Actinomycosis A42.9

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Synonym(s)

Actinomycosis; Cervicofacial Primary Cutaneous Actinomycosis; Cutaneous actinomycosis; Leptotrichosis; Lumpy Jaw; primary cutaneous actinomycosis; Radiation fungal disease; Streptotrichosis

History
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Israel 1878; Bollinger 1877

Definition
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Globally occurring, rare (constantly decreasing in industrialized countries), endogenous (mostly after dental surgery), bacterial (mixed) infectious disease caused by a facultative pathogen (Actinomyces israelii) occurring in the physiological oral cavity flora which causes the infection in connection with symbiotic accompanying bacteria.

Pathogen
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Anaerobic, Gram-positive and Grocott-positive pathogens, especially Actinomyces israelii, more rarely Actinomyces naeslundi and Actinomyces radingae; Actinomyces bovi also occurs in humans in individual cases. Always mixed infections(staphylococci, streptococci, Pseudomonas aeruginosa, Fusobacteria, etc.).

Classification
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According to the localization of the manifestations 3 forms are distinguished:

  • Cervicofacial actinomycosis: about 80-85% of all cases.
  • Thoracic actinomycosis: about 13-15% of all cases.
  • Abdominal actinomycosis: about 3% of all cases
  • Other (see casuistry)

Occurrence/Epidemiology
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Worldwide appearance. It occurs more frequently among the rural population than among the urban population. More common in developing countries, but very rare in industrialized countries due to the more frequent use of antibiotics.

m:w=3:1;

Manifestation
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Especially 20-40. LJ.

Localization
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Mostly in the soft tissues of the face and neck region (cervico-facial form); also thorax (thoracic form), abdomen (abdominal form), arms or buttocks.

Clinical features
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incubation period: about 4 weeks

The infection often spreads from the depth of the lower jaws to the skin. Fever and local pain can be accompanying symptoms.

On the skin (more rarely on the mucous membrane: macroglossia) and the deep tissue there are hard, blue-red, infiltrated indurations and nodules with a tendency to ulceration or melting with a tendency to fistulas and pronounced scarring. Often adhesions in the surrounding tissue. In the exiting pus macroscopically recognizable, 0.2-0.5 cm large, irregularly shaped, yellowish, solid grains ( drusen) can already be seen. No spontaneous healing tendency.

Histology
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Non-specific granulation tissue with eosinophil granulocytes or plasma cells. Partially leukocyte-rich fusion necroses. The granules (drusen), which are almost pathognomic for actinomycosis, can be detected in melting abscesses also in HE section. The individual actinomycetes are sintered together in the centre, where they are not recognisable as individual elements. Only in the periphery are individual, thread-like structures detectable. In addition to the HE staining, the Grocott method is recommended for the visualisation of the drusen.

Diagnosis
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Clinic, histology from a deep excision biopsy (punch biopsies are not sufficient with regard to their depth), detection of drusen in smears from fistula ladder in Gram staining, cultivation of the pathogen from smears or from biopsy and resistogram (increasing antibiotic resistance!), detection of the pathogen by PCR.

Differential diagnosis
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Tuberculous abscesses

syphilitic gums

chronic pyoderma

Dentogenic fistulas

Osteomyelitis

Oral floor phlegmon.

When sitting on the buttocks: Acne conglobata or Hidradenitis suppurativa

venereal lymphogranuloma

Complication(s)
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Oral floor phlegmon, lockjaw. Miliary seeding can occur in rare cases.

Therapy
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Combination of surgical and chemotherapeutic procedures.

Internal therapy
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Antibiotic therapy for weeks or months.

  • The drug of first choice is penicillin G: benzylpenicillin (e.g. penicillin Grünenthal) initially as a short infusion twice a day 10 million IU i.v. over at least 4-6 weeks. Then phenoxypenicillin (e.g. Baycillin Mega) 2-5 million IU/day p.o. over 4-6 months or benzathine penicillin (e.g. Tardocillin 1200), 2 ampoules i.m. every 4 weeks.
  • Alternatively ampicillin (e.g. Binotal) 4 times/day 0.5-1.0 g p.o. or 100-150 mg/kg bw/day i.v. over at least 4-6 weeks.
  • Alternative: Cephalosporin for parenteral application is especially recommended Cefoxitin (e.g. Mefoxitin) 3-4 times/day 1.0-2.0 g i.v. because of its broad spectrum and the special anaerobic component.
  • Alternatively: Tetracycline (e.g. Tetracycline-ratiopharm) 3-4 times/day 0.5 g p.o. over 4-6 weeks or Lincomycin (e.g. Albiotic) 3-4 times/day 500 mg p.o. or 3-4 times/day 600 mg/day i.v.
  • In case of mixed infections with staphylococci or other anaerobes, flucloxacillin (e.g. Staphylex Kps.) is additionally applied 3-4 times/day 0.5-1.0 g p.o., i.m. or i.v. Alternatively, clindamycin (e.g. sobelin) can be applied 3-4 times/day 300 mg p.o. or 3-4 times/day 600 mg i.v.
  • In case of resistance to therapy, it is recommended to cultivate the pathogen and to treat it with resistogram-adapted therapy.

Operative therapie
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Incision and drainage of abscesses, excision of chronic fibrotic tissue that is not supplied with blood.

Progression/forecast
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Highly chronic course; no impairment of the general condition; however, the board-like infiltrates and osteomyelitis lead to retracted and disfiguring scars. Cervical actinomycosis has a favourable prognosis if diagnosed in time and treated sufficiently (Jeong YJ et al. 2017).

Case report(s)
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In a 44-year-old patient a largely symptom-free, 3x2cm red, exulcerated induration developed on the outside of the right upper arm after a slight dog bite for more than half a year. In the course of this time a nodular size progression occurred, with increasing ulceration and constant purulent secretion. An analogous focal point appeared on the left (!) arm. Laboratory examination revealed leukocytosis (11,500/ml), as well as increased inflammatory parameters (BSG: 35/h; CRP:5.2mg/dl). A peroral antibiotic therapy with clindamycin did not show any improvement. A deep excision biopsy revealed deep granulation tissue with neutrophil abscesses. No evidence of drusen. However, a microbiological examination of the tissue carried out at the same time led to the detection of Actinomyces naeslundi. The germ was resistant to clindamycin. The antibiotic therapy was changed to a combination treatment with moxifloxacin and ampicillin/sulbactam. Including healing of the findings after 6 weeks.

Literature
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  1. Charalabopoulos K et al (2003) Lung, pleural and colon actinomycosis in an immunocompromised patient: a rare form of presentation. Chemotherapy 49: 209-211
  2. Chaudhry SI, Greenspan JS (2000) Actinomycosis in HIV infection: a review of a rare complication. Int J STD AIDS 11: 349-355
  3. Clarridge JE 3rd, Zhang Q (2002) Genotypic diversity of clinical Actinomyces species: phenotype, source, and disease correlation among genospecies. J Clin Microbiol 40: 3442-3448
  4. Cocuroccia B et al (2003) Primary cutaneous actinomycosis of the forehead. J Eur Acad Dermatol Venereol 17: 331-333
  5. Israel JA (1885) Clinical contributions to the knowledge of actinomycosis in humans. A. Hirschwald (Berlin), S. 152 pp
  6. Israel JA (1885) Clinical contributions to the knowledge of actinomycosis in humans. Z Klin Med 6: 392
  7. Jeong YJ et al (2017) Cervicofacial Primary Cutaneous Actinomycosis: Surgical Treatment for Complete Remission of the Disease. J Craniofac Surg 28:e269-e271.
  8. Kobayashi KI et al.(2019) Erysipelothrix rhusiopathiae bacteremia following a cat bite.
    IDCases 18:e00631.
  9. Kodali U et al (2003) Abdominal actinomycosis presenting as lower gastrointestinal bleeding. Endoscopy 35: 451-453
  10. Olson JM et al (2013) Primary cutaneous Actinomyces neuii infection of the breast successfully treated with doxycycline. Cutis 92:E3-E4
  11. Park JK et al (2003) Cervicofacial actinomycosis: CT and MR imaging findings in seven patients. AJNR Am J Neuroradiol 24: 331-335
  12. Tedeschi A et al (2003) A case of pelvic actinomycosis presenting as cutaneous fistula. Eur J Obstet Gynecol Reprod Biol 108: 103-105
  13. Varga R et al (2012) Primary cutaneous actinomycosis of the femorogluteal region: two case reports. Acta Derm Venereol 92:445-446

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Last updated on: 29.10.2020