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ACTINOMYCOSIS

Dr.T.V.Rao MD

DR.T.V.RAO MD

WHAT IS ACTINOMYCTES
Gram-positive, pleomorphic nonsporeforming, nonacid-fast anaerobic or Microaerophilic bacilli of the genus Actinomyctes and the order Actinomycetales cause actinomycosis. Actinomyces are very closely related to Nocardia species; both were once considered to be fungal organisms.
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TAXONOMY OF THE ANAEROBIC ACTINOMYCTES


Anaerobic non - sporulating grampositive rods consist of two groups based on guanosine (G) plus cytosine (C) DNA content: Low mole percent (3053%) and high mole percent (49-68%) Actinomyctes species member of the high G+C group

SEVERAL SPECIES CAN CAUSE ACTINOMYCOSIS AND CAN BE POLYMICROBIAL INFECTION

Actinomyces is a gram positive, non-sporeforming anaerobic or microaerophilic bacterial rod . Actinomyces israelii causes most Actinomyces infections in humans, although other forms such as Actinomyces Odontolyticus, Actinomyces Viscosus, Actinomyces Meyeri, Actinomyces Gerencseriae, and Propionibacterium Propionicum have also been reported. Actinomyces infections are commonly polymicrobial .
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ACTINOMYCOSIS
Actinomycosis is an infectious bacterial disease caused by Actinomyces species such as Actinomyces israelii or A. gerencseriae. It can also be caused by Propionibacterium propionicus
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ACTINOMYCES
Anaerobic, filamentous, gram positive bacillus Exhibit true branching Mykes Greek for fungus Thought by early microbiologist to be fungi because of: Morphology Disease they cause

ACTINOMYCOSIS
A. israelii the commonest A .meyeri A.naeslundii A.odontolyticus A. viscosus

ACTINOMYCES IS A NORMAL FLORA


Actinomyces species that cause human disease are not found in nature but are normal flora of the oropharynx, GI tract, and female genital tract. This is not an exogenous infection; therefore, no person-toperson spread of the pathogen occurs

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ACTINOMYCOSIS
Not highly virulent (Opportunist) Component of Oral Flora Periodontal pockets Dental plaque Tonsilar crypts Take advantage of injury to penetrate mucosal barriers Coincident infection

Trauma
Surgery

CULTURING OF ACTINOMYCES
Actinomyces species grow well in enriched media with brain-heart infusion and may be aided in growth by an atmosphere of 6-10% ambient carbon dioxide. They grow best at 37C. Colonies can appear at 3-7 days, but, to ensure that no growth is missed, observe cultures for 21 days.

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PATHOPHYSIOLOGY
In general, Actinomyces species, being members of the normal flora, are agents of low pathogenicity and require disruption of the mucosal barrier to cause disease. Oral and cervicofacial diseases are commonly associated with dental procedures, trauma, oral surgery, or dental sepsis. Pulmonary infections usually arise after aspiration of oropharyngeal or GI secretions. GI infection frequently follows loss of mucosal integrity, such as with surgery, appendicitis, diverticulitis, trauma, or foreign bodies.
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TYPICAL APPEARANCE OF HISTOPATHOLOGICAL EXAMINATION WITH SPECIAL STAINS

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PEOPLE AT RISK WITH ACTINOMYCOSIS


Having a dental disease or recent dental surgery (for jaw abscess) Aspiration (liquids or solids are sucked into lungs) (for lung abscess)

Having bowel surgery (for abdominal abscess)


Swallowing fragments of chicken or other bones (for abdominal abscess) For women: having an intrauterine contraceptive device (IUD) in place for many years (for abscess affecting the reproductive organs)
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CERVICOFACIAL ACTINOMYCOSIS
This is the most common and recognized presentation of the disease. Actinomyces species are commonly present in high concentrations in tonsillar

crypts and gingivodental crevices. Many patients have


a history of poor dentition, oral surgery or dental procedures, or trauma to the oral cavity. Chronic tonsillitis, mastoiditis, and otitis are also important risk factors for actinomycosis.
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INFECTION CERVICOFACIAL REGION


Periostitis or osteomyelitis can develop if the infection extends to facial and maxillary bones. The mandible appears to be one of the most common osteomyelitis sites.

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INTESTINAL ACTINOMYCOSIS
The infection usually develops after GI mucosal integrity is broken from surgical procedures or trauma, although, on many occasions, the inciting conditions may not be apparent.

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ABDOMINAL ACTINOMYCOSIS
Appendicitis with perforation is the most common predisposing event, and, as a result, right-sided abdominal infection is far more common than left-sided abdominal infection. The inciting event can precede the diagnosis by months to years.
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CNS DISEASE
Clinical features are indistinguishable from those of other infections of the CNS. The findings in those patients without meningeal involvement are typically those of a space-occupying lesion with focal neurologic defects and increased intracranial pressure. Patients with chronic meningitis have an indolent picture that is no different from other chronic meningitides with headaches, low toxicity, and subtle neurologic findings dominating the picture.
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THORACIC ACTINOMYCOSIS
Thoracic actinomycosis involves the lungs and mediastinum . The disease begins with fever, cough, and sputum production.. Multiple sinuses may extend through the chest wall, to the heart, or into the abdominal cavity. Ribs may be involved. Occasionally, Cervicofacial and thoracic disease may result in nervous system complications - most commonly brain abscesses or meningitis.

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PELVIC ACTINOMYCOSIS
This condition is extremely rare in the pediatric population and is almost exclusively is observed in patients who present with prolonged use of intrauterine contraception devices, usually for longer than 2 years.

Pelvic actinomycosis may develop from extension of intestinal infection, commonly from indolent Ileocecal disease. Patients present with an indolent history of vaginal discharge, abdominal or pelvic pain, menorrhagia, fever, weight loss, and prolonged use of an intrauterine contraceptive device.
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DIAGNOSIS:
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Gram stain.
Culture. (poor growth in culture only in less than 50% of cases.) Sulphur granules (yellowish myecelial masses)

Specimens open biopsy, aspiration material

The discharge should mix with sterile saline in a universal bottle and allow to stand, particles will separate out. Place between 2 slides Crush and gram stain Observe for Gram positive branching filaments
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EXAMINATION OF DISCHARGES WILL HELP IN DIAGNOSIS

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Examination of drained fluid under a microscope shows "sulphur granules" in the fluid. They are yellowish granules made of clumped organisms

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DIAGNOSIS OF ACTINOMYCES ISRAELII IS DIFFICULT


Culture requires 57 days but may take 24 weeks. Sulphur granules are actually yellow colored aggregates of microorganisms; they do not contain sulphur and are therefore a misnomer. These are usually isolated from purulent material and can be visible macroscopically as well as microscopically. Not all Actinomyces species form sulphur granules.

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DIAGNOSIS
In the earlier stage, this bacterial infection is difficult to diagnose because it can be can be confused with other conditions. Often, a correct diagnosis is made after taking and examining a sample (biopsy). It is more easily diagnosed in its later stages, after its hallmark sinus tracts have appeared in the surface of the skin. Culture of the tissue or fluid shows Actinomyces species. Examination of drained fluid under a microscope shows "sulfur granules" in the fluid. They are yellowish granules made of clumped organisms. Examination under a microscope shows the Actinomyces

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species of bacteria.

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TREATMENT OF ACTINOMYCOSIS
Treatment classically begins with IV penicillin for 26 weeks, followed by oral therapy with penicillin or amoxicillin for 612 months. For penicillin allergic patients, tetracycline, erythromycin, minocycline and clindamycin have been administered. Imipenem and ceftriaxone have been described as successful in reports .

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Programme Created by Dr.T.V.Rao MD for Medical and Paramedical Students in the Developing World

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