clinical case - Dental and Medical Problems

clinical case - Dental and Medical Problems

clinical case
Dent. Med. Probl. 2012, 49, 4, 595–599
ISSN 1644-387X
© Copyright by Wroclaw Medical University
and Polish Dental Society
Szymon Frank1, A, E, Paweł Nieckula1, B, D, Monika Jodko2, E, F
Treatment of Cervicofacial Type of Actinomycosis
in a Patient with Allergy to Penicillin – Case Report
Leczenie pacjentki uczulonej na penicylinę
chorej na szyjno-twarzową postać promienicy – opis przypadku
¹ Department of Oral Surgery, Medical University of Warsaw, Poland
² Student Scientific Circle of the Department of Oral Surgery, Medical University of Warsaw, Poland
A – koncepcja i projekt badania; B – gromadzenie i/lub zestawianie danych; C – opracowanie statystyczne;
D – interpretacja danych; E – przygotowanie tekstu; F – zebranie piśmiennictwa
Abstract
Actinomycosis is an infectious disease caused by the gram positive anaerobic bacteria from the Actinomyces species. Infection most often develops following tooth extraction or as a result of an injury in the face or neck region.
The aim of the study is to present the case of a female patient allergic to penicillin who was clinically treated for
actinomycosis. A 50-year-old female patient presented at the Department of Oral Surgery of the Medical University
of Warsaw for extraction of the roots of the 36 tooth with gangrenous pulp. Medical history revealed an allergy
to lignocaine, penicillin and metronidazole. The patient had cervicofacial actinomycosis. The suggested algorithm
of treatment in the patient’s case produced the desired effect and resulted in recovery. Surgical treatment of the
lesion and the administration of doxycycline led to effective healing of the patient (Dent. Med. Probl. 2012, 49,
4, 595–599).
Key words: Actinomycosis, cervicofacial, Actinomyces.
Streszczenie
Promienica jest chorobą zakaźną wywołaną przez Gram-dodatnie bakterie beztlenowe z rodzaju Actinomyces.
Zakażenie rozwija się najczęściej po usunięciu zęba lub w następstwie urazu twarzy lub szyi. Celem pracy jest przedstawienie przypadku klinicznego pacjentki z alergią na penicylinę leczonej z powodu promienicy. 50-letnia kobieta
zgłosiła się do Zakładu Chirurgii Stomatologicznej WUM w celu ekstrakcji korzeni zęba 36 z miazgą w stanie
zgorzelinowego rozpadu. W wywiadzie ustalono alergię na lignokainę, penicylinę oraz metronidazol. Stwierdzono
u niej szyjno-twarzową postać promienicy. Zaproponowane postępowanie w tym przypadku przyniosło pożądany
rezultat i pacjentka wyzdrowiała. Leczenie chirurgiczne zmiany oraz podanie doksycykliny pozwoliło ją całkowicie
wyleczyć (Dent. Med. Probl. 2012, 49, 4, 595–599).
Słowa kluczowe: promienica, szyjno-twarzowa, leczenie chirurgiczne i antybiotykowe.
Actinomycosis is a disease caused by Gram-positive anaerobic or microaerophilic bacteria of
the genus Actinomyces. As a clinical entity, it was
described more than 100 years ago [1, 2]. Actinomycosis is a rare human infectious disease, much
more common in animals (pigs, horses, cattle and
dogs). The most commonly isolated species of actinomycetes are: Actinomyces israeli, A. meyeri,
A. bovis, A. naeslundii, A. viscous and A. odontolitycus [2, 3]. These microorganisms are widespread
in nature. As saprophytes, they dwell in the human body, in the mouth especially in the interdental spaces, gingival pockets, airways and gastrointestinal tract [1, 2].
Actinomycosis occurs three times more often
in men than in women. This disease usually af-
596
fects the age group of 20–50-year-olds. The most
common variant form of actinomycosis is the cervicofacial form, which makes up approximately
50–70% of cases [4].
Actinomycetes may become pathogenic as
a result of interruption of the barrier of the skin or
mucosa. The infection usually develops after tooth
extraction or due to injury (chemical, thermal or
mechanical) of the facial or neck region. Actinomycosis is spread most commonly by continuity.
The immunity and virulence of oral microorganisms which are in synergism with actinomycetes
affect the course of the specific inflammatory process. It should be remembered that actinomycosis
infection is nearly always combined. Untreated or
inadequately treated disease results in significant
tissue destruction.
Among the culture media predisposed to actinomycosis development, periapical granulation
tissue of the teeth with gangrenous pulp, inflamed
gingival pockets, chronic purulent tonsillitis, inflammation of the bone, jaw fractures and infected
wounds of the oral mucosa may be mentioned.
Characteristic symptoms of actinomycosis are
swelling with associated redness and the presence
of solid tumors with purulent lesions. In the later stage of the disease those lesions create fistulae
excreting druses – light yellow grains with a diameter of 0.1–0.5 mm (Fig. 1) [​​5]. The name of
the species comes specifically from the presence
of characteristic rays in these grains. Then begins
granulation tissue formation, which eventually becomes fibrosis, resulting in the formation of scar
tissue.
Case Report
A 50-year-old woman in good general condition reported to the Department of Oral Surgery
of the Medical University of Warsaw to extract the
roots of the 36 tooth (Fig. 2). The woman was generally healthy. Allergy to lignocaine, metronidazole, and penicillin was recorded in an interview.
After the use of these drugs, the patient reported
maculopapular rash and bronchospasms causing
labored breathing.
In the medical history, the patient reported
pain occurring around the 36 tooth. The pain had
lasted 2 days and increased under pressure on the
36 tooth. In clinical examination in the vestibule
of the mouth, palpation tenderness around the
36 tooth was found. Further study found pain on
percussion of the 36 tooth in the horizontal and
vertical plane, absence of mucosal redness and
negative fluctuate symptoms in the vestibule of
the mouth around the 36 tooth. Submandibu-
S. Frank, P. Nieckula, M. Jodko
Fig. 1. Extraoral fistula excreting purulent content with
the contents of characteristic “actinomycete grains”
Ryc. 1. Przetoka zewnątrzustna z wydzielającą się treścią ropną, z zawartością charakterystycznych „ziaren
promieniczych”
Fig. 2. 36 tooth, qualified for extraction
Ryc. 2. Ząb 36 – zakwalifikowany do ekstrakcji
lar lymph nodes on the left side were enlarged,
though smooth, painless and movable in relation
to ground and skin. On the right side they were
impalpable. The patient was referred for pantomographic imaging. On the basis of radiological and
clinical research, a large carious cavity in the 36
tooth, a trace of filler material in the distal canal
of this tooth and periapical change of an osteolysis
character around the media root were concluded.
In tooth 37 mesial-occlusal secondary caries were
found. Tooth 38 had a crown destroyed by caries
and pulp in gangrenous disintegration.
Due to the patient’s allergy to lignocaine, an
intradermal allergy test to marcaine was performed. The reading after 30 minutes and 24 hours
was negative, which determined the choice of marcaine as an anesthetic substance. Under local anesthesia, extraction of the roots of 36 tooth was
Cervicofacial Type of Actinomycosis in a Patient with Allergy to Penicillin
Fig. 3. Swelling of the cheek on the left side, which
appeared 10 days after extraction of 36 tooth
Ryc. 3. Obrzmienie policzka po stronie lewej, które
pojawiło się 10 dni po ekstrakcji zęba 36
Fig. 4. Taking purulent discharge for examination
Ryc. 4. Pobranie wydzieliny ropnej do badania
carried out. After that, the tissue granulation was
removed. Tooth 38 was planned to be removed in
the next stage of treatment.
After a period of ten days after extraction, the
patient reported again with swelling of the cheek
on the left side, which was painful to the touch
(Fig. 3). According to the patient, swelling started to slowly grow three days after the extraction
of the roots of the 36 tooth. Clinical examination
revealed redness and hard, warm swelling of the
skin of the left cheek. The patient denied increased
body temperature from the date of extraction. The
exaggerated cheek was punctured extraorally and
a scanty purulent content was obtained. The resulting fluid was sent for histopathological examination in the direction of actinomycosis (Fig. 4).
Subsequently under local anesthesia of 0.5% Marcaine, the skin coat on the top of the swelling
was incised. The cavity of the cheek abscess was
597
opened and drained. A drain and extraoral bandage was established. The next day, hard swelling
of the cheek continued without evidence of clinical improvement. The roots of the 38 tooth were
removed under local anesthesia. Full sanation of
the mouth was finished. On the same visit, the abscess cavity was flushed with saline. Scanty blood-purulent content was removed. A drain and bandage was established.
The patient was referred to an allergist to perform allergy tests for penicillin, cephalosporin,
clindamycin, clarithromycin, erythromycin and
metronidazole. Due to persistent serous-purulent
effusion from the abscess cavity, until histopathology results were received, treatment by lavage of
the abscess cavity with saline and casting was continued daily for 10 days. Results of the allergy tests
to antibiotics proved to be positive for all investigated. Histopathological examination revealed
Actinomycosis – an infection of A. israeli. Due to
the continued left cheek swelling and redness of
the skin of this area, the exaggerated are had been
repeatedly extraorally incised and cleaned.
The patient was referred to the Regional Hospital of Infectious Diseases in Warsaw in order to
continue treatment. During hospitalization, which
lasted seven days, the oral antibiotic doxycycline
was implemented – Unidox 0.1 g, 1 tablet every
12 hours. Antibiotic therapy lasted for 4 weeks.
In addition, the patient took Trilac (Lactobacillus acidophilus, Lactobacillus delbrueckii, Bifidobacterium lactis), Claritin, calcium, Kaldyum (potassium chloride), Magnezin (magnesium carbonicum) and Hydroxyzine. After leaving the hospital
the patient signed up for a check-up visit to the
Department of Oral Surgery, Medical University
of Warsaw. The clinical picture has improved significantly. Cheek swelling subsided and soft tissue
infiltration decreased. 7 days after the patient left
the hospital, the intraoral fistula was closed.
The proposed algorithm in this case has
brought the desired effect and led to curing the
patient (Figure 5, 6).
Discussion
Rapid diagnosis and beginning effective pharmacotherapy in the case of actinomycosis is a necessary condition to remission of the disease and
prevention of its complications. Actinomycosis
can spread into the tissues and penetrate into spaces such as leaf-mandibular, leaf-palatal, parapharyngeal and into the orbit. Unlike other suppurative infections, this can spread in ways contrary
to the natural anatomy. A serious complication is
the spread of actinomycosis through the holes of
598
S. Frank, P. Nieckula, M. Jodko
Fig. 5. Status after treatment – extraoral view
Ryc. 5. Stan po leczeniu – widok zewnątrzustny
Fig. 6. Status after treatment – intraoral view
Ryc. 6. Stan po leczeniu – widok wewnątrzustny
the skull with the result that it can cause meningitis. While on the descending way it can get into
the mediastinum.
Correct diagnosis and treatment of actinomycosis has many difficulties [1, 6, 7]. The clinical
picture of the disease and its course is variable and
depends on many factors such as immunity, the
location of the primary site of the disease and bacterial virulence. The course of the disease depends
on how fast a diagnosis is made and how effective
the therapy is. The complications of actinomyco-
sis are often the result of ineffective treatment. It
should be noted that the frequent recurrence of
a purulent appearance around the face and neck
region, occurring without a specific cause, should
always be a possible indicator of actinomycosis,
and it is advisable to commence the relevant tests
in order to form a proper diagnosis.
The first stage of the clinical disease may be
characterized by the presence of bad breath (halitosis) and hard tissue infiltration, from which it is
difficult to obtain purulent content. A disadvantage in the diagnosis of actinomycosis is the need
for multiple microbiological or histopathological tests when the primary test result is negative,
since this does not exclude actinomycosis and the
test should be repeated. Routine blood tests usually show no abnormalities, and sometimes there
may be leukocytosis. Imaging by computed tomography and magnetic resonance imaging can
give nonspecific results [8]. All these factors contribute to difficulties in making an accurate diagnosis of the present entity.
Cervicofacial actinomycosis most often affects
the submandibular space, cheeks, teeth, tongue,
parotid, lymph nodes, peri-pharyngeal space and
around the thyroid gland [2].
The treatment for actinomycosis is surgical drainage of abscesses and long-term antibiotic therapy. The result of treatment depends on
the patient’s general condition, their sensitivity
to drugs and the severity and duration of the disease [5]. The drug of choice for actinomycosis remains penicillin [2, 8–12]. In severe cases, crystalline penicillin administered intravenously for 4–6
weeks in combination with surgical drainage and
then many months of treatment with oral penicillin [2] are recommended.
In the case discussed, because of the patient’s
allergy to penicillin, research commenced in order
to choose the appropriate antibiotic. Finally, because of the patient’s allergy to penicillins, cephalosporin, clindamycin, clarithromycin, erythromycin and metronidazole, the decision was made
to start doxycycline therapy. In the case discussed,
the use of doxycycline in a Unidox preparation
100 mg twice daily for four weeks led to successful
treatment of the patient. The fistula was closed.
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Address for correspondence:
Szymon Frank
Department of Oral Surgery WUM
Nowogrodzka 59
02-006 Warszawa
Poland
Tel.: +48 22 502 12 42
E-mail: [email protected]
Received: 3.02.2012
Revised: 27.08.2012
Accepted: 25.10.2012
Praca wpłynęła do Redakcji: 3.02.2012 r.
Po recenzji: 27.08.2012 r.
Zaakceptowano do druku: 25.10.2012 r.