due to Actinomyces meyeri and Actinobacillus actinomycetemcomitans. Scand J Infect Dis. 1992;24(5):667-72. [Medline].

  33. Lequerre T, Nouvellon M, Kraznowska K, et al. Septic arthritis due to Actinomyces naeslundii: report of a case. Joint Bone Spine. Oct 2002;69(5):499-501. [Medline].

  34. Lippes J. Pelvic actinomycosis: a review and preliminary look at prevalence. Am J Obstet Gynecol. Feb 1999;180(2 Pt 1):265-9. [Medline].

  35. Litwin KA, Jadbabaie F, Villanueva M. Case of pleuropericardial disease caused by Actinomyces odontolyticus that resulted in cardiac tamponade. Clin Infect Dis. Jul 1999;29(1):219-20. [Medline].

  36. Mabeza GF, Macfarlane J. Pulmonary actinomycosis. Eur Respir J. Mar 2003;21(3):545-51. [Medline].

  37. Macfarlane DJ, Tucker LG, Kemp RJ. Treatment of recalcitrant actinomycosis with ciprofloxacin. J Infect. Sep 1993;27(2):177-80. [Medline].

  38. Oostman O, Smego RA. Cervicofacial Actinomycosis: Diagnosis and Management. Curr Infect Dis Rep. May 2005;7(3):170-174. [Medline].

  39. Pulverer G, Schutt-Gerowitt H, Schaal KP. Human cervicofacial actinomycoses: microbiological data for 1997 cases. Clin Infect Dis. Aug 15 2003;37(4):490-7. [Medline].

  40. Reddy I, Ferguson DA Jr, Sarubbi FA. Endocarditis due to Actinomyces pyogenes. Clin Infect Dis. Dec 1997;25(6):1476-7. [Medline].

  41. Rothschild B, Naples V, Barbian L. Bone manifestations of actinomycosis. Ann Diagn Pathol. Feb 2006;10(1):24-27. [Medline].

  42. Sabbe LJ, Van De Merwe D, Schouls L, et al. Clinical spectrum of infections due to the newly described Actinomyces species A. turicensis, A. radingae, and A. europaeus. J Clin Microbiol. Jan 1999;37(1):8-13. [Medline].

  43. Scarano FJ, Ruddat MS, Robinson A. Actinomyces viscosus postoperative endophthalmitis. Diagn Microbiol Infect Dis. Jun 1999;34(2):115-7. [Medline].

  44. Schaal KP, Lee HJ. Actinomycete infections in humans--a review. Gene. Jun 15 1992;115(1-2):201-11. [Medline].

  45. Schaal KP, Pape W. Special methodological problems in antibiotic susceptibility testing of fermentative actinomycetes. Infection. 1980;8 Suppl 2:S176-82. [Medline].

  46. Sharma M, Briski LE, Khatib R. Hepatic actinomycosis: an overview of salient features and outcome of therapy. Scand J Infect Dis. 2002;34(5):386-91. [Medline].

  47. Smego RA Jr, Foglia G. Actinomycosis. Clin Infect Dis. Jun 1998;26(6):1255-61; quiz 1262-3. [Medline].

  48. Smith AJ, Hall V, Thakker B, Gemmell CG. Antimicrobial susceptibility testing of Actinomyces species with 12 antimicrobial agents. J Antimicrob Chemother. Aug 2005;56(2):407-9. [Medline].

  49. Soria-Aledo V, Flores-Pastor B, Carrasco-Prats M, et al. Abdominopelvic actinomycosis: a serious complication in intrauterine device users. Acta Obstet Gynecol Scand. Sep 2004;83(9):863-5. [Medline].

  50. Wagenlehner FM, Mohren B, Naber KG, Mannl HF. Abdominal actinomycosis. Clin Microbiol Infect. Aug 2003;9(8):881-5. [Medline].

  51. Warren NG. Actinomycosis, nocardiosis, and actinomycetoma. Dermatol Clin. Jan 1996;14(1):85-95. [Medline].

  52. Weese WC, Smith IM. A study of 57 cases of actinomycosis over a 36-year period. A diagnostic 'failure' with good prognosis after treatment. Arch Intern Med. Dec 1975;135(12):1562-8. [Medline].

  53. Wust J, Steiger U, Vuong H, Zbinden R. Infection of a hip prosthesis by Actinomyces naeslundii. J Clin Microbiol. Feb 2000;38(2):929-30. [Medline].

  54. Xia T, Baumgartner JC. Occurrence of Actinomyces in infections of endodontic origin. J Endod. Sep 2003;29(9):549-52. [Medline].

  55. Yung BC, Cheng JC, Chan TT, et al. Aggressive thoracic actinomycosis complicated by vertebral osteomyelitis and epidural abscess leading to spinal cord compression. Spine. Mar 15 2000;25(6):745-8. [Medline].

 
Previous
Next
 
Actinomycosis in the endometrial tissue, low-power view. Image courtesy of Paul Gibbs, MD.
Actinomycosis in the endometrial tissue, high-power view. Image courtesy of Paul Gibbs, MD.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.