The patient was depressed, uncooperative, seeking only
relieving of the pain in the hard palate. The patient was suffering from social
problems due to her husband death and was treated in the psychiatric clinic and
used (promazen 1gm/day) as an antidepressant for the last year.
Extraoral examination revealed no facial swelling on the
left side of the face. Neither asymmetry nor lymph node involvement were
detected.
Clinical intraoral examination revealed a gray-black
necrotic palatal lesion between the upper left first and second molar teeth
with loss of interdental papillae buccally and palatally (reverse architecture)
superimposed by yellowish discharge. Grade III mobility was detected in the second
molar, and grade I in the first molar. There was a 7mm loss of attachment
distal to the upper left first molar and 9mm attachment loss mesiopalatal
to the upper left second molar. Oral hygiene was fair, with no gingival
inflammation except in the area of the lesion. No deep pockets were detected in other sites
(Fig. 1 & 2).
Periapical radiographs of the area of the lesion revealed
advanced bone loss around upper second molar and moderate bone loss distal to
the first molar. The maxillary first and second molars had large and deep
restorations. The upper left third molar was impacted (Fig. 3).
Adequate surgical debridement under local anaesthesia
was carried out interproximally between upper left first and second molars as
an emergency treatment. A biopsy was performed with considerable amount of
granulation tissue curetted from areas with the lesion from the alveolus and
areas with absence of frank tissue necrosis. The specimen was sent for
histopathological evaluation. Oral penicillin therapy was started as 500 mg
Amoxicillin three times daily.
One week later, the patient came with the result of
the histopathological report as Actinomycosis. The pain decreased but the
tenderness of the upper left second molar persisted. The lesion was improved as
there was no pus discharge. Extraction of upper left second molar was carried out due to advanced bone loss
and grade III mobility. Amoxicillin was continued for four weeks after the
diagnosis of actinomycosis was established.
Six weeks after, the patient came with no pain, no tenderness
of the teeth, improved tissue condition, with no complaints in the upper 1st
molar.
Discussion
Actinomycosis is considered as “the most misdiagnosed
disease” even by experienced clinicians and is listed as a “rare disease” by
the Office of Rare Disease (ORD) of the National Institute of Health (NIH).(13)
The first case of actinomycosis in humans was, described by Von Lnagebeck, in
1845 and it was attributed to a fungus.(14) Aktino referred
to the radiating organism in the sulfur granules as ray fungus that exhibits a
number of simple fungus like characteristics, such as tendency to grow as mass
of rounded bodies (clubs) and filaments in tissue, low virulence, and the
property of eliciting suppuration, necrosis, and a chronic granulomatous tissue
response. The unique nature of the organism is the absence of a nuclear
membrane, which places Actinomyces species among the higher prokaryotic
bacteria.(13)
Five species of Actinomyces have been
identified: A israelli, A bovis, A naeslundii, A viscousus and A
odontolyticus. Actinomyces are either strict or facultative anaerobic
gram positive rods. Morphologically they are filamentous and branching in nature,
except for A bovis, all the species are normal inhabitants of the human
oral cavity. Actinomycosis is caused primarily by Actinomyces israelii,
residing as commensal in periodontal pockets and gingival crevices, in carious
teeth, dental plaques, tonsillar crypts or in the periodontium.(12)
One
of the characteristics of Actinomycosis is the lack of immediate tissue
reaction after implantation of the organism. It usually requires 6 weeks or
longer for an actinomycotic swelling to break down and discharge pus.
Precipitating factors that are believed to lead to
disease in the cervicofacial region include carious teeth, dental manipulations
and maxillofacial trauma. The pathogenesis is related to the microorganism ability
to act as an intracellular parasite therefore resisting phagocytosis as well as
its tendency to spread regardless of the established tissue plains or anatomic
barriers.
The presentation is facilitated by dental extraction
and trauma to the tissues that facilitate the invasion of the microorganism, so
it is considered as one of many post extraction complications. The common site
of presentation following extraction is the region around the angle of the
mandible.(15)
This patient was under treatment by antipsychotic drug
(promazen). The most common side effect of psychiatric medication is a dry
mouth (xerostomia) caused by reduced salivary flow. This has a significant
impact on oral health, increasing the risk of dental caries, periodontal disease
and oral infections.(16)
Actinomycosis is relatively rare; most reports cite an
incidence of one case per year per institution. There is a slight male predominance
from 1.5:1 to 3:1. Actinomycosis is seen more in patients in the 4th
to 6th decade of life, it is very rare in infants and children.(17)
There are no known predisposing racial, environmental or geographic factors.(18)
The
microorganism that cause actinomycosis does not spread via the lymphatic system
because of the size of the bacterium, that is why regional lymphadenopathy is
uncommon or it develops late.(19,20)
The lesions of the nasal, oral and pharyngeal cavities
contiguously extended to the adjacent neck spaces, crossing facial planes .This
infiltrative nature is also reported in the abdominopelvic and thoracic
actinomycosis, and it may be attributed to the actions of the proteolytic
enzymes of the organism.(21,22)
Actinomycosis is often difficult to diagnose and most
of the cases are misdiagnosed.(23) Cervicofacial
actinomycosis may mimic either a malignant neoplasm of the head and neck or a
chronic granulomatous lesion such as that due to tuberculosis or fungal
infection.(24)
At present the actinomycosis of the oral cavity and
face occurs rarely with relatively small inflammatory reaction and the
formation of small periodontal abscesses, together with progressing destruction
of the maxillary bone.(25)
Actinomyces israelii is sensitive to most commonly used antibiotics, Penicillin
being a narrow-spectrum antibiotic, is considered a good choice for treatment in
most cases of actinomycosis, antimicrobial therapy is the only treatment
required, although surgery can be adjunctive in selected cases. The traditional
treatment of extensive actinomycosis is usually a long term course, generally
with up to one month intravenous penicillin G, followed by weeks to months of
oral penicillin.(26)
Cervicofacial actinomycosis is especially responsive to brief courses of antibiotic
treatment. In recent series, 3-6 weeks
of oral antibiotic therapy combined with surgical drainage, has been curative.(27,28)
In the microscopic picture the presence of
actinomycosis colonies are evident. Colonies are surrounded by numerous
neutrophilic granulocytes and macrophages containing fat bodies (Xanthoma cells).
Outside the lesion there is new connective tissue (granulation tissue).(29)
Conclusion
Cervicofacial
actinomycosis is a relatively infrequent infection, despite the fact that this
organism is part of the normal oral flora. Predisposing factors include
debilitating states such as diabetes, malignancy and immunodepression. There
can be also local predisposing conditions such as trauma, surgical intervention,
poor oral hygiene or dental caries.
Actinomycosis should be included in the differential
diagnosis of a relatively homogenously enhancing soft tissue masses associated
with substantial inflammatory reaction and infiltration of the cervicofacial
area. Even in the absence of typical clinical presentation, i.e., discharging
sinus tract on the skin surface, Actinomycosis infection should be considered
in the case of unusual destruction in the oral tissues.
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