IADVL
Indexed with PubMed and Science Citation Index (E) 
 
Users online: 751 
     Home | Feedback | Login 
About Current Issue Archive Ahead of print Search Instructions Online Submission Subscribe What's New Contact  
  Navigate here 
  Search
 
  
 Resource links
   Similar in PUBMED
    Search Pubmed for
    Search in Google Scholar for
   Article in PDF (1,368 KB)
   Citation Manager
   Access Statistics
   Reader Comments
   Email Alert *
   Add to My List *
* Registration required (free)  

 
  In this article
   References
   Article Figures

 Article Access Statistics
    Viewed1574    
    Printed33    
    Emailed0    
    PDF Downloaded78    
    Comments [Add]    

Recommend this journal

 


 
 Table of Contents    
LETTER TO THE EDITOR - CASE LETTER
Year : 2017  |  Volume : 83  |  Issue : 4  |  Page : 468-469

Actinomycotic osteomyelitis


1 Dental Wing, Yashwantrao Chavan Memorial Hospital, Pune, Maharashtra, India
2 Department of Oral Pathology and Microbiology, Dr. D. Y. Patil Vidyapeeth's Dr. D. Y. Patil Dental College and Hospital, Pune, Maharashtra, India
3 Department of Oral Medicine and Radiology, Dr. D. Y. Patil Vidyapeeth's Dr. D. Y. Patil Dental College and Hospital, Pune, Maharashtra, India

Date of Web Publication5-Jun-2017

Correspondence Address:
Supriya Kheur
Dr. D. Y. Patil Vidyapeeth's Dr. D. Y. Patil Dental College and Hospital, Pimpri, Pune - 411 018, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdvl.IJDVL_685_16

Rights and Permissions



How to cite this article:
Ingle Y, Madalli R, Reddy MG, Kheur S, Ingle M. Actinomycotic osteomyelitis. Indian J Dermatol Venereol Leprol 2017;83:468-9

How to cite this URL:
Ingle Y, Madalli R, Reddy MG, Kheur S, Ingle M. Actinomycotic osteomyelitis. Indian J Dermatol Venereol Leprol [serial online] 2017 [cited 2019 Apr 26];83:468-9. Available from: http://www.ijdvl.com/text.asp?2017/83/4/468/206720


Sir,

Actinomycosis is a rare, chronic disease caused by a group of anaerobic, Gram-positive bacterium, Actinomyces israelii. A. israelii accounts for 52% of the infections, whereas Actinomyces viscosus, Actinomyces odontolyticus,  Arachnia propionica Scientific Name Search  and Actinomyces meyeri contribute to 40%, 5%, 2%, 2% and 1%, respectively.[1] It is a non-acid fast, filamentous branched bacterium. Cope in 1938 suggested that the infection may be anatomically classified as cervicofacial (i.e. lumpy jaw), thoracic or abdominal. The most common presentation is cervicofacial, which accounts for over half of the reported cases.[2] Although rarely seen in day-to-day dental practice, due to its aggressive and locally destructive nature, actinomycosis of the oral cavity is a highly significant condition.[3]

Mucosal discontinuity is needed to lead to infection. We report a case of actinomycotic osteomyelitis leading to extensive destruction of mandibular right anterior region following tooth extraction.

A 28-year-old man reported to the dental outpatient department in Yashwantrao Chavan Memorial Hospital, Pimpri-Chinchwad, Pune, Maharashtra, India, with the chief complaint of painful swelling on the lower right premolar and molar region. On taking a detailed past history, the patient explained that he was diagnosed for noma for which surgical intervention was done by a local doctor. Later, he got his mobile tooth 46 extracted and skin graft was placed elsewhere. After 15 days of extraction, swelling developed in the left premolar region for which he reported to the dental outpatient department in a medical hospital. On extraoral examination, a diffuse swelling extending from the lower right corner of the mouth to the left corner of the mouth was noticed without marginal induration. The swelling was tender on palpation. Intraoral examination revealed pieces of white necrotic bone (sequestrum) and swelling in the buccal mucosa [Figure 1]. The mucosa over the swelling was reddish showing sinus tract with purulent exudate on the alveolar ridge at the site of tooth extraction. Right submandibular regional lymphadenopathy was seen. Radiographic examination revealed mottled bone appearance.
Figure 1: Ulcer on the anterior alveolar ridge with necrotic bony spicules

Click here to view


The swelling was then incised under local anesthesia in aseptic conditions. Caseous material was observed with purulent discharge. Pus culture showed the presence of nonsporing Gram-positive rods. Biopsy was taken and the tissue was histopathologically analyzed. Hematoxylin and eosin stained sections revealed bone with empty lacunae indicating sequestrum. Numerous actinomycotic colonies consisting of club-shaped filaments with basophilic central core and eosinophilic peripheral portion were seen with some neutrophils [Figure 2] and [Figure 3]. The histological appearance of the biopsied material was consistent with that of osteomyelitis in association with infection by Actinomyces organisms. Based on this, a diagnosis of actinomycotic osteomyelitis was given. Incision and drainage was performed and amoxicillin along with clavulanic acid 625 mg orally twice daily was prescribed for 7 days. The patient was recalled after a week and continued the medication for another 2 weeks. The patient reported after 2 months with no complaints.
Figure 2: Necrotic bone and actinomycotic colonies in the marrow spaces (H and E, ×100)

Click here to view
Figure 3: Necrotic bone with empty lacunae and actinomycotic colonies (ray fungus) (H and E, ×400)

Click here to view


Osteomyelitis due to Actinomyces has been reported infrequently. The spread of Actinomyces by hematogenous route with intraosseous granuloma formation and minimal subperiosteal bone reaction has been reported by Bala et al.[4] In cervicofacial actinomycosis which is the most frequent the mandible is more commonly involved than maxilla (4:1). It requires a break in the integrity of the mucous membranes and the presence of devitalized tissue to invade deeper body structures and to cause disease which occurs through oro-maxillofacial trauma, dental extractions, dental caries or most probably through any dental intervention as the causative organism Actinomyces is not virulent.[2]

Mandibular actinomycotic osteomyelitis is usually underappreciated by many clinicians in their assessment of head and neck infections. Most of the cases are traced to an odontogenic source with periapical tooth abscess and posttraumatic or surgical complication as the key antecedent events.[5] Hence, a biopsy should be performed on any persistent periapical lesion with osteomyelitis even though a chronic draining sinus or cervicofacial abscess does not exist. The most important clinical relevance is to send the discharge for microbial examination rather than only biopsy.

Even though the proper surgical incision and drainage and the administration of antibiotics caused the lesion to regress, sometimes, it can prove potentially fatal. Hence, this disease needs to be considered frequently in the diagnosis of head, neck and intraoral infections.

In the background of debilitating bacterial infections, a vigorous antimicrobial regimen should be followed before undertaking any surgical procedure. Actinomycotic osteomyelitis is a chronic specific suppurative osteomyelitis which is not refractory to treatment. In our case, the patient developed actinomycotic osteomyelitis after tooth extraction as a postprocedural complication. As actinomycotic osteomyelitis develops in patients with poor host immune response, the morbidity and mortality rate should be reduced with proper management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Ozaki W, Abubaker AO, Sotereanos GC, Patterson GT. Cervicofacial actinomycoses following sagittal split ramus osteotomy: A case report. J Oral Maxillofac Surg 1992;50:649-52.  Back to cited text no. 1
[PUBMED]    
2.
Belmont MJ, Behar PM, Wax MK. Atypical presentations of actinomycosis. Head Neck 1999;21:264-8.  Back to cited text no. 2
[PUBMED]    
3.
Crossman T, Herold J. Actinomycosis of the maxilla – A case report of a rare oral infection presenting in general dental practice. Br Dent J 2009;206:201-2.  Back to cited text no. 3
[PUBMED]    
4.
Bala S, Narwal A, Gupta V, Duhan J, Goel P. Actinomycotic osteomyelitis of mandible masquerading periapical pathology. J Oral Health Comm Dent 2011;5:97-9.  Back to cited text no. 4
    
5.
Freeman LR, Zimmermann EE, Ferrillo PJ. Conservative treatment of periapical actinomycosis. Oral Surg Oral Med Oral Pathol 1981;51:205-8.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
Print this article  Email this article

    

Online since 15th March '04
Published by Wolters Kluwer - Medknow