CERVICOFACIAL ACTINOMYCOSIS PDF

Language: English Italian. Cervicofacial actinomycosis, a rare chronic infectious disease, is, however, an important clinical entity, due to the difficulties involved, still today, in its diagnosis. Following personal experience in a case referred to our Department, and in agreement with reports in the literature, attention is drawn to the presenting clinical manifestations, stressing that these are often confusing since they mimic those of other diseases, Moreover, many pre-operative investigations radiological scans, incisional biopsy, fine-needle aspiration are generally non-specific. Finally, surgical excision of the mass is now the last essential step to make a definitive diagnosis and define the appropriate antibiotic therapy. Actinomycosis is a suppurative and granulomatous chronic infectious disease, that usually spreads into adjacent soft tissues without regard for tissue planes or lymphatic drainage; it may also be associated with a draining sinus tract 1 — 3. Actinomyces are Gram-positive, non-acid fast, anaerobic or microaerophilic filamentous branched bacteria, living as commensal organisms in the human oral cavity and respiratory and digestive tracts, becoming invasive when, through a mucosal lesion, they gain access to the subcutaneous tissue.

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Language: English Italian. Cervicofacial actinomycosis, a rare chronic infectious disease, is, however, an important clinical entity, due to the difficulties involved, still today, in its diagnosis. Following personal experience in a case referred to our Department, and in agreement with reports in the literature, attention is drawn to the presenting clinical manifestations, stressing that these are often confusing since they mimic those of other diseases, Moreover, many pre-operative investigations radiological scans, incisional biopsy, fine-needle aspiration are generally non-specific.

Finally, surgical excision of the mass is now the last essential step to make a definitive diagnosis and define the appropriate antibiotic therapy. Actinomycosis is a suppurative and granulomatous chronic infectious disease, that usually spreads into adjacent soft tissues without regard for tissue planes or lymphatic drainage; it may also be associated with a draining sinus tract 1 — 3. Actinomyces are Gram-positive, non-acid fast, anaerobic or microaerophilic filamentous branched bacteria, living as commensal organisms in the human oral cavity and respiratory and digestive tracts, becoming invasive when, through a mucosal lesion, they gain access to the subcutaneous tissue.

Thus, dental caries, dental manipulations and oromaxillofacial traumas are the most common triggering events 1 4 — 9. The first of these manifestations is the most frequent, although fairly uncommon: a review of literature revealed 48 cases of cervicofacial actinomycosis reported over the last 25 years.

The condition is considered an important clinical entity, on account not only of the difficulties involved in the diagnosis but also the long-term treatment necessary to eradicate the disease 10 — Antibiotic therapy, previously prescribed by a physician, did not lead to a decrease in size of the mass. The patient denied any history of oromaxillofacial trauma or recent dental extraction. Head and neck examination revealed a 4 x 4 cm mass in the right submandibular region, which was tender upon palpation and partially fixed on the deep tissue planes, covered by slightly erythematous skin, but without breakdown associated with the mass.

Panendoscopy was normal. Routine blood tests were normal and PPD was placed which was found to be nonreactive and there was no response to PPD. A computed tomograpy CT scan of the neck revealed an expansive large mass approximately 4. A haematic-caseous discharge from the lower fluctuant portion of the mass was collected through a percutaneous incision. A specimen submitted to microbiologic culture revealed the presence of Fresobacterium Nucleatum, Porphyromonas Asaccharolytica and Staphylococcus Aureus.

The patient, therefore, underwent surgical excision of the mass, the histopathological examination of which showed chronic inflammation with the presence of multiple granules surrounded by polymorphocytes: this microscopic finding being consistent with diagnosis of actinomycosis Fig. Microscopic findings of chronic inflammation with the presence of multiple granules surrounded by polymorphocytes were consistent with diagnosis of actinomycosis haematoxylin and eosin stain; magnification X The patient was started on high doses of penicillin for 4 weeks by the specialist in infectious diseases.

The patient made a complete recovery and, moreover, follow-up revealed no recurrence of the infection. In man, the pathogenic Actinomyces most frequently isolated is A. Israelii ; less commonly, infection is caused by A.

Propionica , A. Naeslundii , A. Viscosus and A. These bacteria are all normal commensals of the human oral cavity 3 11 14 — In cervicofacial actinomycosis, which is the most frequent manifestation, infection is frequently the result of oromaxillofacial trauma, dental manipulation or dental caries In the present case, the patient denied any clinical history of oromaxillofacial trauma and showed no sign of immunodeficiency: lack of these risk factors did not help us make the diagnosis.

The infection, most commonly, presents as a chronic, often fluctuant mass, frequently located at the border of the mandible, becoming progressively larger within weeks or months Initially, the mass may be surrounded by induration or erythema; later, it may become tender to palpation, on account of a central necrosis process 17 Since our patient presented a submandibular mass without external drainage, a glandular disease was initially suspected.

Although Actinomyces rarely involves the lymph nodes, regional lymphadenopathy is sometimes observed. Furthermore, imaging techniques computed tomo-graphy CT and magnetic resonance imaging MRI scan usually yield non-specific findings, contributing only to define radiological features of the mass and its involvement in adjacent soft tissues. Also in the present case, CT was found to be useful in planning the surgical treatment 20 On account of these non-specific manifestations and radiological aspect, the clinical differential diagnosis of actinomycosis still remains difficult.

Thus, microbiological identification of this organism is often impossible. The macroscopic presence of the classic sulfur granules in tissue specimens or drainage may be of some help when making diagnosis, even if these features are not pathognomic, since nocardiosis may also present with sulfur granules Several Authors agree that incisional biopsy can be of great help in the diagnosis of actinomycosis, since microscopic examination reveals a typical finding of an outer zone of granulation and a central zone of necrosis which contains multiple basophilic granules, that represent lobulated micro-colonies of Actinomyces 5.

Over the last few years, as investigators have been searching for less invasive diagnostic techniques, fine-needle aspiration FNA has become more and more important, since not only does it allow morphologic identification, comparable to that obtained from incisional biopsy, but is also an effective means of collecting material for microbiologic identification 24 — Even if surgery plays an important role both in the diagnosis and treatment of actinomycosis, recurrence following surgery alone is very common, and weeks of high-dose intravenous antibiotics are a fundamental part of treatment, followed by months of oral antibiotics.

Penicillin is the drug of choice; tetracycline and erythromycin are employed in patients allergic to penicillin 9 28 In the acute phase of treatment, penicillin can be replaced by cephalosporins which are also effective if a co-infection with other bacteria not responding to penicillin causes the persistence of symptoms due to Actinomyces 30 — Also in our case, in accordance with data reported in the literature, surgical excision was ultimately required for definitive diagnosis, and complete resolution of symptoms was achieved after adequate post-operative antibiotic treatment.

In conclusion, although it is a rare infectious cervicofacial disease, actinomycosis of the head and neck represents, among neck masses, an interesting disease, on account of the difficulties involved in the diagnosis.

A comparison between clinical and microbiologic findings avoids serious errors in the differential diagnosis. National Center for Biotechnology Information , U. Journal List Acta Otorhinolaryngol Ital v. Acta Otorhinolaryngol Ital. Author information Article notes Copyright and License information Disclaimer. Address for correspondence: Dr. Received Nov 19; Accepted Jan 3. This article has been cited by other articles in PMC.

Summary Cervicofacial actinomycosis, a rare chronic infectious disease, is, however, an important clinical entity, due to the difficulties involved, still today, in its diagnosis. Keywords: Head and Neck, Actinomycosis, Diagnosis. Introduction Actinomycosis is a suppurative and granulomatous chronic infectious disease, that usually spreads into adjacent soft tissues without regard for tissue planes or lymphatic drainage; it may also be associated with a draining sinus tract 1 — 3.

Open in a separate window. References 1. Bennhoff DF. Actinomycosis: diagnostic and therapeutic considerations and a review of 32 cases. Laryngoscope ; Pisa: Pacini Editore; Clin Infect Dis ; Anaerobic infections of the head and neck.

Otolaryngol Clin North Am ; Brown JR. Human actinomycosis. A study of subjects. Hum Pathol ; Norman JE. Cervicofacial actinomycosis. Cervicofacial actinomycosis following orthognathic surgery: report of 2 cases.

J Oral Maxillofac Surg ; Cervico-facial and intra-oral actinomycosis: a 5-year retrospective study. Br J Oral Surg ; A study of 57 cases of actinomycosis over a year period. Arch Intern Med ; Arch Otolaryngol ; Atypical presentations of actinomycosis. Head Neck ; Actinomycosis of the face and neck.

Actinomycosis: its recognition and treatment. Ann Intern Med ; Oral and cervicofacial actinomycosis. Presentation of five cases. Enferm Infecc Microbiol Clin ; Tonsillar actinomycosis: a clinicopathological study. Acta Trop ; Stewart MG, Sulek M. Pediatric actinomycosis of the head and neck. Ear Nose Throat J ; Miller M, Haddad AJ. Cervicofacial actinomycosis: a diagnostic challenge.

Abscess with sulfur granules with organisms consistent with Actinomyces species. Arch Otolaryngol Head Neck Surg ; Actinomycosis: CT findings in six patients. Am J Roentgenol ; CT diagnosis of actinomycosis of the neck.

J Comput Assist Tomogr ;

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Actinomycosis

Actinomyces Israelii is a gram-positive micro organism with worldwide distribution. Cervicofacial actinomycosis results when this organism infects the head and neck area. A history of orofacial trauma, dental manipulations, or infections is often elicited from these patients. A firm, indurated mass, on or near the mandible with associated abscess formation or draining sinus tract, is a typical physical finding in this disease.

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Cervicofacial actinomycosis: still a difficult differential diagnosis

Stephen A. Thacker, C. Cervicofacial actinomycosis is an unusual cause of head and neck masses in children. This low prevalence of disease in children inevitably leads to delay in clinical recognition and often requires invasive intervention for diagnosis and curative therapy. We present an illustrative case and review cases of cervicofacial actinomycosis in the pediatric literature with particular attention to clinical presentation, course, and outcome.

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