Actinomyces diagnosis and management

Actinomyces diagnosis and management

Actinomyces diagnosis and management

Actinomyces species, despite their name, are bacteria which are often confused with fungi because of their filamentousappearance and their propensity to produce chronic suppurative infection with sinuses discharging purulent material.Most human disease is caused by Actinomyces israelii,an oral commensal, and occurs in the presence of chroniclack of dental hygiene. The characteristic pathological feature is that tissue boundaries are crossed and bone isinfected. There is a fibrotic reaction around suppurating areas which accounts for the induration detected in palpablelesions. Three major forms of disease occur: cervicofacial,thoracic and disseminated actinomycosis.In cervicofacial actinomycosis the characteristic lesion isa painless swelling below the border of the mandible,bluish, fluctuant and slowly enlarging. Sometimes the abscess is painful and is usually apparent long before thereis any spontaneous discharge.Thoracic actinomycosis may result from aspiration oforal debris, or may occur after thoracic surgery; it is easilyconfused with carcinoma. The chest radiograph shows unilateralconsolidation, with evidence of chest wall involvement.Nowadays the disease is usually diagnosed before discharging sinuses develop.Actinomycosis may be disseminated haematogenouslyand lesions may occur at almost any site. The abdomenis the most common, usually in the ileocaecal region.Because of the chronic course and the difficulty of diagnosis,sinus or fistula formation is still seen in abdominal actinomycosis. Other rare sites of infection are the pelvis,CNS and bones.

Diagnosis and management Microscopy of tissues reveals the Gram-positive organisms,with surrounding acute or chronic inflammatoryreaction and foamy macrophages. The organism can becultured from tissues and, rarely, from blood.Penicillin is the drug of choice and prolonged treatmentin high dose is necessary. Intravenous administration of2.4-3.6 g every 6 hours for 4-6 weeks is followed by oraltreatment with amoxicillin 500 mg every 8 hours for at least6 months. Tetracycline, erythromycin and chloramphenicolare alternatives in penicillin-allergic subjects. Relapse isuncommon if this rigorous approach is adopted. Surgery israrely required but may have to be considered in severelyill patients who fail to respond to medical therapy, and possibly in those with CNS disease.

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