A 40 year old African American male was hospitalized with painful swelling of right knee and painful indurated swelling of left lateral chest wall and axilla of 3 weeks duration. Around this time he also started feeling left shoulder pain. No h/o any trauma, recent fever/chills and insect bite. Two weeks earlier he had dental extraction for dental caries. His past medical history was significant for sickle cell trait and, anemia. He admitted to ethanol abuse and occasional marihuana and cigarette smoking. He denied intravenous drug use. He had a history of penicillin allergy which had manifested as hives.
Physical examination revealed a temperature of 97.4 F; blood pressure, 108/85 mm Hg; heart rate, 86 beats/min, respiratory rate 24 breaths /min and oxygen saturation 95% on room air. He was lethargic, malnourished, had poor oral hygiene and there were no enlarged lymph nodes. Examination of the trunk and left knee revealed erythematous indurated swelling with crepitus in left lateral chest wall and axilla, the left knee was swollen, painful with signs of effusion. The patient had tender hepatomegaly.
Actinomyces spp. is characterized as an elongated Gram-positive branching rod that grows slowly under microaerophillic or strictly anaerobic environments. Actinomyces spp. are known commensals of the oral cavity; they reside in tonsillar crypts and gingival crevices, and causes periodontal disease. Traumatic disruption of oral mucosa allows the organisms to penetrate into deeper tissue and extend to contiguous structures across anatomic boundaries, to form indurated lesions with burrowing sinus tracts and fistulas. Patients with poor oral/dental hygiene are at risk for developing cervicofacial infection. In alcoholics, the organisms may be aspirated into the lungs. It causes slowly progressive bronchopneumonia with invasion of pleura resulting in empyema. Chest wall invasion is complicated by cutaneous sinus/fistula draining sulfur granules. Infection in humans is generally caused by Actinomyces isrealii. There are rare case report of A. meyeri hematogenous spread resulting in infective endocarditis and hematogenous dissemination to lungs and other organs.
Pertinent lab data:
Laboratory studies revealed ESR: 150 mm/h, WBC: 85.4 K/cmm , platelets: 477 K/cmm and RBC: 2.32 M/cmm. The AST and ALT were 139 U/L and 68 U/L respectively. The BUN/Creatinine and PT/INR were 120/3.7, 25.7/2.4 respectively. A chest radiograph and CT chest revealed bilateral patchy infiltrates and air noted in chest wall. Conventional tomograms of the left knee demonstrated soft tissue swelling. Synovial fluid analysis revealed WBC count of 7200 /cmm (75% Neutrophils), RBC 800, Glucose 292 and protein 2.6. The gram staining showed gram positive rods. The synovial fluid, blood and wound cultures grew Actinomyces meyeri.
Our case report is unusual in clinical presentation. The acute fulminant presentation has never been previously reported. Necrotizing cellulitis, fasciitis and pyogenic arthritis as a complication of hematogenous dissemination are novel findings. Dentogingival disease and alcoholism are important risk factors (like in our patient) that permit the development of pulmonary infection via aspiration of mouth flora, including A. meyeri. Hematogenous seeding to distant organs occurs particularly frequently with A. meyeri, compared with other actinomyces, and often originates from a pulmonary focus of infection that should be carefully sought. Our patient’s illness started as dental caries. Dental extraction. resulted in bacteremia and dissemination with seeding of organisms to distant organs including lungs, joint, subcutaneous tissue and fascia. In addition, he developed life-threatening sepsis and multiorgan failure as manifested by septic shock, acute respiratory distress syndrome and disseminated intravascular coagulation. He received ventilator and hemodynamic support to stabilize his condition. Prompt recognition and isolation of Actinomyces Meyeri by anaerobic cultures resulted in prompt institution of appropriate specific therapy. Our patient did well clinically and discharged home.
Sherris Medical Microbiology, 5e > Part III. Pathogenic Bacteria > Chapter 28. Actinomyces and Nocardia >http://www.accessmedicine.com/popup.aspx?
Hermida et al. International Journal of Dermatology 2009, 48, 154-156.
Disseminated Infection Due to Actinomyces meyeri: Case Report and Review C. Apotheloz and C. Regamey. Clin Infect Dis. 1996 Apr;22(4):621-5.