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Actinomyces Species: Clinical Aspects and Diagnostic Possibilities

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Actinomyces Species: Clinical Aspects and Diagnostic Possibilities © by author ESCMID Online Lecture Library Actinomyces species: Clinical aspects and diagnostic possibilities © by author Willem Manson ESCMID Online Lecture Library Prof. dr. John Degener, dr. Willem Manson University Medical Center Groningen UMCG AIM OF THIS PRESENTATION, to gain knowledge of: • the clinical importance of Actinomyces spp. • Clinical pitfalls. • Basic bacteriological properties of Actinomyces spp. • Methods of isolation and identification. • Recent taxonomic changes. • Antimicrobial susceptibility and therapeutc options. © by author ESCMID Online Lecture Library • A 41 year old man complains since some weeks of fever, malaise and weight loss • Since 2 days pain in the left chest • Moderately ill, dyspnea • Temp 38 C, • Friction rub. • BSE 67 mm L 15.5 • X –thorax: infiltrate left • CTscan: diminished© perfusionby author • DIAGNOSIS: lung embolism ESCMID Online Lecture Library • Intravenous heparin was administered and after 10 days the patient was discharged • Symptoms of malaise, weight loss and periods of fever persisted • BSE 127 mm, L 19.0, T 37.5 • Sputum cultures didn’t reveal any pathogenic microorganism. ZN negative • Gram stain pleural fluid: L+++, no micro-organisms, culture neg • No diagnosis was© made by and author the patient was discharged again ESCMID Online Lecture Library • Clinical condition deteriorated and 15 weeks after the first admission the patient was admitted for the third time. • Because of a suspicion of a malignancy a thoracotomy was performed. • PATHOLOGY: a inflammatory infiltrate neutrophils. Clusters of branched bacteria. No malignacy • Microbiology: Gram© Lby +++, author sporadic branched Gram positive rods ESCMID Online Lecture Library • Culture: Actinomyces species Treatment with i.v.penicillin G for 2 months followed by oral doxycyclin for 6 months At follow-up 12 months after starting therapy the patient was in a good condition without pulmonary complaints. It was© noted by howeverauthor that his dental status was poor and he was advised to visit his ESCMIDdentist for sanitation. Online Lecture Library • Actinomycosis presenting as carcinoma. Hinnie J, Jaques BC, Bell E, Hansell DT, Milroy R. • Pulmonary actinomycosis resembling an anterior mediastinal tumor Sato T, Takada N,Dobashi Y, Suzuki M, Ouchi M,Abe Y • Cervical actinomycosis. A rare differential diagnosis of parotid tumor Lang-Roth R, Schippers C, Eckel HE. • Abdominal actinomycosis presenting as a malignant tumor--report of a case and review of the literature Molnar T, Nagy A, Ligeti E, Gyulai C, Marton J, Nagy F. • Endobronchial actinomycosis simulating endobronchial tuberculosis: a case report. Lee SH, Shim JJ, Kang EY, Lee© SYby, Jo JYauthor, In KH, Yoo SH, Kang KH. • Abdominal actinomycosis misdiagnosed as a secondary bladder tumor: a case report. KawaharaESCMID M, Kawahara Online K, Goto T, Yamamoto Lecture S, Fuchinoue Library S, Matsumoto T ACTINOMYCES / NOCARDIA Bacteria that masquerade as fungi or cancer C. Sullivan, S. Chapman. Proc.Am. Thorac. Soc. 2010. 7: 216-221 Order Actinomycetales: Aerobic: Nocardia, Gordona,Tsukamurella,Streptomyces, Rhodococcus, Corynebacteria © by author Anaerobic: Actinomyces,Arachnia,Rothia, Bifidobacterium ESCMID Online Lecture Library ACTINOMYCOSE • 1877 infections in cattle (Bollinger) • 1878 Actinomyces was found during an obduction (Israel) • 1879 oral-cervicofacial abscess (Ponflick) • 1891 isolation of Actinomyces by Israel & Wolf • 1898 Actinomyces© by author israelii ESCMID Online Lecture Library Deep Actinomyces infections are rare 1 : 100.000-300.000 • CERVICOFACIAL 60% • ABDOMINAL 20% • THORACAL 15% • OTHERS 5% © by author ESCMID Online Lecture Library CERVICAL ACTINOMYCOSIS © by author ESCMID Online Lecture Library ACTINOMYCOSE OF THE LUNG © by author ESCMID Online Lecture Library ACTINOMYCOSE OF THE LUNG © by author ESCMID Online Lecture Library SECTION OF LESION IN THE LONG, CAUSED BY ACTINOMYCES © by author ESCMID Online Lecture Library Brain abscess due to a combined Actinomyces- Actinobacillus actinomycetemcomitans infection. Zijlstra EE, Swart GR, Godfroy FJM, DegenerJE. J. Infection 1992. 25:83-87. © by author ESCMID Online Lecture Library Actinomycosis of 54 years' duration Clin. Infect Dis 1998: 27:889 • 72 years old man was wounded at the 6th of june 1944 at the hand. After some weeks a purulent discharge appeared with yellow-white granula • Actinomyces israelii • Treatment with courses© by of erythromycin,author oral penicillins, tetracyclines and clindamycin all gave only temporarily resolution of symptoms ESCMID Online Lecture Library • The disease persisted for 54 years ACTINOMYCETES: • Heterogeneous group Gram pos. mo • Grampositive rods, often branched • Sulphur granula • (facultative) anaerobe mo • molar like aspect • Motility: - • catalase - ( excl. A.viscosus en A.neuii) • indole - © by author ESCMID Online Lecture Library © by author ESCMID Online Lecture Library © by author ESCMID Online Lecture Library © by author ESCMID Online Lecture Library Actinomyces • Sulphur granules- purulent discharge originating from Actinomyces infection © by author ESCMID Online Lecture Library © by author ESCMID Online Lecture Library © by author ESCMID Online Lecture Library Actinomyces • Grows slowly in culture- should be observed for up to 21 days • Selective medium- MMBA • Molar tooth colonies © by author ESCMID Online Lecture Library © by author ESCMID Online Lecture Library ISOLATION - IDENTIFICATION • SELECTIVE MEDIA: • Cadmium Fluoride Acriflavin Tellurite agar • Mupirocin Metronidazole Blood Agar (MMBA) (Columbia agar with 128 mg/L mupirocin en 2.5 mg/L metronidazole) • Colony morphology • GLC © by author • PHENOTYPIC • ESCMIDSEQUENCE (16s RNA) Online Lecture Library • Malditof 97% correct id Online Lecture Library Slide withheld at request© byof author author ESCMID Online Lecture Library Online Lecture Library Slide withheld at request© byof author author ESCMID Online Lecture Library ACTINOMYCES ( presently 42 species, 2 subsp) • A. israelii • A. europaeus • A. naeslundii • A. neuii • A. viscosus • A. radinga • A. odontolyticus • A. turicensis • A. georgiae • A. cardiffensis • A. meyeri • A. houstonensis • A. gerencseriae • A. hongkongensis • A. graevenitzii © by author• A. funkei ESCMID Online Lecture Library taxonomic changes among Actinomyces and closely related genera from human sources Year current name previous or source taxonomic position 1994 A. neuii supsp anitratus CDC gr 1 coryneform abscess, blood 1994 A. neuii subsp neuii CDC gr 1 like coryneform abscess, blood 1995 A. radingae A. pyogenes - like polymicrobial 1995 A. turicensis A. pyogenes - like polymocrobial 1995 A. europaeus new abscess 1997 A. graevenitzii new resp.tract 2000 A. radicidentis new oral cavity 2000 A. urogenitalis new urogenital 2001 A. funkii new blood 1997 Actinobaculum schaalii ©new by author blood 1997 Arcanobacterium bernardiae A. bernardiae abscess, blood 1998 Arcanobacterium pyogenes A. pyogenes polymicrobial ESCMID Online Lecture Library Sarkonen, et al. J.Clin. Microbiol(2001) Online Lecture Library Slide withheld at request© byof author author ESCMID Online Lecture Library Phenotypic identification of Actinomyces, obsolete? © by author ESCMID Online Lecture Library IDENTIFICATION OF ACTINOMYCES BY AMPLIFIED 16S RIBOSOMAAL DNA Val Hall et al. J.Clin. Microbiol 39: 3555 (2001) 475 clinical Actinomyces isolates 331 (70%) Actinomyces species 44(9%) no Actinomyces 113 A. meyeri : 21 A. meyeri 63 A. turicensis 7 other Actinomycetes 22 not identified© by author ESCMID Online Lecture Library SUSCEPTIBILITY OF ACTINOMYCES • All Actinomyces spp are susceptible to penicillins, cefalosporins, linezolid • Most of the Actinomyces spp are resistant against ciprofloxacin • A. turicensis is less susceptible to tetracycline • A. europaeus is less susceptible to erythromycin and clindamycin © by author ESCMID Online Lecture Library Smith et al. J. Antimicrobiol. Chemother. (2005) THERAPY FOR ACTINOMYCOSIS • SURGIGAL THERAPY • ANTIBIOTIC THERAPY 12 – 24 ME i.v. Penicillin G 2 – 6 weeks 6 (3) – 12 months oral therapy © by author Alternatives 1: clindamycin, erythromycin, doxycycline AlternativesESCMID 2: Online ceftriaxone, Lecture imipenem Library Medical management of pulmonary actinomycosis: data from 49 consecutive cases, co-morbidity 70% 46 patients iv antibiotics 21.5 days 43 patients oral antibiotics 115 days (penicillins, doxycyclin, macrolide) 16 patients side effects 5 patients lost for follow up 41 patients follow-up for 27 months 35 patients were cured (85%) 6 recurrence “Pulmonary actinomycosis with duration of AB treatment © by author adequate antibiotic treatment 5/6 recurrence treatment < 3 month (p<0.001 compared with 35 patients with uneventful follow-up)has an excellent prognosis” KolditzESCMID et al. (JAC 2009. 4: 839-841) Online Lecture Library OPTIMAL DURATION OF IV AND ORAL ANTIBIOTICS IN THE TREATMENT OF THORACIC ACTINOMYCOSIS _______________________________________________ n= 28 IV antibiotc PO antibiotic days days _______________________________________________ Surgical (n=13) 8 (3 – 17) 150 (0 – 534) Medical (n= 15) 2 (0 – 18) 167 (76 -412) _______________________________________________© by author NoESCMID disease recurrence Online with Lecturea short treatment Library regimen Choi et al. Chest (2005) Human Pathology (2006) Volume: 37, Issue: 1, Pages: 61-67 © by author ESCMID Online Lecture Library Online Lecture Library Slide withheld at request© byof author author ESCMID Online Lecture Library Online Lecture Library Slide withheld at request© byof author author ESCMID Online Lecture Library .
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