Actinomycosis Clinical Presentation

Updated: Oct 10, 2019
  • Author: Jason F Okulicz, MD, FACP, FIDSA; Chief Editor: Michael Stuart Bronze, MD  more...
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Presentation

History

Cervicofacial actinomycosis

Cervicofacial actinomycosis (ie, lumpy jaw) may have the following features:

  • 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 use [1, 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

Thoracic actinomycosis may have the following features:

  • 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

Abdominal actinomycosis may have the following features:

  • 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

Pelvic actinomycosis may have the following features:

  • History of IUCD

  • Lower abdominal discomfort, abnormal vaginal bleeding or discharge

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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

Findings may include the following:

  • 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

Findings may include the following:

  • 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

Findings may include the following:

  • Pelvic mass

  • Menometrorrhagia

  • Other manifestations, as in abdominal actinomycosis

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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. The continued development of advanced molecular methods has led to the identification of additional Actinomyces species isolated from human material, with a total of 25 Actinomyces and Actinomyces-like organisms emerging as potential causes of infection at various body sites. [5] 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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Complications

See the list below:

  • Osteomyelitis of the mandible, ribs, and vertebrae

  • CNS disease, including brain abscess; chronic meningitis; actinomycetoma; cranial, epidural, and subdural infection; and spinal epidural infection

  • Hepatic actinomycosis

  • Disseminated actinomycosis

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