AtlasInfectionsCervicofacial Actinomycosis

Maxillofacial Infections

Cervicofacial Actinomycosis

aka Lumpy Jaw

Chronic granulomatous suppurative infection by Actinomyces israelii producing woody induration, multiple sinuses and characteristic sulphur granules.

Organism
A. israelii
Sign
Sulphur granules
Rx
Penicillin 6–12 mo

§ overviewOverview

Chronic bacterial infection caused by filamentous Gram-positive anaerobic Actinomyces species, most commonly A. israelii.

§ icdICD Classification

A42.2

§ etiologyEtiology

  • 01Actinomyces israelii (most common)
  • 02A. naeslundii, A. viscosus, A. odontolyticus
  • 03Polymicrobial with Aggregatibacter, Fusobacterium

§ riskRisk Factors

  • 01Recent dental extraction/trauma
  • 02Poor oral hygiene
  • 03Immunosuppression, diabetes
  • 04IUD (pelvic), aspiration (thoracic)

§ epidemiologyEpidemiology

≈55% of cases are cervicofacial; M:F 3:1; ages 30–60.

§ pathogenesisPathogenesis

Endogenous oral commensal invades disrupted mucosa/bone, forming central abscess with peripheral fibrosis; sulphur granules are colonies embedded in eosinophilic Splendore–Hoeppli material.

§ clinicalClinical Features

  • 01Slowly enlarging, indurated, painless mass at the angle of the mandible
  • 02Multiple discharging sinuses through skin
  • 03Yellow 'sulphur granules' in pus
  • 04Trismus, low-grade fever
  • 05Crosses tissue planes (unlike malignancy following fascia)

§ differentialDifferential Diagnosis

  • 01Chronic osteomyelitis
  • 02Tuberculous lymphadenitis
  • 03Mandibular malignancy
  • 04Odontogenic abscess
  • 05Nocardiosis

§ histopathHistopathology

  • 01Granulation tissue with central abscess
  • 02Sulphur granules — basophilic colonies with eosinophilic clubs (Splendore–Hoeppli)
  • 03Filamentous Gram-positive branching bacilli

§ investigationsInvestigations

  • 01Gram stain and anaerobic culture of pus (needs 5–14 days)
  • 02Histopathology: sulphur granules with radiating filaments
  • 03CT/MRI: soft-tissue mass with cortical erosion
  • 0416S rRNA PCR

§ treatmentTreatment

  • 01High-dose IV penicillin G 18–24 MU/day × 4–6 weeks, then oral penicillin/amoxicillin 6–12 months
  • 02Alternatives: doxycycline, clindamycin, erythromycin (penicillin allergy)
  • 03Surgical drainage and excision of sinuses/necrotic bone

§ complicationsComplications

  • 01Osteomyelitis of mandible
  • 02Sinus tract fistulisation
  • 03CNS extension (rare)
  • 04Recurrence with short antibiotic course

§ prognosisPrognosis

Excellent with prolonged antibiotics; recurrence common if therapy <6 months.

§ examKey Examination Points

  • 01Woody induration crossing tissue planes
  • 02Sulphur granules in pus
  • 03History of recent extraction

§ revisionQuick Revision Summary

  • 01A. israelii · sulphur granules · long-course penicillin

§ vivaBDS Viva Questions

  • 01What are sulphur granules?
  • 02Why prolonged antibiotics?
  • 03Differentiate from TB.

§ mcqsMCQs — Assessment (3)

Question 1

Most common causative organism:

Question 2

Sulphur granules represent:

Question 3

First-line antibiotic:

References

  1. Wong VK. BMJ 2011
  2. Neville BW. Oral & Maxillofacial Pathology, 4e

Draft — pending faculty review. Educational use only; verify against current guidelines and primary sources before clinical application.