Actinomycosis

Abstract

We describe an unusual case of actinomycosis that appeared as a nasal mass. The diagnosis was established when Actinomyces viscosus was isolated from pus obtained from the right maxillary antrum by intranasal antrostomy. The patient was treated with intravenous crystalline penicillin and made an uneventful recovery within 10 days.

Introduction

Actinomycosis is an indolent, suppurative, and granulomatous infection caused by gram-positive organisms that form branching filaments. (1) Depending on the anatomic region that is involved, actinomycosis is classified as one of three clinical forms: cervicofacial (the most common), thoracic, or abdominopelvic. (2,3) The specific etiologic agents include Actinomyces israelii, Actinomyces naeslundii, Actinomyces odontolyticus, and Actinomyces viscosus. (1,2) A odontolyticus and A viscosus are more often associated with dental caries. (1) All these species are facultative anaerobes and part of the normal oral microflora.

The clinical manifestations of actinomycosis are myriad, and this infection poses a diagnostic challenge. (3) Cervicofacial actinomycosis frequently affects the maxillary sinus and causes swelling of the cheek, a woody induration, and draining sinus tracts. Isolated lesions have been reported on the tongue, (4) salivary glands, (5) infratemporal fossa, (6) and larynx. (7) In this article, we describe an unusual case of actinomycosis.

Case report

A 62-year-old nonhypertensive, nondiabetic woman was admitted to the hospital with a 2-month history of nasal obstruction, headache, and persistent nasal discharge, which began immediately following a tooth extraction from the right upper quadrant. ENT examination revealed tenderness of the paranasal and right frontal sinuses and decreased airflow on the right side. A profuse foul-smelling discharge was observed in the right nasal cavity and the right middle meatus. An exophytic mass with papillary projections was seen on the right latera1 nasal wall, the origin of which could not be ascertained, The left nasal cavity was normal. Examination of the oral cavity revealed poor oral hygiene and pus points on the tooth sockets in the right upper jaw.

Sinus x-ray demonstrated a haziness in the frontal, ethmoid, and maxillary sinuses on the right. Computed tomography detected an enhancing lesion in the area of the nasal passage and the right maxillary and right sphenoid sinuses. The provisional clinical diagnosis was either an inverted papilloma or rhinosporidiosis. Intranasal antrostomy yielded a thick, foul-smelling pus from the right maxillary antrum. Gram's staining of the purulent material revealed few polymorphonuclear lymphocytes and numerous gram-positive branching filaments (figure). Modified acid-fast staining ruled out Nocardia spp. Culture and biochemical reactions identified the organism as A viscosus. Histopathologic examination of the lesion biopsy revealed that it was an inflammatory polyp.

The patient was administered intravenous crystalline penicillin and made an uneventful recovery within 10 days.

Discussion

Common causes of actinomycosis include tooth extraction, poor dental hygiene, and traumas to the mouth or jaw. (8) The probable source of the infection in our patient was the tooth extraction that immediately preceded the onset of symptoms. Culture of the pus from her tooth sockets revealed the presence of A viscosus. This finding allowed us to make the diagnosis.

The presence of sulfur granules is pathognomonic of actinomycosis, but their absence in the clinical specimen does not rule it out because the granules reside deep in the tissue. (8) Sulfur granules have been reported in only 40% of cases. (9)

Actinomycosis can rightly be called the "masquerader" of the head and neck. Because its symptoms are vague and nonspecific, its diagnosis can be delayed until a vital organ becomes eroded or obstructed. (8) Our case represents an uncommon manifestation of actinomycosis. A diagnosis of actinomycosis should be always considered in a patient who has soft-tissue swelling in the head and neck region.

References

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(3.) Russo TA. Agents of actinomycosis. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. Philadelphia: Churchill Livingstone, 2000:2645-52.

(4.) Vazquez AM, Marti C, Renaga I, Salavert A. Actinomycosis of the tongue associated with human immunodeficiency virus infection. Case report. J Oral Maxillofac Surg 1997;55:879-81.

(5.) Appiah-Anane S, Tickle M. Actinomycosis--an unusual presentation. Br J Oral Maxillofac Surg 1995;33:248-9.

(6.) Carrau RL, Greenwall K, Canaan RE, Moore JC. Actinomycosis of the infratemporal fossa. Am J Otolaryngol 1993;14:1-4.

(7.) Nelson EG, Tybor AG. Actinomycosis of the larynx. Ear Nose Throat J 1992;71:356-8.

(8.) Ryan KJ. Actinomyces and Nocardia. In: Ryan KJ, ed. Sherris Medical Microbiology. Norwalk, Conn.: Appleton and Lange, 1994:417-9.

(9.) Weese WC, Smith IM. A study of 57 cases of actinomycosis over a 36-year period. A diagnostic "failure" with good prognosis after treatment. Arch Intern Med 1975;135:1562-8.

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