Actinomycosis¶
Chapter 180 | Harrison's 22e · Part 5 – Infectious Diseases: Bacterial
Detailed clinical reference synthesised from Harrison's Principles of Internal Medicine, 22nd Edition
🔑 Key Clinical Points¶
- See source text for full details
📑 Table of Contents¶
📋 Figures in This Chapter¶
| # | Type | Description |
|---|---|---|
| 1 | 🔀 Flowchart | Microscopic evaluation of actinomycotic sulfur granules |
| 1 | 🖼 Figure | Thoracic actinomycosis |
| 2 | 🖼 Figure | Computed tomogram showing pelvic actinomycosis associated with in an intrauterine contraceptive device |
| 3 | 🖼 Figure | Bisphosphonate-associated maxillary osteomyelitis due to Actinomyces to viscosus |
| 4 | 🖼 Figure | Thoracic actinomycosis |
| 5 | 🖼 Figure | Thoracic actinomycosis |
| 6 | 🖼 Figure | Thoracic actinomycosis |
RAW CONTENT¶
[PAGE 1363] Actinomycosis 1363 CHAPTER 180 who receive bisphosphonate treatment (see “Oral–Cervicofacial Disease,” 180 Actinomycosis below) are probably at higher risk. ■ PATHOGENESIS AND PATHOLOGY Thomas A. Russo, John C. Hu The etiologic agents of actinomycosis are members of the normal oral flora and are often cultured from the bronchi, the gastrointestinal tract, and the female genital tract. The critical step in the development Actinomycosis is uncommon, and most physicians’ personal experi- of actinomycosis is disruption of the mucosal barrier. Local infection ence with its clinical presentations is limited. Laboratory identification may ensue. Once established, actinomycosis spreads contiguously in of the etiologic agents from the order Actinomycetales is not routine. a slow, progressive manner, ignoring tissue planes. Although acute Thus, actinomycosis remains a diagnostic challenge, even for a skilled inflammation may initially develop at the infection site, the hallmark clinician. However, this infection is usually curable with medical of actinomycosis is the characteristic chronic, indolent phase mani- therapy alone. Therefore, an awareness of the full spectrum of clinical fested by lesions that usually appear as single or multiple indurations. syndromes can expedite diagnosis and treatment and minimize unnec- Central necrosis consisting of neutrophils and sulfur granules develops essary surgical interventions, morbidity, and mortality. and is virtually diagnostic. The fibrotic walls of the mass are typically Classical actinomycosis is an indolent, slowly progressive infection described as “wooden.” The responsible bacterial and/or host factors caused by anaerobic or microaerophilic bacteria, primarily of the genus have not been identified. Over time, sinus tracts to the skin, adjacent Actinomyces, that colonize the mouth, colon, and vagina. Mucosal dis- organs, or bone may develop. In rare instances, distant hematogenous ruption may lead to infection at virtually any site in the body. In vivo seeding may occur; lymphatic spread and associated lymphadenopathy growth of actinomycetes usually results in the formation of characteris- are uncommon. As mentioned above, these unique features of actino- tic clumps called grains or sulfur granules. The clinical presentations of mycosis mimic malignancy, with which it is often confused. actinomycosis are myriad. Common in the preantibiotic era, actinomy- Foreign bodies appear to facilitate infection. This association most cosis has diminished in incidence, as has its timely recognition. Actino- frequently involves IUDs. Reports have described an association of mycosis has been called the most misdiagnosed disease, and it has been actinomycosis with HIV infection; transplantation; common variable said that no disease is so often missed by experienced diagnosticians. immunodeficiency; chronic granulomatous disease; treatment with Three “classic” clinical presentations that should prompt consider- anti–tumor necrosis factor α agents, glucocorticoids, or bisphospho- ation of this unique infection are (1) the combination of chronicity, nates; and radio- or chemotherapy. Actinomycosis after SARS-CoV-2 progression across tissue boundaries, and mass-like features (mimick- infection is reported but the association is not well-established. Ulcer- ing malignancy, with which it is often confused); (2) the development ative mucosal infections (e.g., by herpes simplex virus or cytomegalo- of a sinus tract, which may spontaneously resolve and recur; and (3) a virus) may facilitate disease development. refractory or relapsing infection after a short course of therapy, since cure of established actinomycosis requires prolonged treatment. ■ CLINICAL MANIFESTATIONS ■ ETIOLOGIC AGENTS Oral–Cervicofacial Disease Actinomycosis occurs most fre- Actinomycosis is most commonly caused by A. israelii, A. naeslundii, quently at an oral, cervical, or facial site, usually as a soft tissue swell- Schaalia (Actinomyces) odontolyticus, A. viscosus, Schaalia (Actinomy- ing, abscess, mass, or ulcerative lesion that is often mistaken for a ces) meyeri, A. graevenitzii, and A. gerencseriae. Infections due to Win- neoplasm. Dental diseases or procedures are common precipitating kia (Actinomyces) neuii have been increasingly recognized. Most if not factors. The angle of the jaw is generally involved, but a diagnosis of all actinomycotic infections are polymicrobial. Aggregatibacter (Acti- actinomycosis should be considered with any mass lesion or relapsing nobacillus) actinomycetemcomitans, Eikenella corrodens, Enterobacte- infection in the head and neck. Radiation therapy and medication- riaceae, and species of Fusobacterium, Bacteroides, Capnocytophaga, related osteonecrosis of the jaw (MRONJ) due to antiresorptive therapy Staphylococcus, and Streptococcus are commonly isolated with actino- with bisphosphonates and anti–receptor activator of nuclear factor-κβ mycetes in various combinations, depending on the site of infection. ligand (RANKL) such as denosumab, angiogenesis inhibitors, and Their contribution to the pathogenesis of actinomycosis is uncertain. tyrosine kinase inhibitors have all been recognized as contributing to Genome-based analysis and comparative 16S rRNA gene sequenc- an increasing incidence of actinomycotic infection of the mandible and ing have led to the identification of an ever-expanding list of Actino- maxilla (Fig. 180-1). Canaliculitis (commonly due to P. propionicum), myces species and a reclassification of some species to other genera. In recent years, many prior Actinomyces species have been placed into new genera including Schaalia, Winkia, Gleimia, and Pauljensenia, though most publications have yet to adapt these new taxonomic changes. At present, 33 species remain in the Actinomyces genus with at least 26 species implicated as causes of human disease. Gleimia (Actinomyces) europaeus, A. radingae, Schaalia (Actinomyces) turicensis, Schaalia (Actinomyces) cardiffensis, A. urogenitalis, Pauljensenia (Actinomyces) hongkongensis, Schaalia (Actinomyces) georgiae, Schaalia (Actinomyces) massiliensis, A. timonensis, Schaalia (Actinomyces) funkei, Trueperella (Arcanobacterium) pyogenes, Trueperella (Arcanobacterium) bernar- diae, and Propionibacterium propionicum are additional causes of human actinomycosis, albeit not always with a “classic” presentation. ■ EPIDEMIOLOGY Actinomycosis has no geographic boundaries and occurs throughout life, with a peak incidence in the middle decades. Males have a three- fold higher incidence than females, possibly because of poorer dental hygiene and/or more frequent trauma. Improved dental hygiene and the initiation of antimicrobial treatment before actinomycosis fully develops have probably contributed to a decrease in incidence since FIGURE 180-1 Bisphosphonate-associated maxillary osteomyelitis due to Actinomyces the advent of antibiotics. Individuals who do not seek or have access to viscosus. A sulfur granule is seen within the bone. (Reprinted with permission from health care, those who have an intrauterine contraceptive device (IUD) NH Naik, TA Russo: Bisphosphonate related osteonecrosis of the jaw: The role of in place for a prolonged period (see “Pelvic Disease,” below), and those Actinomyces. Clin Infect Dis 49:1729, 2009. © 2009 Oxford University Press.)
[PAGE 1364] 1364 PART 5 Infectious Diseases A B FIGURE 180-2 Thoracic actinomycosis. A. A chest wall mass from extension of pulmonary infection. B. Pulmonary infection is complicated by empyema (open arrow) and extension to the chest wall (closed arrow). (Courtesy of Dr. C. B. Hsiao, Division of Infectious Diseases, Department of Medicine, State University of New York at Buffalo.) otitis, sinusitis, and laryngeal disease also can develop. Pain, fever, and Abdominal Disease Abdominal actinomycosis poses a great diag- leukocytosis are variably reported. Contiguous extension to the cra- nostic challenge. Months or
Flowcharts & Algorithms¶
Reproduced from Harrison's 22nd Edition.
Flowchart 1¶
Caption: FIGURE 180-5 Microscopic evaluation of actinomycotic sulfur granules. A. eosinophilic, proteinaceous coating called the Splendore-Hoeppli phenomenon. B. Ayesha Arshad, MD, VA Western New York Healthcare System.)
Figures & Illustrations¶
Reproduced from Harrison's 22nd Edition.
Figure 1¶
Caption: FIGURE 180-2 Thoracic actinomycosis. A. A chest wall mass from extension of extension to the chest wall (closed arrow). (Courtesy of Dr. C. B. Hsiao, Division of otitis, sinusitis, and laryngeal disease also can develop. Pain, fever, and leukocytosis are variably reported. Contiguous extension to the cra- nium, cervical spine, or thorax is a potential sequela. Thoracic Disease Thoracic actinomycosis, which may be facili- tated by aspirated foreign material such as animal bones or teeth, usually follows an indolent progressive course, with involvement of
Figure 2¶
Caption: FIGURE 180-4 Computed tomogram showing pelvic actinomycosis associated with in an intrauterine contraceptive device. The device is encased by endometrial fibrosis (solid arrow); also visible are paraendometrial fibrosis (open triangular arrowhead) and an area of suppuration (open arrow). has been used but removed, pelvic symptoms should prompt consider- ation of actinomycosis. The risk, although not quantified, appears small. The disease rarely develops when the IUD has been in place for <1 year, but the risk increases with time. Symptoms are typically indolent; fever, weight loss, abdominal pain, and abnormal vaginal bleeding or discharge
Figure 3¶
Caption: FIGURE 180-1 Bisphosphonate-associated maxillary osteomyelitis due to Actinomyces to viscosus. A sulfur granule is seen within the bone. (Reprinted with permission from NH Naik, TA Russo: Bisphosphonate related osteonecrosis of the jaw: The role of Actinomyces. Clin Infect Dis 49:1729, 2009. © 2009 Oxford University Press.)
Figure 4¶
Caption: FIGURE 180-2 Thoracic actinomycosis. A. A chest wall mass from extension of extension to the chest wall (closed arrow). (Courtesy of Dr. C. B. Hsiao, Division of otitis, sinusitis, and laryngeal disease also can develop. Pain, fever, and leukocytosis are variably reported. Contiguous extension to the cra- nium, cervical spine, or thorax is a potential sequela. Thoracic Disease Thoracic actinomycosis, which may be facili- tated by aspirated foreign material such as animal bones or teeth, usually follows an indolent progressive course, with involvement of
Figure 5¶
Caption: FIGURE 180-2 Thoracic actinomycosis. A. A chest wall mass from extension of extension to the chest wall (closed arrow). (Courtesy of Dr. C. B. Hsiao, Division of otitis, sinusitis, and laryngeal disease also can develop. Pain, fever, and leukocytosis are variably reported. Contiguous extension to the cra- nium, cervical spine, or thorax is a potential sequela. Thoracic Disease Thoracic actinomycosis, which may be facili- tated by aspirated foreign material such as animal bones or teeth, usually follows an indolent progressive course, with involvement of
Figure 6¶
Caption: FIGURE 180-2 Thoracic actinomycosis. A. A chest wall mass from extension of extension to the chest wall (closed arrow). (Courtesy of Dr. C. B. Hsiao, Division of otitis, sinusitis, and laryngeal disease also can develop. Pain, fever, and leukocytosis are variably reported. Contiguous extension to the cra- nium, cervical spine, or thorax is a potential sequela. Thoracic Disease Thoracic actinomycosis, which may be facili- tated by aspirated foreign material such as animal bones or teeth, usually follows an indolent progressive course, with involvement of
Generated from Harrison's Principles of Internal Medicine, 22nd Edition.