Actinomycosis

Actinomycosis - the chronic illness caused by various kinds of Actinomyces. It is characterised by a lesion of various organs and tissues with formation of dense infiltrates which then abscess with the advent of fistulas and an original lesion of a skin.

Actinomycosis aetiology

Originators - various kinds of Actinomyces, or radiant mushrooms. The cores from them is the following: Actinomyces israelu, Actinomyces bovis, Actinomyces albus, Ac. violaceus. Actinomyces well grow on nutrient mediums, forming colonys of the irregular form, is frequent with radiant edges. Are pathogenic for many kinds of agricultural and laboratory animals. In a pathological stuff meet in the form of druses which represent yellowish lumps in diameter of 1-2 mm. At microscopy in the centre of druses the clump of strands of a mycelium, and on periphery - flasklike inflations is found. At a coloration a hematoxylin - eosine the central part of druse is imbued in dark blue colour, and flasks in the pink. There are druses at which the border from flasklike cells is absent. Actinomyces are sensitive to a benzylpenicillin (20 Unit/ml), streptomycin (20 mkg/ml), Tetracyclinum (20 mkg/ml), Levomycetinum (10 mkg/ml) and erythromycin (1,25 mkg/ml).

Actinomycosis epidemiology

The actinomycosis is extended in all countries. With it humans and agricultural animals are ill. However cases of infestation of the human from sick humans or animals it is not described. Originators of an actinomycosis eurysynusic in the nature (hay, straw, bedrock, etc.). Actinomyces often find in healthy humans in an oral cavity, a debris, lacunas of tonsils, on a mucosa of a gastrointestinal tract. Matters both exogenous, and endogenous infestation means.

Actinomycosis pathogenesis

The most frequent is the endogenous path of an infection contamination. Actinomyces eurysynusic in the nature, in particular on plants, can get with plants to an organism and be on mucosas as a saprophyte. Transition of Actinomyces from saprophytical in a parasitic state is promoted by inflammatory diseases of mucosas of an oral cavity, a respiratory and gastrointestinal tract. On a place of introduction of Actinomyces the infectious granuloma which sprouts in surrounding tissues is formed. In granulations there are abscesses which, breaking, form fistulas. The skin lesion has secondary character.

In formation of pyeses the role and secondary, mainly staphylococcal infection contamination plays. Antigens of radiant mushrooms lead to a specific sensibilization and allergic rearrangement of an organism (a hypersensibilization of the slowed down phylum), and also to antibody formation (complement-linked, agglutinins, precipitin, etc.).

Symptoms and actinomycosis flow

Duration of an incubation interval is not known. He can fluctuate over a wide range and reach till several years (from time of a becoming infected development of demonstrative forms of an actinomycosis).

The basic clinical forms of an actinomycosis:

1. An actinomycosis of a head, tongue and a neck
2. A thoracal actinomycosis
3. The abdominal
4. An actinomycosis of genitourinary organs
5. A skin actinomycosis
6. A mycetoma
7. An actinomycosis of the central excitatory system

The actinomycosis concerns to initially-persistent infections with long progressing flow. At infiltrate growth the skin is involved in process. In the beginning very dense and almost painless infiltrate is defined, the skin becomes tsianotichno-crimson, there is a fluctuation, and then educe is long not healing fistulas. In pus find belovato-yellowish fine lumps (druses).

Cervicofacial actinomycosis meets most often. On expression of process it is possible to secure the deep (muscular) form when process is localised in an intermuscular fat, hypodermic and dermal forms of an actinomycosis. At the muscular form process is localised mainly in masseters, under a fascia covering them, forming dense, cartilaginous consistences an infiltrate in the field of a mandible angle. The person becomes azygomorphous, the masticatory spasm of various intensity educes. Then in an infiltrate there are locuses of a ramollissement which are spontaneously dissected, forming the fistulas abjointing purulent or krovjanisto-purulent fluid, sometimes with an admixing of yellow grains (druses). A cyanotic coloration of a skin round fistulas it is long remains and is characteristic implication of an actinomycosis. On a neck original changes of a skin in the form of cross-section located platens are formed. At the dermal form of an actinomycosis infiltrates ball-shaped or semiball-shaped, localised in a hypodermic fat. A masticatory spasm and disturbances of processes of chewing it is not observed. The dermal form meets seldom. Actinomycotic process can grasp cheeks, labiums, tongue, tonsils, a trachea, orbits, a larynx. Flow rather congenial (in comparison with other forms).

Thoracal actinomycosis (an actinomycosis of organs of a thoracal lumen and a thoracal side), or an actinomycosis of lungs. The beginning gradual. There is a delicacy, subfebrile temperature, tussis, in the beginning dry, then with a mucopurulent sputum, is frequent with a blood admixing (the sputum has an odour of the earth and taste of copper). Then the peribronchitis picture educes. The infiltrate extends from the centre to periphery, grasps a pleura, a thoracal side, a skin. There is a tumescence with extremely expressed stinging morbidity at a palpation, the skin becomes bagrovo-cyanotic. Fistulas educe, in pus druses of Actinomyces are found. Fistulas intercommunicate with bronchuses. They settle down not only on a thorax, but can appear on a loin and even on a hip. Flow serious. Without treatment patients die. On frequency the thoracal actinomycosis takes the second place.

Abdominal actinomycosis also meets often enough (takes the third place). The primary locuses are more often localised in ileocecal range and in the field of an appendix (over 60 %), then there are other departments of a colon and the stomach or a thin intestine, an esophagus is very seldom amazed initially.

The abdominal wall is amazed again. The primary infiltrate is localised in ileocecal range more often, quite often imitates surgical diseases (an appendicitis, impassability of an intestine, etc.). Extending, the infiltrate grasps also other organs: the liver, nephroses, a column, can reach an abdominal wall. In the latter case there are characteristic changes of a skin, the fistulas intercommunicating with an intestine. Are located usually in inguinal range. At an actinomycosis of a rectum infiltrates cause occurrence of specific paraproctites, fistulas are dissected in perianal range. Without etiotropic treatment the lethality reaches 50 %.

Genital actinomycosis and Pelvic actinomycosis meets rare. As a rule, it is secondary lesions at infiltrate diffusion at an abdominal actinomycosis. Primary actinomycotic lesions of generative organs meet very seldom.

Actinomycosis of bones and joints meets rare. This form arises or as a result of transition of an actinomycotic infiltrate from the next organs, or is a consequence of hematogenous drift of a mushroom. Osteomyelites of bones of an anticnemion, a basin, a column, and also a lesion patellar and other joints are described. Quite often process is preceded by a trauma. Osteomyelites proceed with a destruction of bones, formation of sequesters. Attracts attention, that despite the expressed osteal changes, sick keep ability to move, at lesions of joints function seriously is not broken. At formation of fistulas there are characteristic changes of a skin.

Skin actinomycosis arises, as a rule, again at primary localisation in other organs. Skin changes become appreciable when actinomycotic infiltrates reach a hypodermic fat and are especially characteristic at formation of fistulas.

Mycetoma - an original variant of an actinomycosis. This form was known for a long time, often enough met in the tropical countries. Disease begins with appearance on stop, mainly on a sole, one or several dense circumscribed knots in size from a pea and more, covered at first not variated skin, further over inspissations the skin becomes red-violet or brownish. In the neighbourhood with pristine knots appear new, the skin swells, autopodium is enlarged in volume, changes the form. Then knots are softened and dissected with formation of deeply going fistulas excreting purulent or is serous-purulent, sometimes bloody fluid, is frequent with a fetor. In abjointed fine grains of usually yellowish colour (druse) are appreciable. Knots are almost painless. Process slowly progresses, all sole is penetrated by knots, toes turn up. Then knots and fistulous courses appear and on autopodium back. All autopodium turns to the deformed and pigmented mass penetrated by fistulas and lumens. Process can pass to muscles, tendons and bones. The atrophy of muscles of an anticnemion is sometimes observed. Usually process grasps only one autopodium. Disease proceeds very longly (10-20 years). Complications. Stratification of a secondary bacteriemic infection contamination.

The diagnosis and the differential diagnosis. In far come cases with formation of fistulas and characteristic changes of a skin the diagnosis of difficulties does not represent. It is more difficult to diagnose initial forms of an actinomycosis.

For diagnostics the intracutaneous test with actinolysathos has some value. However in attention it is necessary to accept only positive and sharply positive assays as weakly positive intracutaneous tests often happen at patients to diseases of dens (for example at an alveolar pyorrhea). Assay Negative takes not always allow to exclude an actinomycosis as at patients with serious forms they can be negative owing to sharp oppression of cellular immunodefence, they are always negative at a HIV-infected. Abjection of culture of Actinomyces from a sputum, a mucosa of a fauces, a nose has no diagnostic value as Actinomyces are quite often found and in healthy faces. The reaction of binding complement with actinolysathos which happens positive at 80 % of patients has diagnostic value. The greatest diagnostic value has abjection (detection) of Actinomyces in pus from fistulas, in biopsy samples of the amazed tissues, in druses, in the last is sometimes microscopically mycelium strands are found only. In these cases it is possible to try to secure culture of Actinomyces by stuff sowing on medium of the Aloe.

Actinomycosis of lungs is necessary for differentiating from neoplasms of lungs, abscesses, other deep mycoses (an aspergillosis, a nocardiosis, a histoplasmosis), and also from a pulmonary tuberculosis. The abdominal actinomycosis should be differentiated from various surgical diseases (an appendicitis, a peritonitis and so forth). A lesion of bones and joints-from of purulent diseases.

Actinomycosis treatment

The best results are given by a combination of a causal treatment (antibiotics) and immunotherapies. At the is cervical-maxillofacial form prescribe inside a phenoxymethylpenicillin for 2 grammes/days and at duration of a course not less than 6 weeks. It is possible to prescribe also Tetracyclinum in the big doses (on 0,75 gramme 4 times a day within 4 weeks or on 3 gramme a day only in the first 10 days, and then on 0,5 gramme 4 times a day within last 18 days). Erythromycin is prescribed on 0,3 gramme by 4 times a day within 6 weeks. At abdominal forms and at an actinomycosis of lungs prescribe the big doses of a benzylpenicillin (10000000 Unit/day and more) intravenously within 1-1,5 months with the subsequent transition to a phenoxymethylpenicillin in a daily dose of 2-5 gramme within 2-5 months. At consecutive infection stratification (staphilococcuses, an anaerobic microflora) prescribe long courses of a dicloxacillin or antibiotics of tetracycline bunch, at a mephitic gangrene - metronidazole. For an immunotherapy actinolysathos it is possible to introduce subcutaneously or intradermally, and also it is intramuscular. Under a skin and intramusculary introduce on 3 ml actinolysathos 2 times a week. On a course of 20-30 injections, duration of a course 3 months At an abscess, an empyema spend surgical treatment (dissecting and a drainage). At extensive damages of a pulmonary tissue sometimes resort to a lobectomy. From antibiotics the most effective are Tetracyclinums, then go a phenoxymethylpenicillin and erythromycin is less effective. Refractory to these antibiotics of strains of Actinomyces did not meet.

Actinomycosis forecast

Without etiotropic treatment the forecast serious. At an abdominal actinomycosis 50 % of patients died, at the thoracal all patients perished. Rather the is cervical-maxillofacial actinomycosis is easier proceeded. All it causes necessity of early diagnostics and the beginning of therapy before development of serious anatomical damages. Considering possibility of relapses, convalescents should be under long observation (6-12 months).

Actinomycosis preventive maintenance and actions in the locus

Hygiene of an oral cavity, timely treatment of dens, inflammatory changes of tonsils and an oral cavity mucosa. Specific preventive maintenance is not developed. Actions in the locus do not spend.