1. Cervicofacial actinomycosis
Cervicofacial actinomycosis develops slowly. The area becomes markedly indurated, and the overlying skin becomes reddish or cyanotic. Abscesses eventually draining to the surface persist for long periods. “Sulfur granules”—masses of filamentous organisms—may be found in the pus. There is usually little pain unless there is secondary infection. Trismus indicates that the muscles of mastication are involved. Radiography may reveal bony involvement. Cervicofacial or thoracic disease may occasionally involve the CNS, most commonly brain abscess or meningitis.
2. Thoracic actinomycosis
Thoracic involvement begins with fever, cough, and sputum production with night sweats and weight loss. Pleuritic pain may be present. Multiple sinuses may extend through the chest wall, to the heart, or into the abdominal cavity. Ribs may be involved. Radiography shows areas of consolidation and in many cases pleural effusion.
3. Abdominal actinomycosis
Abdominal actinomycosis usually causes pain in the ileocecal region, spiking fever and chills, vomiting, and weight loss; it may be confused with Crohn disease. Irregular abdominal masses may be palpated. Pelvic inflammatory disease caused by actinomycetes has been associated with prolonged use of an intrauterine contraceptive device. Sinuses draining to the exterior may develop. CT scanning reveals an inflammatory mass extended to involve bone.
The anaerobic, gram-positive organism may be demonstrated as a granule or as scattered branching gram-positive filaments in the pus. Anaerobic culture is necessary to distinguish actinomycetes from nocardiae because specific therapy differs for the two infections. Histopathology examination of affected tissue and bone is useful in identifying organisms that are fastidious and slow to culture.