The Great Imitator: Cervicofacial Actinomycosis Masquerading as Cancer Recurrence.

Cervicofacial actinomycosis being one of the unusual infections is of high relevance to a head and neck onco-surgeon. As the diagnosis may be made difficult by its nature to mimic malignancy and egregiously low culture sensitivity, the differential diagnosis for a lesion appearing to be malignant after irradiation does not usually include actinomycotic infection. Treatment usually requires a long-term antibiotic course after confirmation with histopathology, albeit surgical debridement is required in selective cases. Here we report two cases that were clinico-radiologically diagnosed as osteoradionecrosis and histopathological analysis done to rule out cancer recurrence. Unanticipated, they turned out to be cervicofacial actinomycosis, subsequently treated with long-term antibiotics following which the infection subsided.

Tonsillar actinomycosis that mimics tonsillar neoplasm.

Actinomycosis is a chronic suppurative infection that can develop almost anywhere in the body. Cervicofacial actinomycosis is the most common form of the disease. We report a case of tonsillar actinomycosis that causes massive, asymmetric enlargement of tonsil and mimics the neoplasia. The most common cause of asymmetric tonsil hypertrophy is tonsillar squamous cell carcinoma and lymphomas. Tonsillar actinomycosis is a rare entity that should be kept in mind, if cases cannot be clarified with clinical and laboratory findings, when radiological findings are suspicious about malignancy.

Cervicofacial actinomycosis following third molar removal: case-series and review.

Actinomycosis is an opportunistic infection caused by bacteria of the Actinomyces spp., commonly A. israelii. These are non-pathogenic commensals in the mouth, gut, and female genital tract. An infection may arise following trauma or surgery, such as tooth extraction. More than half of cases of actinomycosis occur in the perimandibular area and are termed cervicofacial actinomycosis. Initially, the infection develops as a painful, rapidly progressive swelling. The lesion may then indurate and is often painless while the overlying skin discolors red to purple-blue. Prolonged treatment with antibiotics and surgery are often required for resolution, unless treatment is promptly started. However, diagnosis may be delayed or missed because of difficult bacterial culturing and frequent confusion with malignancy and other infections. This case study describes six patients who developed cervicofacial actinomycosis following third molar extraction. The purpose of this study is to inform clinicians on this stubborn and deceitful disease entity and to highlight the importance of clinical recognition for quick resolution with minimal morbidity.

Cervicofacial actinomycosis: important considerations on a mimicking disease / Actinomicosis cervicofacial: consideraciones importantes sobre una enfermedad imitadora

SUMMARY Actinomycosis is a rare chronic suppurative infection that affects upper airways and the gastrointestinal tract. The aim of this work was to review important information regarding the etiopathogenesis, clinical features and treatment of cervicofacial actinomycosis. According to the anatomic site affected, it is classified into three clinical forms: cervicofacial (50%), thoracic (30%) and abdominal (20%). We present here a literature review focusing on important aspects of cervicofacial actinomycosis. Despite the name comprising the term mycosis, the disease is caused by Gram-positive bacteria of the genus Actinomyces, mainly Actinomyces israelii, which are commensals of the oral microbiota. Nevertheless, when the integrity of the oral mucosa is compromised, they can become pathogenic. Actinomycosis evolves slowly and it often mimics other clinical conditions such as malignancies. Treatment consists in antibiotic therapy and can last up to 12 months in severe cases. Health care professionals' knowledge about the disease is crucial in a way to promote its prevention, early diagnosis and proper treatment.

RESUMEN La actinomicosis es una enfermedad infecciosa muy infrecuente de tipo crónico y supurativo que afecta al área cervicofacial e el tracto gastrointestinal. El presente trabajo tuvo como objetivo, revisar informaciones importantes en cuanto etiopatogenia, presentación clínica y tratamiento de la actinomicosis cervicofacial. Se puede clasificar de tres maneras a depender del sitio anatómico: cervicofacial (50%), torácica (30%) y abdominal (20%). Presentamos una revisión de la literatura con foco en aspectos importantes de la actinomicosis cervicofacial. Aunque se le denomine micosis, la enfermedad es causada por bacterias grampositivas del género Actinomyces, siendo que A. israelli es el agente etiológico más frecuente, cuales son microorganismos comensales de la boca. Sin embargo, si la integridad de la mucosa es violada, ellos se tornan patogénicos. La actinomicosis es lentamente progresiva y frecuentemente imita otras condiciones clínicas como malignidades. El tratamiento consiste en terapia antibiótica y puede durar 12 meses en casos más graves. El conocimiento de los profesionales de salud acerca de esa enfermedad es fundamental para promover su prevención, diagnóstico precoz y tratamiento correcto.

Actinomicosis mandibular

RESUMEN Mujer de 46 años, tiroidectomizada por bocio hiperfuncionante, con bicitopenia (anemia y leucopenia) en estudio, acude por tumoración y dolor del maxilar inferior y secreción purulenta, de 4 meses de evolución, con fiebre intermitente. Presentó disminución de ingesta de alimentos con pérdida de 20 kg de peso aproximadamente. Ya recibió varios esquemas de tratamiento entre los que se incluye antimicrobianos, sin mejoría. Muestras de secreción con cultivo: negativos. Tomografía del macizo facial con lesiones osteolíticas y fractura del maxilar inferior. La biopsia muestra inflamación crónica inespecífica y presencia de Actinomyces sp. Biopsia osteomedular: probable efecto tóxico medular. Recibió tratamiento prolongado con antimicrobiano, mejorando. Actualmente en planes de reconstrucción de maxilar inferior.

ABSTRACT A 46-year-old woman, thyroidectomized by hyperfunctional goiter, with bicytopenia (anemia and leukopenia) under study, consults because of a tumor, pain of the lower jaw and purulent secretion of 4 months of evolution, with intermittent fever. She presented decrease in food intake with loss of approximately 20 kg of weight. She has already received several treatment schemes, including antimicrobials, without improvement. Culture secretion samples: negative. Tomography of the facial massif showed osteolytic lesions and fracture of the lower jaw. The biopsy shows nonspecific chronic inflammation and the presence of Actinomyces sp. Osteomedullary biopsy: probable spinal toxic effect. She received prolonged treatment with antimicrobial, improving. Currently she is in reconstruction plans of the lower jaw.

Actinomyces turicensis: An unusual cause of cervicofacial actinomycosis presenting as ludwig angina in an immunocompromised host - Case report and literature review.

Actinomyces is an anaerobic, gram-positive bacillus that is known to cause chronic granulomatous infections. Common risk factors predisposing patients to this life-threatening infection are recent dental procedures, immunosuppression from malignancy, or history of smoking and alcohol use. Actinomyces, commonly found in the normal flora of the oral cavity, is one of the pathogens that can cause Ludwig's angina. Ludwig's angina is diffuse cellulitis and edema of the soft tissues of the neck and floor of the mouth. Cervicofacial actinomyces is an invasive infection that can form life-threatening abscesses through its rapid spread. Actinomyces turicensis is an isolate that has emerged recently to cause infections in humans. There are few reported cases of this species causing abdominal and genital infections; however, there is no report of it invading the cervicofacial space. A feared complication of Ludwig's angina and cervicofacial actinomyces is airway compromise. Therefore, prompt initiation of intravenous antibiotics is required for the treatment and prevention of deadly complications. We present a patient with left-sided neck swelling after a recent oral surgical procedure and was found to grow Actinomyces turicensis on wound culture. The patient was treated with intravenous ampicillin-sulbactam, which not only decreased the swelling but improved the necrotic appearance of his abscess wound.

Atypical Form of Cervicofacial Actinomycosis Involving the Skull Base and Temporal Bone.

BACKGROUND:: Cervicofacial actinomycosis is an uncommon indolent infection caused by Actinomyces spp that typically affects individuals with innate or adaptive immunodeficiencies. Soft tissues of the face and neck are most commonly involved. Actinomyces osteomyelitis is uncommon; involvement of the skull base and temporal bone is exceedingly rare. The authors present a unique case of refractory cervicofacial actinomycosis with development of skull base and temporal bone osteomyelitis in an otherwise healthy individual. METHODS:: Case report with literature review. RESULTS:: A 69-year-old man presented with a soft tissue infection, culture positive for Actinomyces, over the right maxilla. Previous unsuccessful treatment included local debridement and 6 weeks of intravenous ceftriaxone. He was subsequently treated with conservative debridement and a prolonged course of intravenous followed by oral antibiotic. However, he eventually required multiple procedures, including maxillectomy, pterygopalatine fossa debridement, and a radical mastoidectomy to clear his disease. Postoperatively he was gradually transitioned off intravenous antibiotics. CONCLUSIONS:: Cervicofacial actinomycosis involves soft tissue surrounding the facial skeleton and oral cavity and is typically associated with a history of mucosal trauma, surgery, or immunodeficiency. The patient was appropriately treated but experienced disease progression and escalation of therapy. Although actinomycosis is typically not an aggressive bacterial infection, this case illustrates the need for prompt recognition of persistent disease and earlier surgical intervention in cases of recalcitrant cervicofacial actinomycosis. Chronic actinomycosis has the potential for significant morbidity.

"Holes" in the Jaw-A Report of Two Cases of Periapical Actinomycosis.

Periapical actinomycosis is a relatively rare form of cervicofacial actinomycosis, which typically involves the periapical region with subsequent potential spread to the jaw bones. We hereby present two cases of periapical actinomycosis. Both patients presented with jaw pain and "holes" in their gum and lacked the characteristic clinical features commonly seen in cervicofacial actinomycosis such as jaw mass, draining ulcers, sinuses and fistulae. The first patient was an immunocompetent host with chronic stable medical conditions but with a rather bad dentition requiring multiple recent teeth extractions. The second patient was edentulous, had refractory multiple myeloma, was on low-dose chronic steroids and pomalidomide therapy and therefore relatively immunocompromised. Both cases of actinomycosis were diagnosed by jaw bone histopathology, which showed characteristic sulfur granules and embedded Actinomyces-like organisms. The two patients had excellent clinical response to six months of penicillin therapy without any need for surgical intervention. The cases remind clinicians of including actinomycosis in the differential diagnosis of periapical lesions and illustrates the possibility of achieving cure with non-surgical treatment.

Craniofacial Actinomyces osteomyelitis evolving from sinusitis.

Craniofacial Actinomyces osteomyelitis progression is rare, as patients are soon treated. A 56-year-old male smoker presented with sinusitis and was managed medically. This patient failed to follow up and presented 1 year later with erosive bony disease. He was managed medically and surgically; however, his disease evolved to include his midface, skull base, and cranium. He underwent staged debridement and free tissue reconstruction. His disease is controlled but not cured. The literature includes case reports and small series describing limited disease treated successfully with surgical and medical management. Although craniofacial Actinomyces osteomyelitis is uncommon, it can become debilitating. This case demonstrates how craniofacial Actinomyces osteomyelitis can progress and highlights the benefit of a multidisciplinary approach.

Actinomicosis orofaríngea como diagnóstico diferencial de carcinoma de cavum: Reporte de un caso / Cervicofacial actinomycosis as differential diagnosis of cavum carcinoma: case report

La actinomicosis es una enfermedad infrecuente en pediatría que implica, habitualmente, un desafío diagnóstico. Es producida por bacterias del género Actinomyces. La forma cervicofacial suele originarse tras la disrupción de la mucosa oral secundaria a alteraciones odontógenas. Se presenta el caso de una adolescente que, tras la colocación de un piercing en la lengua, comenzó con odinofagia y cambios del tono de voz. Luego de ocho meses de persistencia de los síntomas y habiendo realizado múltiples tratamientos antibióticos con leve mejoría, se efectuó una biopsia y se diagnosticó carcinoma de cavum, por lo que se derivó a este Hospital para su tratamiento. Al analizar nuevamente la biopsia, se descartó la patología oncológica y se diagnosticó actinomicosis orofaríngea. Cumplió 6 meses totales de tratamiento antibiótico, con buena evolución. Si bien la colocación de piercings orales no ha sido descrita hasta el momento como factor de riesgo, la disrupción mucosa generada podría favorecer el inicio del cuadro.

Paediatric actinomycosis is an infrequent infectious disease caused by Actinomyces spp. Cervicofacial infections are usually related to disruption in oral mucosal membranes. We discuss the case of a 15-year-old girl who refers an 8-month history of odynophagia and changes in her tone of voice after getting a tongue piercing. She received multiple antibiotic treatments with slight improvement. Nasopharyngeal carcinoma was diagnosed by endoscopic biopsy. The patient was referred to our Hospital for treatment but, when the biopsy was analyzed again, oncological pathology was excluded and oropharyngeal actinomycosis was diagnosed. She received a total of 6 months of antibiotic treatment with favorable evolution.

[Cervicofacial actinomycosis as differential diagnosis of cavum carcinoma: case report]. / Actinomicosis orofaríngea como diagnóstico diferencial de carcinoma de cavum. Reporte de un caso.

Paediatric actinomycosis is an infrequent infectious disease caused by Actinomyces spp. Cervicofacial infections are usually related to disruption in oral mucosal membranes. We discuss the case of a 15-year-old girl who refers an 8-month history of odynophagia and changes in her tone of voice after getting a tongue piercing. She received multiple antibiotic treatments with slight improvement. Nasopharyngeal carcinoma was diagnosed by endoscopic biopsy. The patient was referred to our Hospital for treatment but, when the biopsy was analyzed again, oncological pathology was excluded and oropharyngeal actinomycosis was diagnosed. She received a total of 6 months of antibiotic treatment with favorable evolution. While oral piercings have not been yet described as a risk factor for oropharyngeal actinomycosis, the mucosal disruption could favor the onset of this disease.

La actinomicosis es una enfermedad infrecuente en pediatría que implica, habitualmente, un desafío diagnóstico. Es producida por bacterias del género Actinomyces. La forma cervicofacial suele originarse tras la disrupción de la mucosa oral secundaria a alteraciones odontógenas. Se presenta el caso de una adolescente que, tras la colocación de un piercing en la lengua, comenzó con odinofagia y cambios del tono de voz. Luego de ocho meses de persistencia de los síntomas y habiendo realizado múltiples tratamientos antibióticos con leve mejoría, se efectuó una biopsia y se diagnosticó carcinoma de cavum, por lo que se derivó a este Hospital para su tratamiento. Al analizar nuevamente la biopsia, se descartó la patología oncológica y se diagnosticó actinomicosis orofaríngea. Cumplió 6 meses totales de tratamiento antibiótico, con buena evolución. Si bien la colocación de piercings orales no ha sido descrita hasta el momento como factor de riesgo, la disrupción mucosa generada podría favorecer el inicio del cuadro.

Persistence of a Cervical Neck Mass, Not Just the Lymphoma.

Actinomycosis is a rare, chronic granulomatous infection caused by gram-positive, anaerobic to microaerophilic branching filamentous bacteria. In the cervicofacial region, it usually presents as an enlarging neck mass. It remains a diagnostic challenge due to the fact that cultures show no growth in more than 50% of cases. We report a case of a 67-year-old patient known to have a neck mass secondary to lymphoma in which the neck mass persisted despite therapy. Upon evaluation, the diagnosis of culture-negative actinomycosis was based on histopathology findings, and the patient received antibiotic therapy. We will discuss the diagnosis and pathology of actinomycosis, attempting to explore the relationship between actinomycosis and lymphoid malignancy.

Six Cases of Cervical Actinomycosis / 대한이비인후과학회지

Actinomycosis is an unusual subacute chronic disease caused by gram-positive anaerobic organisms such as Actinomycetes israelii, A. bovis, A. odontolyticus, and A. viscosus. Actinomycetes are prominent among the normal flora of the oral cavity. Because these organisms are not virulent, a break in the integrity of mucosa is necessary to cause human illness. Three common forms of illness are cervicofacial, thoracic and abdominopelvic actinomycosis. Cervicofacial form is the most common (55%) and often occurs after oral surgery, tooth extraction and cervicofacial trauma. Cervicofacial actinomycosis is characterized by initial soft tissue swelling, along with development of fistulas that discharge purulent yellow sulfur-like material (sulfur granules). Sulfur granule is the pathognomonic pathologic finding of actinomycosis but it has not been reported in all cases. Here, we report 6 cases of cervical actinomycosis that were trea-ted with surgical intervention and administration of proper antibiotics, with the review of literatures.

Cervicofacial actinomycosis mimicking lymphangioma circumscriptum.

Primary cutaneous actinomycosis caused by Actinomyces israelii occurs most commonly in the cervicofacial area. It commonly presents as "lumpy jaw" with draining sinuses which discharge the characteristic "sulfur granules". A low index of suspicion and a low sensitivity in culturing the organism, due to its fastidious nature often delays the diagnosis. An atypical clinical presentation mimicking lymphangioma circumscriptum with grouped papulovesicular and nodular lesions along the lower jaw extending from skin to the inner buccal mucosa, confirmed on histology and an excellent therapeutic response to penicillin is reported.

A Case of Cervical Actinomycosis Misdiagnosed to Malignant Tumor / 대한이비인후과학회지

Actinomyces are gram positive anaerobes which exist as normal flora in the oral and digestive tract. Actinomycosis is a very rare subacute or chronic infectious disease that causes sinus fistula, tract or abscess due to the invasion of surrounding soft tissue when normal mucosa is damaged by inflammation. Clinically, it is categorized into cervicofacial, thorax, abdomen, pelvis, and systemic infection, in which cervicofacial infection accounts for 50% of all actinomycosis. With various nonspecific clinical manifestations and uncertain results of fine needle aspiration cytology and culture examination, treatment may be difficult since it may be misdiagnosed as malignancy or tuberculosis. Along with literature, we present a case of a 57-year old male patient with cervical actinomycosis in the submandibular mass, which was mistaken for malignancy.

Case Report: Cervicofacial Actinomycosis-Misdiagnosed to Parotid Abscess / 대한이비인후과학회지

Actinomycosis is a disease caused by an anaerobic bacteria called Actinomyces species (predominantly Actinomyces israelii), which is a common and normally nonpathogenic organism found in the nose and throat. The four major clinical presentations of actinomycosis include the cervicofacial, thoracic, abdominal, and pelvic region. Actinomycosis is difficult to diagnose because of variable presentation and fastidious nature of the organism in culture. A high index of suspicion and biopsy are often necessary to make the diagnosis, because the disease can mimic neoplasm or a chronic granulomatous infection. We present, with the appropriate review, a case of actinomycosis in the mandibular angle area which was mistaken for a parotid abscess.

A Case of Actinomycosis of the Neck / 대한이비인후과학회지

Actinomycosis of cerivcofacial region is an uncommon disease and presents as an abscess or chronic lesion mimicking malignancy, tuberculosis, or fungal lesion. Actinomycosis is difficult to diagnose because of fastidious nature of the organism in culture and general lack of familiarity with the disease. So, a high index of suspicion is required to make an accurate and timely diagnosis. We present a case of male patient with actinomycosis of submandibular triangle complaining of neck mass.

FACIAL ACTINOMYCOSIS FOLLOWING THE EXTRACTION OF LOWER THIRD MOLAR