eMedicine Specialties > Infectious Diseases > Bacterial Infections
Actinomycosis
Updated: Feb 24, 2009
Introduction
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 in eMedicine’s Dermatology volume, Actinomycosis in eMedicine’s Pediatrics: General Medicine volume, and Actinomycosis in eMedicine’s Ophthalmology volume.
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.
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).
Clinical
History
- Cervicofacial actinomycosis (ie, lumpy jaw)
- History of dental manipulation or trauma to the mouth, poor oral hygiene, dental caries, or periodontal disease; may arise following local tissue damage caused by neoplasm or by osteonecrosis of the jaw or maxilla due to radiation treatment or bisphosphonate use1,2,3,4
- Painless or occasionally painful soft-tissue swelling involving the submandibular or perimandibular region; over time, multiple sinuses drain pus containing sulfur granules; tendency to remit and recur
- Reddish or bluish discoloration of the skin overlying the lesion
- Chewing difficulties (ie, with involvement of mastication muscles)
- Thoracic actinomycosis
- History of aspiration (Risk factors include seizure disorder, alcoholism, and poor dental hygiene.)
- Dry or productive cough, occasionally blood-streaked sputum, shortness of breath, chest pain
- Fever, weight loss, fatigue, anorexia
- Abdominal actinomycosis
- History of abdominal surgery, perforated viscus, mesenteric vascular insufficiency, or ingestion of foreign bodies (eg, fish or chicken bones)
- Nonspecific symptoms; the most common symptoms are as follows:
- Low-grade fever
- Weight loss
- Fatigue
- Change in bowel habits
- Vague abdominal discomfort
- Nausea
- Vomiting
- Sensation of a mass
- Pelvic actinomycosis
- History of IUCD
- Lower abdominal discomfort, abnormal vaginal bleeding or discharge
Physical
- Cervicofacial actinomycosis
- Patients with cervicofacial actinomycosis present with nodular lesion(s), usually located at the angle of the jaw. These gradually increase in size and number (ie, multiple abscesses), and ultimately form sinuses that open onto the cheek or submandibular area. Sulfur granules may be seen in the exudate.
- Nodules may be tender in the initial stages are typically nontender and woody hard in the later stages.
- Lymphadenopathy is typically absent.
- Trismus is present if the mastication muscles are involved.
- Fever is variably present.
- Thoracic actinomycosis
- Fever, cachexia, abnormal breath sounds, cough (dry or productive of purulent sputum), hemoptysis
- Sinus tracts with drainage from the chest wall (ie, pleurocutaneous fistula)
- Abdominal actinomycosis
- Scar(s) from antecedent abdominal surgery
- Low-grade fever and cachexia (variably present)
- Mass most often located in the right lower quadrant, less frequently in the left lower quadrant; mass typically firm-to-hard in consistency, nontender, often fixed to underlying tissue
- Sinus tracts with drainage from either the abdominal wall (ie, peritoneocutaneous fistula) or the perianal region
- Pelvic actinomycosis
- Pelvic mass
- Menometrorrhagia
- Other manifestations, as in abdominal actinomycosis
Causes
Actinomycosis is caused by filamentous, gram-positive, non–acid-fast, non–spore-forming bacteria. They belong to the order of Actinomycetales, family Actinomycetaceae, genus Actinomyces. Members of the genera Propionibacterium, Actinobaculum, and Bifidobacterium may cause similar clinical syndromes. Actinomyces organisms grow slowly in anaerobic-to-microaerophilic conditions, forming colonies with a characteristic molar tooth appearance. The most common isolated species are Actinomyces israeli, Actinomyces gerencseriae, Actinomyces turicensis, Actinomyces radingae, and Actinomyces europaeus, followed by Actinomyces naeslundii, Actinomyces odontolyticus, Actinomyces viscosus, Actinomyces meyeri, and Propionibacterium propionicum.
In addition to these microorganisms, almost all actinomycotic lesions contain so-called companion bacteria. The most important of these bacteria is Actinobacillus actinomycetemcomitans, followed by Peptostreptococcus, Prevotella, Fusobacterium, Bacteroides, Staphylococcus, and Streptococcus species, and Enterobacteriaceae, depending on the location of actinomycotic lesions. These companion bacteria appear to magnify the low pathogenic potential of actinomycetes.
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Further Reading
Keywords
actinomycosis, cervicofacial actinomycosis, thoracic actinomycosis, abdominal actinomycosis, pelvic actinomycosis, Actinomyces israeli, Actinomyces gerencseriae, Actinomyces naeslundii, Actinomyces odontolyticus, Actinomyces viscosus, Actinomyces turicensis, Actinomyces meyeri, A israeli, A gerencseriae, A naeslundii, A odontolyticus, A viscosus, A turicensis, A meyeri, Propionibacterium propionicus, Actinobacillus actinomycetemcomitans, Prevotella, Fusobacterium, Bacteroides, Staphylococcus, Streptococcus, Enterobacteriaceae, actinomycetes, actinophytosis, lumpy jaw, hepatic actinomycosis, disseminated actinomycosis
