Review Article Actinomycosis : An Update Moniruddin ABM1, Begum H2, Nahar K3 Abstract: Endocaditis8, Pericarditis12, Pneumonia (Community Acquired1 or Nosocomia15), Lung absecess5, Actinomycosis is a very rare disease caused usually by one Bronchiectasis5, Empyema Thoracis12 etc when caused by of a group of oppurtunistic otherwise harmless commensals these organisms remain undiagnosed or if not properly that may be complicated by one or more of another group of treated would endanger the life of the patient. There are co-pathogens. Because of its rarity, there is a chance of significant morbidities as well. missing its diagnosis & proper treatment leading to substantial morbidity & mortality. Maltreated patients are Aetiology at risk of developing life threatening complications. This The causative organisms are non-motile, non-spore forming, article is intended to review the present status of aetiology, non-acid fast, Gram positive pleomorphic, anaerobic-to- pathology, clinical features, complications & management microaerophilic filamentous bacterial rods3. The most of actinomycosis. common ones are1 Actinomyces israeli, Actinomyces gerencseriae, Actinomyces naeslundii, Actinomyces Keywords odontolyticus, Actinomyces viscosus, Actinomyces Actinomyces israeli, Actinomyces gerencseriae, Actinomyces turicensis, Actinomyces meyeri, Propionibacterium naeslundii, Actinomyces odontolyticus, Actinomyces propionicus. In addition to these microorganisms, almost all viscosus, Actinomyces turicensis, Actinomyces meyeri, actinomycotic lesions contain so-called companion bacteria. Propionibacterium propionicus, Peptostreptococcus, The most important of these bacteria is Actinobacillus Actinobacillus actinomycetemcomitans, Prevotella, actinomycetemcomitans, followed by Peptostreptococcus, Fusobacterium, Bacteroides, Staphylococcus, Streptococcus, Prevotella, Fusobacterium, Bacteroides, Staphylococcus, Enterobacteriaceae, actinomycetes. and Streptococcus species, and Enterobacteriaceae, depending on the location of actinomycotic lesions. These Introduction: companion bacteria appear to magnify the low pathogenic Actinomycosis was once a common & ultimately fatal potential of actinomycetes2. disease1. Now the number has declined since the Actinomycosis can affect people of all ages, but the introduction of antimicrobial agents. The outlook of patients majority of cases are reported in young to middle-aged suffering from this infection has improved remarkably. Few adults (aged 20-50 yrs)2. No racial predilection exists. For physicians see many cases. As patients no longer commonly unknown reasons, men are affected more commonly than present advanced disease, actinomycosis has become a more women, with the exception of pelvic actinomycosis11. The diagnostic challenge2. Actinomycosis is a subacute-to- reported male-to-female ratio2 is 3:1. chronic bacterial infection characterized by contiguous spread, suppurative and granulomatous inflammation, and Actinomycosis occurs worldwide, with likely higher formation of multiple abscesses and sinus tracts that may prevalence rates in areas with low socioeconomic status and discharge ‘sulfur granules’3. As a disease process, the poor dental hygiene. causative organism can primarily or secondarily invade History gum, jaw4, neck, pleura, lungs5, liver6, kidney7, appendix7, caecum7, skin1, heart8, meninges9 etc. Even bones like Bollinger first reported the yellow granules in jaw masses of mandible, ribs & vertebra (causing osteomyelitis)10 are not cattle in 1877. In 1878, Israel described the first human immune to its invasion. The most common clinical forms of case. In 1879, Hartz first observed the microscopic actinomycosis are cervicofacial (ie, lumpy jaw), thoracic, appearance of granules of actinomyces infection1. and abdominal1. In women, pelvic actinomycosis is documented11. Epidural abscesses9, Meningitis9, Frequency Actinomycosis is a rare infection; Its exact incidence is not 1. ABM Moniruddin MBBS, FCPS(S) Consultant, Surgery, General Hospital, Narayanganj. known in Bangladesh. During the 1970s, the reported 2. Hamida Begum MBBS, FCPS annual incidence in the Cleveland area of the United States Assistant Professor, Department of Obstetrics and Gynaecology was 1 case per 300,0002. Improved dental hygiene and Bangabandhu Sheikh Mujib Medical University, Dhaka widespread use of antibiotics for various infections probably 3. Khairun Nahar MBBS, FCPS Assistant Professor, Department of Obstetrics and Gynaecology have contributed to the declining incidence of this disease1. Bangabandhu Sheikh Mujib Medical University, Dhaka 2010 Volume 22 Number 01 43 REVIEW ARTICLE Pathology recent or remote bowel surgery (eg, perforated acute appendicitis, perforated colonic diverticulitis following Actinomycetes are prominent among the normal flora of the trauma to the abdomen) or ingestion of foreign bodies (eg, oral cavity but less prominent in the lower gastrointestinal chicken or fish bones), during which actinomycetes is tract and female genital tract. As these microorganisms are introduced into the deep tissues. The ileocecal region is not virulent, they require a break in the integrity of the involved most frequently and the disease presents mucous membranes and the presence of devitalized tissue to classically as a slowly growing tumor. Diagnosis is usually invade deeper body structures and cause human illness. established postoperatively, following exploratory Furthermore, actinomycosis generally is a polymicrobial laparotomy for a suspected malignancy. Involvement of any infection, with isolates numbering as many as 5-10 bacterial abdominal organ, including the abdominal wall, can occur species2. Establishment of human infection may require the by direct spread, with eventual formation of draining presence of such companion bacteria, which participate in sinuses. Actinomycosis of the pelvis most commonly occurs the production of infection by elaborating a toxin or enzyme by the ascending route from the uterus in association with or by inhibiting host defenses. These companion bacteria intrauterine contraceptive devices (IUCDs). In such cases, appear to act as copathogens that enhance the relatively low an IUCD has been in place for an average of 8 years. invasiveness of actinomycetes. Specifically, they may be responsible for the early manifestations of the infection and Complications for treatment failures. Once infection is established, the host Osteomyelitis of the mandible, ribs, and vertebrae, CNS mounts an intense inflammatory response (ie, suppurative, granulomatous), and fibrosis may develop subsequently. disease, including brain abscess, chronic meningitis, Infection typically spreads contiguously, frequently ignoring actinomycetoma, cranial, epidural, and subdural infection, tissue planes and invading surrounding tissues or organs. and spinal epidural infection, Hepatic actinomycosis, Renal Ultimately, the infection produces draining sinus tracts. actinomycosis, Endocaditis8, Pericarditis12, Pneumonia Hematogenous dissemination7 to distant organs may occur (Community Acquired1 or Nosocomial5), Lung absecess5, in any stage of the infection, whereas lymphatic Bronchiectasis5, Empyema Thoracis12 etc. In addition to its dissemination is unusual. serious nature of organ involvement, it can complicate other operations or situations like hip prosthesis infection13, septic Cervicofacial actinomycosis arthritis14, endodontic infection15, IUD infection16, pos- Cervicofacial actinomycosis is the most common operative viscous endophthalmitis17, etc. Opportunistic manifestation, comprising 50-70% of reported cases. actinomycotic infection has been reported in Infection typically occurs following oral surgery or in osteoradionecrosis18 in patients having head & neck cancer. patients with poor dental hygiene2. This form of Disseminated actinomycosis19 by Actinomyces meyeri & actinomycosis is characterized in the initial stages by soft- and Actinobacillus actinomycetemcomitans has also been tissue swelling of the perimandibular area. Direct spread reported. into the adjacent tissues occurs over time, along with development of fistulas (sinus tracts) that discharge purulent Clinical Features material containing yellow (ie, sulfur) granules. Invasion of 1. History taking20 the cranium or the bloodstream may occur if the disease is left untreated. For Cervicofacial actinomycosis (ie, lumpy jaw): History of dental manipulation or trauma to the mouth, poor oral Thoracic actinomycosis hygiene, dental caries, or periodontal disease; local tissue Thoracic actinomycosis accounts for 15-20% of cases. damage caused by neoplasm or radiation treatment, or of Aspiration of oropharyngeal secretions containing painless or occasionally painful soft-tissue swelling actinomycetes is the usual mechanism of infection. involving the submandibular or perimandibular region; over Occasionally, thoracic actinomycosis may result from the time, multiple sinuses drain pus containing sulfur granules; introduction of organisms via esophageal perforation, by tendency to remit and recur, or of reddish or bluish direct spread from an actinomycotic process of the neck or discoloration of the skin overlying the lesion or of chewing abdomen, or via hematogenous spread from a distant lesion. difficulties (ie, with involvement of mastication muscles) Thoracic actinomycosis3 commonly presents as a pulmonary For Thoracic acinomycosis: History of aspiration (Risk infiltrate or mass, which, if left untreated, can spread to factors include seizure