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Patient Case: Actinomycosis

Patient Case: Actinomycosis

Discussion

Chief Complaint: “I have a swelling on my jaw that has been slowly growing over the past few weeks.”

History of Present Illness:
A 45-year-old male presents to the clinic with a firm, slowly enlarging swelling on the left side of his jaw that started about six weeks ago. He initially noticed a small lump, which gradually increased in size and eventually developed a draining sinus with yellowish discharge. The area is mildly tender, but he denies fever, weight loss, or systemic symptoms.

The patient has a history of poor dental hygiene and recently had a tooth extraction before the swelling appeared. He denies trauma, travel history, or recent infections.

Past Medical History:

  • No known chronic illnesses
  • No history of tuberculosis or cancer

Physical Examination:

  • Head and Neck:
    • Firm, indurated mass along the left mandible
    • Multiple draining sinus tracts with thick, yellowish "sulfur granules" in the exudate
    • No cervical lymphadenopathy
  • Oral Examination:
    • Poor dentition with evidence of previous extractions
    • No visible intraoral lesions

Diagnosis:
Based on the chronic, slow-growing jaw swelling with draining sinus tracts containing sulfur granules, the most likely diagnosis is cervicofacial actinomycosis, a bacterial infection caused by Actinomyces israelii.

Diagnostic Tests:

  • Gram stain and culture of the discharge: Shows Gram-positive, filamentous, branching bacteria
  • Histopathology: Presence of sulfur granules
  • CT scan: Evaluates the extent of tissue involvement

Management Plan:

  • High-dose penicillin (IV for 4-6 weeks, followed by oral therapy for several months)
  • Surgical drainage if necessary for large abscesses
  • Improved dental hygiene to prevent recurrence

The patient is counseled on the importance of completing long-term antibiotic therapy and maintaining oral health to prevent future infections.

Questions
  1. What is the most likely diagnosis in this patient?
    a) Tuberculous lymphadenitis
    b) Cervicofacial actinomycosis
    c) Osteomyelitis
    d) Oral squamous cell carcinoma
  2. What is the characteristic finding in actinomycosis?
    a) Painless vesicles on the mucosa
    b) Rapidly progressing soft tissue necrosis
    c) Sulfur granules in purulent discharge
    d) Enlarged tender cervical lymph nodes
  3. What is the first-line treatment for cervicofacial actinomycosis?
    a) Oral doxycycline for 10 days
    b) IV penicillin followed by prolonged oral therapy
    c) Surgical resection without antibiotics
    d) Metronidazole for 7 days
  4. Which factor most likely contributed to the patient’s infection?
    a) Poor dental hygiene and recent tooth extraction
    b) Travel to an endemic region
    c) Recent antibiotic use altering oral flora
    d) Contact with farm animals
Reveal answers

Answers

  1. (b) Cervicofacial actinomycosis – The slow-growing mass with draining sinus tracts and yellowish sulfur granules is characteristic of actinomycosis, which often occurs after dental procedures or poor oral hygiene.
  2. (c) Sulfur granules in purulent discharge – Actinomycosis produces thick yellow granules in the drainage, which are dense bacterial colonies that help confirm the diagnosis.
  3. (b) IV penicillin followed by prolonged oral therapy – Actinomycosis requires long-term antibiotic therapy, typically high-dose IV penicillin for 4-6 weeks, followed by oral therapy for several months.
  4. (a) Poor dental hygiene and recent tooth extraction – Actinomyces israelii is a normal oral flora that can invade tissue after dental procedures, trauma, or poor hygiene, leading to chronic infections.

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