metacarpal bones.

First a soft tissue infection,

it will eventually spread to the
bony structures. Grains are commonly
seen in this particular form.
Actinomycosis of the central nervous
system (CNS) may present as brain abscess,
meningitis, meningoencephalitis,
subdural empyema, actinomycoma, and
spinal abscess. It is usually secondary to
hematogenous spread.
Laboratory tests considered useful include
direct examination of draining material,
culture, and biopsy. Direct examination
will show the presence of filamentous
Actinomyces on Gram stain. The isolation of
Actinomyces in culture should be considered
diagnostic, if coming from a sterile site.
However, positive culture rates are as low
as 35 percent in some series. The processing
should be done in anaerobic conditions,
and when all techniques available
today are used, the percentage of isolates
that cannot to be identified is as low as 2.8
percent.! '"
The presence of granules, either microscopically
or macroscopically, is very
relevant, especially if obtained from tissues
not connected to mucosal surfaces.
Grains are usually yellow (hence the
name sllifur granules), but can be white,
pinkish gray, gray, or brown. In tissue
samples, special stains, such as BrownBrenn,
Gram, Giemsa, or Gomori stains,
are reqUired to demonstrate filamentous
structures. The number of grains is usually
scanty: only one Single granule was
identified from 25 percent of specimens
in a study of 181 cases.3 The SplendoreHoeppli
phenomenon, a rim of eosinophilic
material, may surround the granules
in tissue cuts. The lack of staining
with Fite modified acid-fast stain separates
Actinomyces from ocardia sp. Eumycetoma
granules stain positive with
periodic acid-Schiff and Gomori,
whereas granules from Botryomycosis
should show clumps of bacteria. Direct
immunofluorescent staining is available
for some species, including A. israelii
(see Table 185-1).

Differential Diagnosis
Depending on the site affected, the differential
diagnosis will include infections
such as tuberculosis, non-infectious
inflammatory processes such as
hidradenitis and inflammatory bowel
disease, and neoplaSia (Box 185-1).

Box 185-1

Differential Diagnosis of
Actinomycosis (Site-Specific)

Most Likely
Face: tuberculosis, odontogenic
abscesses, parotid tumors
Chest: tuberculosis, neoplasm, pyogenic
infections
Abdomen and pelvis: tuberculosis,
inflammatory
bowel disease, hidradenitis suppurativa,
neoplasm

Consider
Face: lupus panniculitis, granuloma
inguinale
Pelvis: granuloma inguinale
dose antibiotics to be given for a long period.
The treatment of choice is penicillin
G 18 to 24 million units intravenously for
2 'to 6 weeks, followed by oral penicillin
or amoxicillin, to be given for 6 to 12
months. Cervico-facial disease or any
more limited disease can receive a shorter
course of therapy. A good rule to follow
is to give therapy until full resolution of
clinically evident disease. Alternative
treatment for those allergic to penicillin
includes tetracycline, doxycycline, erythromycin,
and clindamycin. Irnipenem has
been used successfully as short-term therapy.
Chloramphenicol is the alternative
to penicilIin in cases of CNS involvement.
Risk factors for death or relapse include
duration of disease longer than 2 months,
lack of antibiotic therapy or surgical therapy,
and needle aspiration rather than
open drainage or excision.
With early diagnosis and more limited
disease, as compared to the bulky
disease of the past, treatment can be
shorter: 30 days for cervico-facial disease
and 3 months for pelVic or thoracic
disease.s Periapical actinomycosis can
be successfully treated with curettage
and 10 days of antibiotic therapy.
Surgery is indicated for bulky disease
involVing the chest, abdomen, pelvis,
and CNS. It should be directed to resection
of necrotic tissue, excision of sinus
tracts, draining of empyemas and abscesses,
and curettage of bone, always
accompanied by antibiotic therapy.
Antibiotics that are effective against
synergistic microbes that accompany
the Actinomyces can reasonably be included
in the initial therapy.

Prevention
Prognosis and Therapy
There is general agreement that the treatment
of actinornycosi requires high-

Good oral hygiene and prevention of periodontal

disease may decrease colonization
by Actillomyces. Physicians dealing with pa-

NOCARDIOSIS

'

.-, ...

. ~,,'

. ~' ','

'. ~ .oil,

Aerobic Gram-positive filamentous

bacteria.
Worldwide distribution, environmentally
acquired infection, due to primary traumatic
inoculation.
Pulmonary infections mostly in
immunocompromised
patients and skin infections
mostly in immunocompetent patients.
Skin disease mostly caused by Nocardia
brasiliensis; less commonly N. asterOides,
N. otidiscaviarum, and N. farcinica.
Cutaneous nocardiosis can take the form
of either cellul itis or more characteristic
Iymphocutaneous nodules in asporotrichQid
pattern; skin lesions also occur in
disseminated disease.
Diagnosis is based on Gram stain of clinical
specimen showing thin, gram-positive
branching bacteria, weakly positive with
acid-fast staining; microbiologic isolation
of Nocardia sp. is diagnostic, but requires
keeping cultures under observation 5 to
7days.
Treatment: sulfonamides.
tients using an IUD should be aware of the
risk of developing the disease.

NOCARDIOSIS

Epidemiology
The Nocardia sp. are aerobic, Gram-positive,
filamentous, higher bacteria found
worldwide in soil and decaying organic
plant matter. They can be found in house
dust, beach sand, garden soil, and swimming
pools. They are able to cause disease
in many organs, including the skin.
Approximately 1000 cases of nocardiosis
occur annually in the United States.6
Cutaneous disease comprises 5 percent
to 22 percent of all cases.6 A higher incidence
of primary cutaneous nocardiosis
in Europe may be explained on the basis
of more frequent isolation of . brasiliensis
in the environment. Patients have also
been described in India and Argentina.4
Disease occurs most commonly in males.
Immunocompromised patients account
for 50 percent of cases mostly pulmonary,