Actinomycosis - Causes, symptoms and treatment. MF.
Jun 29, 2018
Causes of Actinomycosis
Pathogenesis of Actinomycetes
Symptoms and Forms of Disease
Prevention of Actinomycosis
Actinomycosis refers to quite specific fungal diseases affecting humans and occurs with a certain frequency in all countries of the planet. Patients with actinomycosis account for up to 10% of all purulent lesions of various localizations. The characteristic formation of specific granulomas with subsequent development of abscesses and fistulas indicates the urgency of the disease for many medical specialties and requires careful differential diagnosis.
Actinomycosis is an infectious disease of chronic course caused by radiant fungi - actinomycetes, affecting both human and animals, and characterized by the formation of specific granulomatous foci on the skin, mucous membranes and internal organs, the so-called actinomycete. Often, the disease leads to the development of purulent complications in the areas of primary localization of foci of actinomycosis. Synonym for the disease is a radiation-fungal disease .
For the first time, the causal relationships of the onset of purulent animal diseases( cattle) with fungal nature( radiant fungi) are assigned to the years 1845 to 1877( scientists O. Bollinger, B. Langenbeck, N. Lebert).In laboratory conditions, the growth of the mycelium of fungi from the material from a sick person was achieved only in 1885, which greatly facilitated the subsequent diagnosis of the disease.
But to this day there is no clear registration of actinomycosis both in Russia and in the countries of the world. Doctors of various specialties( surgeons, dentists, dermatologists, infectious diseases and others) deal with such patients, with the most frequent localization of the foci being the neck and face area( 75-80% of all lesions).An alarming fact is the development in 20% of cases, that is, for every 5 patients, a visceral form of the disease with the defeat of internal organs and systems. The chronic nature of actinomycosis is most often due to late diagnosis of the causes of the lesion.
The causes of the development of actinomycosis
The causative agent of the disease are specific microorganisms - radiant fungi of the genus Actinomyces( actinomycetes) of several species( Actinomycesalbus, A. bovis, A. candidus, A. israelii, violaceus).From the name is a special sign - the growth of fungi is accompanied by the formation of mycelium( or colonies) in the form of strings( druses) with thickening at the end( having the form of cones), located beams. The microscopy of the material with staining( hematoxylin-eosin) reveals the staining of the fungal filaments in blue, and the thickening in pink, and therefore the colonies take on a peculiar form.
Actinomycetes are found in normal microflora( saprophytes) in the oral cavity, cavities of caries-affected teeth, on the surface of the tonsils, in the upper parts of the bronchi, in the digestive system, in the rectum, and in the anus. Actinomycetes are widespread in nature, often found in soil, aquatic environments, dry grass, straw. These findings allow us to distinguish both the exogenous nature of infection and endogenous infection( the spread of fungi from the internal environment of the human body).Actinomycetes are sensitive to a number of antibacterial drugs - benzylpenicillin, streptomycin, tetracycline, levomycetin, erythromycin.
The source of infection of with actinomycosis is often not traced. It is rare to find direct confirmation of the contact of a person with another sick actinomycosis. Given the wide prevalence in nature, as well as in the microflora of many organs and systems of the human body, two types of infection have been identified: exogenous and endogenous.
The mechanism of infection of in case of exogenous infection( which is more and more rare recently) is contact-household, aerogenic with airborne and air-dust transmission routes. With more frequent endogenous infection, actinomycetes enter different plants in the human body, there is no pathogenic effect in a certain period( saprophytic existence), but the development of both a local inflammatory process and lymphogenous or hematogenous infection can occur.
The susceptibility of to actinomycosis is universal. More frequent registration of male patients was noted, which exceeded the female part of patients by 1.8-2 times. The most frequently affected age groups are the able-bodied population from 21 to 40 years old. The outcome of infection, of course, affects the initial state of human immunity. There is an increase in the incidence of cases during the cold season, that is, in the autumn-winter season.
Pathogenic effect of actinomycetes on the human body
1) In case of endogenous infection and transitory saprophyte existence, it is possible to develop inflammatory processes in the mucous membranes( oral cavity, gastrointestinal tract mucosa, respiratory mucosa) in places of localization.
There are risk factors for the onset of actinomycosis: a decrease in the resistance of the entrance gate of the infection( oropharynx), which occurs due to frequent colds;decrease in the body's resistance due to the presence of concomitant pathology( diabetes, tuberculosis, liver cirrhosis, bronchial asthma, oncological diseases and others), the presence of chronic inflammatory foci;supercooling;pregnancy;various surgical interventions for purulent-inflammatory processes;various anatomical abnormalities( bronchial fistula of the neck, urahus - fistula of the bladder and anterior fascia of the abdomen, and others);injuries, injuries, bruises.
A specific granuloma( actinomycoma) is formed, which can be inflated with the formation of abscesses, the formation of fistulas. That is, the development of actinomycoma consistently goes through three stages: the infiltrative stage, the stage of abscess formation, the fistulous stage. Purulent consequences are more often associated with the attachment of a secondary bacterial infection( staphylococcus aureus, streptococcus).The process can spread to the skin.
2) During the life of radiant fungi, toxins are released, which are allergens, causing sensitization of the patient's body( allergic alertness).
Clinical forms and symptoms of actinomycosis
The incubation period is unknown( it can last from several days to several years).For a long time the patient does not complain, and his health does not change.
Clinically, several forms of the disease are distinguished:
1) cervico-facial form( this includes the maxillofacial damage);
2) cutaneous form;
3) osteo-articular form;
4) Thoracic form;
5) abdominal form;
6) urogenital form;
7) nervous form( actinomycosis of the central nervous system);
8) foot actinomycosis( Madurian foot or mycetoma);
9) Rare shapes.
The cervico-facial form of actinomycosis is the most common. The process can be located in the muscle, directly under the skin and in the skin. More often in the area of the muscle( for example, chewing, in the corner of the lower jaw) appears dense knotty formation of a dense consistency. Characterized by asymmetry of the face, pastose or puffiness in the site of the node, a cyanotic skin tone over the formation. Gradually, in the field of education, soft foci( suppuration or infiltrate) are palpated, foci can be opened with fistula formation. Out of the fistulas, a purulent-purulent fluid flows out, upon closer examination, grains of yellow color are seen( druses of actinomycetes).The flow of this form is favorable.
Actinomycosis, maxillofacial form
The cutaneous form of arises in most cases secondarily after cervico-facial muscular damage. If the skin suffers, in the subcutaneous fat cells appear round or oval shaped infiltrates. The process can affect the neck, cheeks, lips, go to the oral cavity, larynx, tonsils, orbits and other areas. A characteristic feature of actinomycosis is a prolonged cyanosis( cyanosis) of the skin in the lesion. The cutaneous form can proceed in several variants: it can be
- atheromatous variant ( infiltrates on the skin look like an ather and occur at a younger age),
- tuberculo-pustular variant of ( there are elevations on the skin, which subsequently transform into pustules),
- gum-knotty variant ( very dense knots),
- peptic variant of ( with severe immunodeficiency, infiltrates occur with subsequent necrosis of tissues and ulcerative skin lesions).
The bony-articular form of of actinomycosis is a fairly rare form of the disease. It develops as a result of hematogenous drift of actinomycetes or germination of the infiltrate from neighboring tissues and organs. The risk factor is patients with injuries, bruises, wounds. Osteomyelitis occurs with a subsequent destructive process, fistulas can form. Osteomyelitis of pelvic bones, spine and other bones, articular lesions are described. Patients complain of pain, but the functions of the affected joints suffer little, the patients retain the ability to move.
The thoracic form of is the second most frequent occurrence in humans. It is also called thoracic actinomycosis or actinomycosis of the lungs. The formation of this form of actinomycosis can be preceded by various chest injuries, chronic inflammatory processes of the lungs and surgical interventions. The disease has no acute onset, as with many pulmonary pathologies. Patients feel weakness, fatigue, low temperature( more often up to 37.5 °), a dry cough appears, which with time becomes wet( sputum purulent with an admixture of blood, an earthy odor or a smell of dampness).There are pains in the chest when coughing and breathing. The formation of the infiltrate in the lungs has a certain dynamics - the spread from the center to the periphery, that is, the surrounding areas( peribronchitis), the pleura, the thorax and, last but not least, the integuments are involved in the process. Visible changes are characterized by swelling or pasty of the lesion, soreness when palpation( palpation), as with skin form, the skin above the focus becomes bluish with a crimson hue. There may also be an autopsy of a purulent infiltrate with the formation of a fistula. The fistula goes to the surface of the skin, fistulas can be opened both on the chest and in the lumbar region. There is a breakthrough in the infiltrate and into the large bronchus itself, in which the patient has a profuse exodus of purulent sputum when coughing. Complications are damage to the heart and breast. This form is usually difficult, without timely medical assistance, the outcome may be unfavorable.
Actinomycosis, thoracic form
Abdominal form of is also a consequence of surgical interventions( removal of appendix, stones in the gallbladder and others), chronic enterocolitis, intestinal obstruction, wounds, injuries. In some patients( up to 10%) actinomycosis is associated with endogenous infection. Up to 60% of the actinomycet is formed in the appendix area, the large intestine, and the small intestine and stomach are less often affected. The patient is concerned about abdominal pain, sometimes acute with irradiation in the bladder, rectum. Then the infiltrate begins to spread to the periphery, affects "everything that is on its way" - the liver, spleen, kidneys and, finally, the abdominal wall can be affected, in the final fistula is formed. Often, the location of fistulas in the abdominal form is the inguinal region, with the defeat of the rectum - the perianal region. This form also occurs severely, with late diagnosis and the absence of specific treatment, an unfavorable outcome for every second patient.
Actinomycosis of the intestine, radiography
Genitourinary form of actinomycosis - infrequent manifestation of the disease. Risk factors are chronic inflammatory diseases of the urinary system and genital organs, IUD, urolithiasis, surgical interventions. Most often occurs the formation of infiltrates in neighboring systems, and the genitourinary system is affected again, that is, germination occurs in the pelvic organs, for example, as a result of the abdominal form.
The nervous form ( actinomycosis of the central nervous system) develops in most cases again after the formation of the cervico-facial form. The infection spreads lymphogenically, hematogenously or contactingly. Meningitis, meningoencephalitis or brain abscess is forming. When distributed with blood flow, multiple actinomycomas can form in the brain. Complaints of patients coincide with those of meningitis and encephalitis( headaches, nausea and vomiting, symptoms of cranial nerve damage, and others).The spinal cord can also be involved in the process.
Foot actinomycosis ( mycetoma, Madurian foot) is characterized by the formation of a dense knot on the plantar surface of the foot or several nodes measuring 1 cm or more, over which the skin color changes from reddish-violet to purple-cyanotic. There is edema of the foot, tenderness when walking due to edema( the nodes themselves are practically painless).Then the node is opened and the fistula is formed on the surface of the skin. The fistula to be separated, as well as in other forms, has a purulent character with bloody inclusions and yellowish specks of druses of actinomycetes, it has a ground smell or a fetid odor. Often the process can progress and move to the rear of the foot, surrounding the muscle tissue, tendons, bone tissue. The process is often one-sided, has a chronic character( decades).
Rare forms affect such organs and systems as the thyroid gland, tonsils, nose, middle ear, tongue, organs of vision, salivary glands, pericardium.
Diagnosis of actinomycosis
1. Preliminary diagnosis - clinical and anamnestic. When a patient is initially treated, the correctly collected history can help in setting the presumptive diagnosis and determine the correct algorithm for further doctor action. The patient's anamnesis is important: trauma, surgical intervention, presence of chronic foci of infection. Clinically, the initial stages of the disease are difficult to diagnose, most patients turn to doctors of various specialties for a long time before the correct diagnosis is made.
Differential diagnosis is performed with purulent skin lesions, subcutaneous fat, osteomyelitis of other etiology, pulmonary tuberculosis, neoplasms, aspergillosis, histoplasmosis, nocardiosis, lung abscess, appendicitis, peritonitis, secondary meningitis and meningoencephalitis of various etiologies, pyelonephritis, prostatitis, uterine myomas andmany other zabolevaniya.
In the stage of abscess formation and fistula formation, diagnosis is facilitated in favor of actinomycosis.
2. The final diagnosis is made after a laboratory-instrumental examination of the patient.
A) Isolation of the culture of actinomycetes in purulent contents of fistulas, biopsies of affected tissues. Crops of phlegm, phlegm and nose are not diagnostic due to the possible detection of saprophytic actinomycetes. For the study, a sowing of the material on the Saburo medium is used, followed by microscopy of the grown colonies. The preliminary result in 3 days, the final result in 10-12 days.
Actinomycetes, culture of radiant fungi
Macroscopically detect infiltrative granulomas( actinomycomes), tissue disintegration, purulent transformation of actinomycetics, fibrosis and the formation of a scar tissue similar to a cartilaginous "honeycomb" in the finale.
Microscopically in the focus of actinomycosis is revealed: tissue proliferation, necrosis and decay of cells of the central part of the granuloma, the formation of fibrous structures around the periphery, the presence of xantom cells and the development of fibrosis. There are two variants of actinomycoma: destructive or initial stage of development( granulation tissue consisting of connective tissue cells and polymorphonuclear leukocytes, a tendency to cell disintegration and suppuration, actinomycete druses) and a destructive-productive or secondary stage( lymphoid, epithelioid,xantom cells, plasma cells, hyaline cells, collagen fibers, scar tissue, druses of actinomycetes).
Druses of actinomycetes are an interweaving of the finest filaments of mycelium, they are lobed in structure, the ends of filaments are bulbous in shape( they occur in aerobic species of actinomycetes).At the same time, filamentous druses can also occur without a bulbous thickening at the ends( anaerobic actinomycetes, which cause more severe forms of the disease).Druses are mainly located in the center of the actinomycete, and peripherally inflammatory infiltration.
Actinomycosis, electron microscopy
B) Positive DSC with actinolysate or RIF-immunofluorescence reaction for the determination of actinomycete species( 80% of patients with actinomycosis have positive reaction data) is important in the diagnosis.
Serological diagnostics and PCR diagnostics are still being developed.
C) X-ray diagnosis in lung lesions reveals the presence of focal infiltrates, similar in location to tuberculosis, signs of peribronchitis, perivasculitis, an increase in the root lymph nodes. There may be cavities of decay, involvement in the process of mediastinum, esophagus, formation of fistulas. The process can affect the share as a whole, but the share boundaries are not an obstacle to the spread of infiltrate( a hallmark of lung cancer).
When radiographing other forms( for example, osteoarticular), there are actinomycotic foci - the so-called scales, peripheral sclerosis, osteolysis, periosteal stratifications, fistulas. A distinctive feature is the absence of narrowing of the joint space. With lesions of the vertebrae - the destruction of intervertebral discs and vertebral bodies, ossification of ligaments, the phenomenon of sclerosis and other changes. With cervico-maxillofacial form - hyperostosis, foci of osteolysis, lack of sequestration.
D) Ultrasound diagnosis of internal organs( with abdominal form of the disease)
E) Paraclinical diagnostic methods have an auxiliary value( blood tests, urine, biochemical blood test).
Treatment of actinomycosis
Treatment includes a number of complex activities complementing each other.
1) Immunotherapy is the introduction of specific drugs( actinolysate).
Actinolysate is a filtrate of broth culture of spontaneously lysing strains of aerobic actinomycetes. Actinolysate is administered intradermic hand according to the scheme( 0.5ml-0.7-0.9-1.0-1.1-1.2-1.3-1.4-1.5-1.6-1,7-1,8-1,9-2,0 ml, then 2 ml each), with no more than 0.5 ml to each point, that is, from the 14th injection to 4 different points. Actinolysate can be injected intramuscularly into the buttocks of 3 ml. Injections of the drug are carried out 2 times a week for 3 months. The interval between treatment courses is 1 month. Intradermal administration is more economical and more effective. After clinical recovery, 1-2 antiretroviral courses are shown, observation is 2 years.
Actinomycosis, actinolysate therapy
2) Antibiotic therapy is carried out with the following drugs: benzylpenicillin1-2 million units / day courses up to 6 weeks, tetracycline 3 g / day for the first 10 days, then 2 g / day for 14-18 days, erythromycin 1,2 gr / day 6 weeks and others. Before treatment it is recommended to carry out an antibioticogram of the isolated material for effective therapy.
All medications are prescribed strictly by a doctor and under his supervision!
3) Surgical treatment methods are indicated when conservative therapy is ineffective and include excision of the lesion and damaged tissue.
The prognosis of the disease is serious. In the absence of specific therapy of severe forms( thoracic, abdominal, nervous), up to 50% of patients may die. All patients are on dispensary observation for 12-24 months to prevent recurrence of the disease.
Prevention of actinomycosis
1) Hygienic education of youth and adherence to sanitary rules in everyday life( oral hygiene, timely dental treatment).
2) Timely diagnosis of chronic foci of infection and their immediate sanitation.
3) Elimination of situations that cause a decrease in the body's defenses( hypothermia, frequent colds).
4) Clinical follow-up of patients with chronic concomitant pathology( bronchial asthma, chronic obstructive pulmonary disease, chronic enterocolitis, liver cirrhosis, Crohn's disease and others).
The doctor infektsionist Bykova N.I.