Actinomycosis of the Maxilla – in BRIEF • Actinomycosis Is a Supparative and Often Chronic Bacterial Infection Most PRACTICE Commonly Caused by Actinomyces Israelii

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Actinomycosis of the maxilla – IN BRIEF • Actinomycosis is a supparative and often chronic bacterial infection most PRACTICE commonly caused by Actinomyces israelii. a case report of a rare oral • Actinomycotic infections may mimic more common oral disease or present in similar way to malignant disease. infection presenting in • Treatment of actinomycosis involves surgical removal of the infected tissue and appropriate antibiotic therapy to general dental practice eliminate the infection.

T. Crossman1 and J. Herold2

Actinomycosis is a suppurative and often chronic bacterial infection most commonly caused by Actinomyces israelii. It is rare in dental practice. In the case reported the patient presented to his general dental practitioner complaining of a loose upper denture. This was found to be due to an actinomycotic infection which had caused extensive destruction and sequestration of the maxillary and nasal bones and subsequent deviation of the nasal septum.

INTRODUCTION of the nose, affecting a patient who Actinomycosis is a suppurative and often initially presented to his general den- chronic bacterial infection most com- tal practitioner complaining of a loose monly caused by Actinomyces israelii . upper denture. Several species have been isolated from the oral cavity of humans, including A. CASE REPORT israelii, A. viscosus, A. naeslundii and An 85-year-old Caucasian male was A. odontolyticus.1 As suggested by Cope referred to the oral and maxillofacial in 1938 the infection may be classifi ed department by his general dental prac- anatomically as cervicofacial, thoracic titioner (GDP) complaining of a loose Fig. 1 Patient at presentation showing bony sequestra bilaterally affecting the upper or abdominal. The most common is cer- upper denture and extrusion of ‘sharp premolar regions vicofacial, which accounts for over half fragments’ bilaterally from his upper of reported cases.2 premolar regions. He also gave a recent Actinomycosis in the maxilla history of recurrent nasal discharge, for accounts for only 0.5-9% of all head and which he was under the care of an ear, neck cases.3 There are only a few cases nose and throat department. His general reported in the literature of primary health was unremarkable apart from an actinomycosis arising within the max- allergy to penicillin. illa. Although rarely seen in day to day On examination the patient was eden- dental practice actinomycosis of the oral tulous in the upper arch and had evi- cavity is a highly signifi cant condition dence of bony sequestra arising from the due to its aggressive and locally destruc- surface of his upper alveolus (Fig. 1). He tive nature. We report a case of actino- was partially dentate in the lower arch mycosis leading to extensive destruction with no evidence of other pathology. and sequestration of the maxillary and The provisional diagnosis included nasal bones and deviation of the nasal either a malignant, infective or infl am- Fig. 2 CT scan of mid-face showing extensive maxillary destruction septum, resulting in a saddle deformity matory process. The patient was sub- sequently investigated with plain radiographs and a CT scan of his mid- although an extensive erosive or infl am-

1*Clinical Assistant in Oral and Maxillofacial Surgery, face (Fig. 2). The CT scan demonstrated matory process could not be excluded 2Consultant Oral and Maxillofacial Surgeon, Brighton extensive irregular demineralisation and from the differential diagnosis. & Sussex University Hospitals Trust, 27 Washington Street, Brighton, BN2 9SR patchy erosion of the nasal and maxil- In order to relieve his symptoms and *Correspondence to: Mr Timothy Crossman lary bones with complete opaciﬁ cation of reach a diagnosis, debridement of the Email: [email protected] the right and to a lesser extent the left infected area (including removal of the Refereed Paper maxillary antra. The report of the CT bony sequestra) was undertaken and the Accepted 4 August 2008 DOI: 10.1038/sj.bdj.2009.115 indicated the appearances were highly tissue was sent for histological exami- ©British Dental Journal 2009; 206: 201-202 suggestive of a diffuse malignant process nation. The histology report showed the

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debrided bone contained large numbers is necessary with periodic review of of organisms consistent with the fea- antibiotic sensitivities and response.1,5 tures of actinomyces, with no evidence Long term follow-up is also needed of malignancy. A diagnosis of actinomy- as infection can recur after a period cosis of the maxillary and nasal bones of quiescence.7 was made. The patient was promptly Before the role of actinomycosis in the treated with oral clindamycin due to his suppurative process became apparent allergy to penicillin. in the case reported here a signifi cant Following the initial debridement amount of bony and cartilaginous tissue the patient continued on oral antibiot- had been lost as a result of the infec- ics for several months and made good tion. As a consequence the nasal septum progress. He underwent an antral wash- collapsed and deviated to the extent out and remained under the care of both that the right nasal passage had become the maxillofacial and ENT departments Fig. 3 Photo showing collapse and deviation completely obstructed. This is illustrated of the nose to the right, leading to a due to his recurrent nasal discharge and ‘saddle deformity’ in Figure 3. subsequent nasal fi stula formation. The improvement in the patient’s CONCLUSION symptoms was maintained but he as well as systemic conditions affecting This case illustrates the need to bear in required further debridement of his the immune system such as diabetes and mind the possibility of an actinomycotic maxilla approximately a year after his HIV infections. infection being either the sole or par- initial presentation due to recurrence Although actinomycotic infections of tial cause of recurrent or persistent oral of bony sequestra. At his last review the cervicofacial region are uncommon, infections and the need for prompt and appointment he had had no symptoms for they are important in dental practice thorough investigation and treatment. several months and the oral mucosa was because they may mimic more common 1. Topazian R G, Goldberg M H. Oral and maxillofacial healthy. He will continue to be reviewed oral disease – primarily dentally related infections, 2nd ed. pp 403-407. Philadelphia: in the maxillofacial department bian- infection – but may also present in a WB Saunders, 1987. 2. Belmont M J, Behar P M, Wax M K. Atypical pres- nually until complete resolution of the similar way to malignant disease. Diag- entations of actinomycosis. Head Neck 1999; infection was apparent. nosis can be diffi cult as it depends on 21: 264-268. 3. Esson M, Lee J. Actinomycosis in the maxilla – the detection of sulphur granules in the a case report. Int J Oral Maxillofac Surg 2005; COMMENT exudate, the characteristic appearance 34 suppl 1: 132. 4. The British Society for Antimicrobial Chemo- In humans species of actinomyces are of the organism on culture and in the therapy. http://www.bsac.org.uk/pyxis/Head_ frequently part of the normal fl ora of tissues on histological examintion.1 and_Neck_Infections/Pharyngeal%20space%20 infections/Cervicofacial%20actinomycosis/ the oropharynx, gastrointestinal tract, Treatment of actinomycosis involves Cervicofacial%20actinomycosisF.htm. Accessed and female genital tract. They are of surgical removal of the infected tis- June 2008. 5. Alamillos-Granados F J, Dean-Ferrer A, García- low pathogenicity and generally only sue and appropriate antibiotic therapy López A, López-Rubio F. Actinomycotic ulcer of cause infection in the presence of local to eliminate the infection. Penicillins, the oral mucosa: an unusual presentation of oral Actinomycosis. Br J Oral Maxillofac Surg 2000; predisposing factors such as a breach of erythromycin, streptomycin, linco- 38: 121–123. the oral mucosa and/or systemic factors. mycin, vancomycin, cephalosporins, 6. Watkins K V, Richmond A S, Langstein I M. Nonhealing extraction site due to Actinomyces Hence oral and cervicofacial actino- chloramphenicol, clindamycin, and naeslundii in patient with AIDS. Oral Surg Oral Med mycosis is a rare complication of den- tetracyclines have all been used with Oral Pathol 1991; 71: 675–677. 5 7. Holly L, Bartell M D, Michael L, Sonabend M D, tal operations, oral and maxillofacial success in actinomycosis. A prolonged Sylvia Hsu M D. Actinomycosis presenting as a trauma and the sequelae of dental caries,6 course of several months treatment large facial mass. Dermatol Online J 2006; 12: 20.

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