Item: ~'?

Mark ~ f> 6t ~ ~ , GJIIA)

0. ld : 3561 Prevoous Next Lab Values Notes Calculator Reverse Color Text Zoom

A 54-year-old woman comes to the office due to a slow-growing, painless mass in the
right submandibular region. The patient had a right molar extraction for severe tooth
decay 2 months ago and soon thereafter developed swelling of the right jaw. There was
no pain or fever so she did not seek medical attention. The swelling slowly worsened
and 3 days ago began draining a thick yellow discharge. The patient has a history of
poorly controlled type 2 diabetes mellitus. Temperature is 37.2 C (99 F), blood pressure
is 134/78 mm Hg, pulse is 88/min, and respirations are 18/min. Physical examination
shows a 4x4 em, firm, nontender, indurated mass below the angle of the right mandible
with erythematous overlying skin. Palpation expresses serosanguineous fluid with small
yellow granules through a small defect in the center of the lesion. There is no crepitus.
Anaerobic culture of the needle aspirate grows filamentous gram-positive rods with
rudimentary branching. Which of the following is the best initial treatment for this patient?

0 A Amphotericin B
0 B. Azithromycin
0 C. Fluconazole
0 D. Isoniazid, rifampicin, pyrazinamide, and ethambutol
0 E. Metronidazole
0 F. Penicillin
0 G. Trimethoprim-sulfamethoxazole

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Item: ~'?Mark ~ f> 6t ~ ~ , GJIIA)
0. ld : 3561 Prevoous Next Lab Values Notes Calculator Reverse Color Text Zoom

A 54-year-old woman comes to the office due to a slow-growing, painless mass in the
right submandibular region. The patient had a right molar extraction for severe to.oth
decay 2 months ago and soon thereafter developed swelling of the right jaw. There was
no pain or fever so she did not seek medical attention. The swelling slowly worsened
and 3 days ago began draining a thick yellow discharge. The patient has a history of
po.orly controlled type 2 diabetes mellitus. Temperature is 37.2 C (99 F), blood pressure
is 134/78 mm Hg, pulse is 88/min, and respirations are 18/min. Physical examination
shows a 4x4 em, firm, nontender, indurated mass below the angle of the right mandible
with erythematous overlying skin. Palpation expresses serosanguineous fluid with small
yellow granules through a small defect in the center of the lesion. There is no crepitus.
Anaerobic culture of the needle aspirate grows filamentous gram-positive rods with
rudimentary branching. Which of the following is the best initial treatment for this patient?

A. Amphotericin B [5%)
B. Azithromycin [8%)
C. Fluconazole [2%)
D. Isoniazid, rifampicin, pyrazinamide, and ethambutol [0%)
E. Metronidazole [8%)
F. Penicillin [61%)
G. Trimethoprim-sulfamethoxazole [15%)

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Explanation: User ld

Cervicofacial Actinomyces

• Dental infections & trauma (extraction)

Risk factors
• Immunosuppression, diabetes mellitus, malnutrition

• Upper/lower jaw (mandible)

• Slowly progressive, nonpainful, indurated mass
Manifestations
• Sinus tracts with sulfur granules
• Fever/lymphadenopathy are uncommon

• Fine needle aspiration

Item: ~'?Mark ~ f> 6t ~ ~ , GJIIA)
0. ld : 3561 Prevoous Next Lab Values Notes Calculator Reverse Color Text Zoom

Cervicofacial A ctinomyces

• Dental infections & trauma (extraction)

Risk factors
• Immunosuppression, diabetes mellitus, malnutrition

• Upper/lower jaw (mandible)

• Slowly progressive, nonpainful, indurated mass
Manifestations
• Sinus tracts with sulfur granules
• Fever/lymphadenopathy are uncommon

Diagnosis • Fine needle aspiration

• Culture >14 days

• Penicillin 2-6 months

Treatment
• Surgery (severe disease)
©UWorld

Actinomyces is an anaerobic bacterium of the oral cavity that may cause invasive
disease in patients with dental infections or trauma (eg, tooth extraction). Risk of
infection is increased in those with poorly functioning immunity due to underlying
immunosuppression, diabetes mellitus, or malnutrition. Infection occurs by direct
extension from the oral cavity and is oblivious to tissue planes. Patients typically
develop a chronic, slow-growing, nontender, indurated mass that eventually forms
multiple sinus tracts to the skin. A pathognomonic feature is the presence of purulent
discharge with "sulfur granules" (discrete yellow granules that resemble sulfur but do
not contain it). Lymphadenopathy and fever are atypical. The mandible is the most
common site of infection (>50%), but other nearby tissues (eg, cheek, chin) may be
affected. Fine needle aspiration with culture is usually required to establish a diagnosis
(cultures often take >1 4 days). High-dose oral penicillin is the first-line treatment for
mild cases (no fistulas); more severe cases require intravenous penicillin and (often)
concomitant surgery.
(Choices A and C) Amphotericin B and fluconazole are common antifungal agents.
This patient has a slowly enlarging, nonpainful jaw mass with sulfur granules after a
dental procedure, strongly suggesting the bacterium Actinomyces (requiring an
antibacterial agent, not an antifungal).
(Choice S) Azithromycin is a macrolide antibiotic often used for respiratory infections
(eg, community-acquired pneumonia, bronchitis) but is not commonly used for
Actinomyces.
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 a dia~jnos>is
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(cultures often take >14 days). High-dose oral penicillin is the first-line treatment for
mild cases (no fistulas); more severe cases require intravenous penicillin and (often)
concomitant surgery.
(Choices A and C) Amphotericin B and fluconazole are common antifungal agents.
This patient has a slowly enlarging, nonpainful jaw mass with sulfur granules after a
dental procedure, strongly suggesting the bacterium Actinomyces (requiring an
antibacterial agent, not an antifungal).
(Choice B) Azithromycin is a macrolide antibiotic often used for respiratory infections
(eg, community-acquired pneumonia, bronchitis) but is not commonly used for
Actinomyces.

(Choice 0) Tuberculosis (TB) is treated with isoniazid, rifampicin, pyrazinamide, and

ethambutol. TB lymphadenitis usually presents with chronic, nontender
lymphadenopathy. Draining sinus tracts are uncommon. TB resembles Actinomyces on
Gram stain, but TB is usually acid-fast (unlike Actinomyces).
(Choice E) Although metronidazole is frequently used in the treatment of anaerobic (and
parasitic) infections, it does not have efficacy against Actinomyces.

(Choice G) Nocardia may be treated with trimethoprim-sulfamethoxazole and

occasionally causes chronic, nonpainful subcutaneous lesions with draining sinus tracts.
Skin inoculation usually occurs during gardening or farming, and infections typically arise
on the feet, legs, or back. This patient with a submandibular lesion after a dental
procedure is more likely to have Actinomyces.
Educational objective:
Actinomyces is part of the normal oral flora but may cause an invasive infection in
patients who have dental infections or trauma (especially in those with weakened
immunity). Symptoms include a chronic, slow-growing, nontender mass at or near the
mandible. Multiple sinus tracts to the skin may drain purulent fluid with sulfur granules
(discrete, yellow granules). Penicillin is the preferred therapy; surgery is sometimes
required for severe cases.

Reference.s:
1. Actinomyces: a great pretender. Case reports of unusual presentations
and a review of the literature.
2. Cervicofacial actinomycosis and mandibular osteomyelitis.

Time Spent: 2 seconds Copyright © UWorld Last updated: [09/20/2016)

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