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ACTINOMYCETACEAEACTINOMYCETACEAE

 Actinomyces Actinomyces NocardiaNocardia

andand StreptomycesStreptomyces

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ObjectivesObjectives

To be familiar withTo be familiar with The clinical infections associated withThe clinical infections associated with

Actinomycetes, Nocardia Actinomycetes, Nocardia  spp. andspp. and

StreptomycesStreptomyces The microscopic morphology and colonialThe microscopic morphology and colonial

morphology ofmorphology of Nocardia Nocardia  andand Actinomycetes Actinomycetes 

Antimicrobial therapyAntimicrobial therapy

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 ACTINOMYCES ISRAELII  ACTINOMYCES ISRAELII 

andand  A. viscosus A. viscosus Normal flora of mouth & GIT Normal flora of mouth & GIT  Opportunistic pathogenOpportunistic pathogen

MORPHOLOGY & GROWTHMORPHOLOGY & GROWTH

 longated branching Gram!positi"e bacillilongated branching Gram!positi"e bacilliAnaerobic or microaerophilicAnaerobic or microaerophilicTemperature range #$!#%Temperature range #$!#%oo Slow growth on blood agar in '!% daysSlow growth on blood agar in '!% days

DISEASEDISEASE ActinomycosisActinomycosis

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ACTINOMYCOSISACTINOMYCOSIS

Source of infectionSource of infection ndogenousndogenous

PathogenesisPathogenesis

After local trauma, organisms in"ade tissuesAfter local trauma, organisms in"ade tissues  organisms multiply (orm hard yellow granulesorganisms multiply (orm hard yellow granules)called)called sulfur granulessulfur granules** which are bacterialwhich are bacterialfilaments solidified with tissue e+udatesfilaments solidified with tissue e+udates

These granules drain outside through sinusesThese granules drain outside through sinuses

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Sites of actinomyces infectionsSites of actinomyces infections

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ACTINOMYCOSISACTINOMYCOSIS

linical !eatures an" Diseaseslinical !eatures an" Diseases

A chronic infectionA chronic infectioner#icofacial Actino$%cosiser#icofacial Actino$%cosis The most common formThe most common form e"elops due to poor dental hygiene &e"elops due to poor dental hygiene &

tooth e+tractiontooth e+traction other dental proceduresother dental procedures

√ Appear as hard tender swellingAppear as hard tender swelling **-umpy-umpy aw aw** that drains pus through sinusthat drains pus through sinustractstracts

√

/ultiple sinuses, scarring on nec0 & sub/ultiple sinuses, scarring on nec0 & subma+illary areama+illary area

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Thoracic ActinomycosisThoracic Actinomycosis

the lungthe lung

result of aspiration of actinomyces from the mouthresult of aspiration of actinomyces from the mouthSinusesSinuses

often appear on the chest walloften appear on the chest wall  and the ribs and spine may be erodedand the ribs and spine may be eroded Primary end bronchial Actinomycosis is anPrimary end bronchial Actinomycosis is an

uncommon complication of an inhaled foreign bodyuncommon complication of an inhaled foreign body

Abdominal ActinomycAbdominal Actinomycosisosis

 Abdominal cases commence in the appendix or, Abdominal cases commence in the appendix or,less frequently, in colonic diverticulaeless frequently, in colonic diverticulae

Pelvic actinomycosisPelvic actinomycosis occurs occasionally inoccurs occasionally in women fitted with plastic intrauterinewomen fitted with plastic intrauterine

contraceptive devicescontraceptive devices

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Other form of infectionsOther form of infections

Nervous systemNervous system MusculoskeletalMusculoskeletal

Are uncommonAre uncommon

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ACTINOMYCOSISACTINOMYCOSIS

LA DIG'OSISLA DIG'OSIS Sulfur granules in pus specimenSulfur granules in pus specimen

Direct Gra$(s$earDirect Gra$(s$ear 

(inely branching filamentous bacilli(inely branching filamentous bacilliulture onulture on  1lood agar anaerobically for '!% days1lood agar anaerobically for '!% days /olar tooth appearance/olar tooth appearance

Histo)atholog%Histo)atholog% 

Treat$entTreat$ent Surgical drainageSurgical drainage 2enicillin for '!3 wee0s2enicillin for '!3 wee0s

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Nocardia spp.Nocardia spp.

!Nocard"!Nocard" Strict aerobes.Strict aerobes. Infections caused byInfections caused by Nocardia Spp Nocardia Spp . can occur in. can occur in

Immuno!compromiseImmuno!compromised andd and immuno!competentimmuno!competentindi"iduals.indi"iduals.

N. asteriodes, N.brasiliensis N. asteriodes, N.brasiliensis  are the maor causes ofare the maor causes ofthese infectionsthese infections

Nocardia spp Nocardia spp . can cause three types of s0in. can cause three types of s0ininfections ininfections in immuno!competentimmuno!competent indi"idualsindi"iduals

4.4. /ycetoma )chronic, locali5ed, painless, subcutaneous/ycetoma )chronic, locali5ed, painless, subcutaneousinfection*infection*

6.6.  S0in abscesses or cellulitisS0in abscesses or cellulitis#.#. -ymphocutaneous infections-ymphocutaneous infections InIn Immuno!compromisedImmuno!compromised indi"idualsindi"iduals Nocardia Spp.Nocardia Spp.

&an cause&an cause in"asi"e pulmonaryin"asi"e pulmonary infections andinfections anddisseminated infections ) disseminated infections ) brain abscessbrain abscess * * 

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PathogenicityPathogenicity #elease of cord factor , which prevents

nocardia from being phagocytosed by

macrophages$ %atalase production, which inactivates

oxygen metabolites which would normally

be toxic to bacteria

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NOCARDIA ASTEROIDESNOCARDIA ASTEROIDES

(80%)(80%)

Gram!positi"e thin branching filamentsGram!positi"e thin branching filaments 7ea0ly acid fast with 48 9l modified Af7ea0ly acid fast with 48 9l modified Af AerobicAerobic

(ound in en"ironment particularly in soil(ound in en"ironment particularly in soil DiseaseDisease : Nocardiosis: Nocardiosis Source of InfectionSource of Infection : Soil )e+ogenous*: Soil )e+ogenous*

$

Nocardia asteriods ! &ram Stain

Nocardia asteriods ! modified A '

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NOCARIOSIS ! C"INICA" #EAT$RESNOCARIOSIS ! C"INICA" #EAT$RESN. asteriodes N. asteriodes 

Pul$onar% 'ocar"iosisPul$onar% 'ocar"iosis ue to inhalation of organismue to inhalation of organism 2neumonia!li0e abscesses2neumonia!li0e abscesses ;sually in immunocompromised patients;sually in immunocompromised patients

N.brasiliensis N.brasiliensis 

S*in & Su+cutaneous Tissue InfectionS*in & Su+cutaneous Tissue Infection ;sually after trauma li0e thorne pric0;sually after trauma li0e thorne pric0 /ay present as sinus tract li0e actinomycosis/ay present as sinus tract li0e actinomycosis

(lcer on the arm of a patient with primary

cutaneous nocardiosis

#ed nodules on a patient with

disseminated nocardiosis

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NOCARIOSISNOCARIOSIS

LA DIAG'OSISLA DIAG'OSIS

S)eci$enS)eci$en : Sputum or pus: Sputum or pusStaining ,ith -Staining ,ith -  Gram!stain or /odified Acid!(astGram!stain or /odified Acid!(ast

ulture on-ulture on-

1lood agar1lood agar -< agar-< agar &rowth is visible after incubation for between ) days and * month+&rowth is visible after incubation for between ) days and * month+

selective growth is favoured by incubation at -.%$ %olonies areselective growth is favoured by incubation at -.%$ %olonies arecream, orange or pin/ coloured+ their surfaces may develop a dry,cream, orange or pin/ coloured+ their surfaces may develop a dry,

chal/y appearance, and they adhere firmly to the mediumchal/y appearance, and they adhere firmly to the mediumTREATME'T TREATME'T  Surgical drainageSurgical drainage Trimethoprim!sulphametho+a5oleTrimethoprim!sulphametho+a5ole