Related Terms

• Abdominal actinomycosis, abscess, Actinomyces, actinomycosis, anaerobic bacteria, cervicofacial actinomycosis, dental hygiene, DNA, fistula, genomics, giant cells, Gram stain, granuloma, intrauterine device, IUD, lumpy jaw disease, macrophages, monoclonal antibodies, penicillin, periodontal disease, phagocytes, polymicrobial infection, subacute infection, sulfur granules, sinus tract, thoracic actinomycosis.

Background

• Actinomycosis is a subacute-to-chronic infection that causes periodontal (gum and jaw) disease. Subacute infections are between acute and chronic in duration, while chronic infections are infections that last more than six months. Actinomycosis infections of the gums and jaws are collectively known as cervicofacial actinomycosis or lumpy jaw disease. Actinomycosis infections can also occur in the chest, abdomen, and, in women, the pelvis.

• Actinomycosis is caused by Actinomyces species, anaerobic-to-microaerophilic bacteria. Anaerobic bacteria grow in the absence of oxygen, whereas microaerophilic bacteria grow in the presence of oxygen but can switch from aerobic respiration to fermentation, which is a type of anaerobic respiration, when oxygen is not present. Fermentation is a process in which sugar is broken down for food in the absence of oxygen. An example of fermentation is the conversion of fruit juice to alcohol by yeast organisms.

• The most common forms of Actinomyces are Actinomyces israelii, Actinomyces gerencseriae, and Propionibacterium propionicus. Some actinomycosis infections may involve up to 5-10 different species of bacteria. This type of infection is known as a polymicrobial infection.

• Actinomyces is commonly found among the normal bacteria in the mouth and throat. In general, the skin and the entire digestive tract normally contain a number of different bacteria and other organisms. Each area of the digestive tract contains a different collection of flora, or organisms. Even the highly acidic environment of the stomach contains bacteria adapted to live there. For an infection to develop, the bacteria must be able to penetrate beneath the surface of the skin or mucous membranes. For example, a cut in the gums or an area of inflamed gum tissue might allow an infection to develop.

• Actinomycosis spreads from the original site of infection to adjacent sites and often forms multiple abscesses, or pockets of infection, fistulas, and sinus tracts. Fistulas and sinus tracts are new passageways that form within tissues. For example, a fistula may form between the chest cavity and the skin.

• Actinomycosis is a rare infection in the United States, which maybe due to the widespread use of antibiotics and dental hygiene practices that tend to be better than in many areas of the world. Worldwide, the infection is more common among people in low socioeconomic class, particularly those with poor dental hygiene and poor access to dental care.

• Men are three times more likely than women to get this infection, for unknown reasons. All races are equally susceptible. Actinomycosis can affect people of all ages, but most cases occur in people from 20 to 50 years of age.

Risk Factors

• Actinomycosis is a rare infection in the United States, probably because of the widespread use of antibiotics and dental hygiene practices that tend to be better than in many areas of the world. Worldwide, the infection is more common among people in low socioeconomic class, particularly those with poor dental hygiene and poor access to dental care.

• Actinomycosis is a bigger health problem in developing countries, where medical and dental treatment is limited. Unless treatment begins early, antibiotics may have to be given for six months to one year.

• Men are three times more likely than women to get this infection, for unknown reasons. All races are equally susceptible. Actinomycosis can affect people of all ages, but most cases occur in people from 20 to 50 years of age.

Causes

• Actinomycosis is caused by Actinomyces species, anaerobic-to-microaerophilic bacteria. Anaerobic bacteria grow in the absence of oxygen, whereas microaerophilic bacteria grow in the presence of oxygen but can switch from aerobic respiration to fermentation when oxygen is not present. Fermentation is a process in which sugar is broken down for food in the absence of oxygen. An example of fermentation is the conversion of fruit juice to alcohol by yeast organisms.

Signs and Symptoms

• Actinomycosis spreads from the original site of infection to adjacent sites and often forms multiple abscesses, or pockets of infection, fistulas, and sinus tracts. Fistulas and sinus tracts are new passageways that form within tissues. For example, a fistula may form between the chest cavity and the skin.

• Cervicofacial actinomycosis, which affects the jaw, face, and neck, is the most common type of actinomycosis infection, accounting for 50-70% of all cases. Infections may occur after oral surgery (e.g., extraction of wisdom teeth) and in patients with poor oral health. In the early stages of infection, painful swelling of the gums occurs. Over time, the infection may spread to adjacent areas and forms fistulas and abscesses. If left untreated, the infection may spread to bones in the skull and even into the bloodstream. The abscesses are filled with pus and yellow granules known as sulfur granules. The term "sulfur granule" refers only to the yellow color; the granules do not contain sulfur.

• Thoracic actinomycosis, which affects the chest cavity, makes up about 15-20% of actinomycosis cases. This type of infection can occur after an injury to the esophagus, the passage from the throat to the stomach, caused by swallowing a sharp food item or object. It can also spread directly to the chest from the neck or abdomen by way of fistulas or sinus tracts. In an X-ray, the infection will appear as a thickened area of the lung, called a pulmonary infiltrate, or a tumor. Without treatment, the infection can spread to the lining of the lungs, the pericardium (the membrane around the heart), and the chest wall, and fistulas with the characteristic sulfur granules will form.

• About 10-20% of actinomycosis infections occur in the abdomen and pelvis. Patients who get this type of infection often have a history of bowel surgery (e.g., an appendectomy) or an intestinal perforation. An intestinal perforation can occur from swallowing a fish bone or any food items with sharp edges that can damage the gastrointestinal lining or from a rupture of an intestinal diverticulum (a weakened outpocket in the intestine). It occurs most commonly in the ileocecal region, which is the lower small intestine and upper large intestine, and resembles an intestinal tumor. Diagnosis is usually made following a surgical procedure for a suspected malignant tumor. As in other areas, abdominal actinomycosis can spread to surrounding areas and form abscesses and fistulas containing sulfur granules.

• Pelvic actinomycosis usually spreads upward from the uterus. The use of intrauterine devices (IUDs) for birth control has increased the incidence of this type of actinomycosis. Most cases of pelvic actinomycosis occur with IUDs that have remained in place for three or more years.

Types of the Disease

• The most common forms of Actinomyces are Actinomyces israelii, Actinomyces gerencseriae, and Propionibacterium propionicus. Some actinomycosis infections may combine between five and 10 different species of bacteria. This type of infection is known as a polymicrobial infection.

Diagnosis

• About 10-20% of actinomycosis infections occur in the abdomen and pelvis. It occurs most commonly in the ileocecal region, which is the lower small intestine and upper large intestine, and resembles an intestinal tumor. Diagnosis is usually made following a surgical procedure for a suspected malignant tumor.

• An earlier diagnosis of cervicofacial actinomycosis can be made in people who have regular dental checkups. If an abscess is present, microscopic examination of the infectious fluid, or pus, will find the characteristic sulfur granules.

• Microscopic examination of infected tissue will find granulomas, which are clumps of tissue with characteristic findings. Also detectable are phagocytes, a type of infection-fighting blood cell, and giant cells, which are large infection-fighting cells that contain many cell nuclei. In addition, Actinomyces bacteria can be detected by staining. They stain dark blue during a test called a Gram stain.

• An X-ray or computed axial tomography (CAT) scan of the chest, abdomen, and sometimes the head may show a dense area that could be a cancerous tumor. For confirmation, bacterial cultures can be taken of phlegm, pus, or tissue.

• Monoclonal antibodies are being developed for faster diagnosis of the disease than is currently available. Monoclonal antibodies are protein structures that can attach to bacteria such as Actinomyces spp. and inactivate them. These antibodies can also be used for specific identification of the bacteria's DNA. Monoclonal antibodies are produced in a laboratory by injecting mice with a bacterium. As a result, the mice make multiple and identical copies of the antibody.

• Actinomycosis is often misdiagnosed as cancer or other type of infection. Sometimes, the disease will appear months or years after a dental extraction or an appendectomy. Misdiagnosis can lead to inappropriate or ineffective treatment.

• Thoracic and abdominal actinomycosis infections are usually harder to diagnose and treat than cervicofacial (gum and jaw) actinomycosis. Cervicofacial actinomycosis can result in disfigurement of the gums and jaws and, if left untreated, can be fatal. If an actinomycosis infection spreads to the brain or spinal cord, more than 50% of patients have permanent brain or nerve damage and more than 25% die.

Complications

• Actinomycosis infections are not contagious. In the early stages of infection, actinomycosis can be treated with penicillin and other antibiotics, such as tetracycline or erythromycin, which are generally safe, except in the case of an allergy to the antibiotic.

• Thoracic and abdominal actinomycosis infections, as well as advanced cervicofacial actinomycosis infections, can require extensive surgical procedures that carry medical risk. Procedures may range from drainage of abscesses to major chest or abdominal surgeries.

• If left untreated, cervicofacial actinomycosis may spread to other bones in the skull and even into the bloodstream. The abscesses are filled with pus and yellow granules known as sulfur granules. The term "sulfur granule" refers to the yellow color; the granules do not contain sulfur.

• Without treatment, thoracic actinomycosis can spread to the lining of the lungs, the pericardium (the membrane around the heart), and the chest wall. If the latter occurs, fistulas with the characteristic sulfur granules will form.

• As in other areas, abdominal actinomycosis can spread to surrounding areas and form abscesses and fistulas containing sulfur granules.

Treatment

• Actinomyces bacteria are usually sensitive to penicillin, which is often used for treatment. If a patient is allergic to penicillin, however, tetracycline and erythromycin can be used. If fistulas are present, they must be flushed with saline and antibiotics to clean and treat the infection site. If an infectious area is found to be due to actinomycosis after surgery, antibiotic treatment must be started to clear up the remaining infection. Unless caught at an early stage, actinomycosis infections are difficult to treat. Antibiotic treatment of an actinomycosis infection can take from six to 12 months

Integrative Therapies

• Note: Currently, there is a lack of scientific data on the use of integrative therapies for the treatment or prevention of actinomycosis. The integrative therapies listed below have been studied for use in bacterial infections in general, should be used only under the supervision of a qualified healthcare provider, and should not be used in replacement of other proven therapies.

• Strong scientific evidence:

• Probiotics: Probiotics are beneficial bacteria and are sometimes called friendly germs. They help maintain a healthy intestine by keeping harmful bacteria and yeasts in the gut under control. Most probiotics come from food sources, especially cultured milk products. Probiotics can be taken as capsules, tablets, beverages, powders, yogurts, and other foods. An increasing number of studies support the use of probiotics as a supplement to antibiotic therapy. Probiotic supplementation during a course of antibiotics has been studied for reducing adverse effects of antibiotics in the intestinal environment. This includes reducing growth of Clostridium difficile bacteria, which can lead to colitis, a common complication of antibiotics, especially in the elderly. Some probiotics may also help prevent the development of antibiotic resistance. In acutely ill children, synbiotics have been linked to greater weight gain and fewer bacterial illnesses after antibiotics are ended. The evidence consistently supports supplementation of antibiotics with probiotics.

• Probiotics are generally considered to be safe and well tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant. Caution is advised when using probiotics in neonates born prematurely or with immune deficiency.

• Unclear or conflicting scientific evidence:

• Blessed thistle: Human research of blessed thistle as a treatment for bacterial infections is currently lacking. Laboratory studies report that blessed thistle (and chemicals contained in blessed thistle, such as cnicin and polyacetylene) may have activity against several types of bacterial infections and no effects on some types. Early studies report no activity of blessed thistle against herpes viruses, influenza, or poliovirus. Further evidence is necessary in this area before a firm conclusion can be drawn.

• Blessed thistle is generally considered to be safe when taken by mouth in recommended doses for short periods of time, with few reported side effects, such as birth defects, bleeding, breathing problems, bruising, cancer of the nose or throat, increased production of stomach acid, itching, kidney disease, liver toxicity, skin rash, stomach discomfort, stomach ulcers, and vomiting. Allergic reactions to blessed thistle, including rash, may occur, as well as cross-sensitivity to mugwort and Echinacea. Cross-reactivity may also occur with bitter weed, blanket flower, Chrysanthemum, coltsfoot, daisy, dandelion, dwarf sunflower, goldenrod, marigold, prairie sage, ragweed, or other plants in the Asteraceae or Compositae family. Avoid if pregnant or breastfeeding.

• Cranberry: Limited laboratory research has examined the antibacterial activity of cranberry. Further research is warranted in this area.

• Avoid if allergic to cranberries, blueberries, or other plants of the Vaccinium species. Sweetened cranberry juice may affect blood sugar levels. Use cautiously with a history of kidney stones. Pregnant and breastfeeding women should avoid cranberry in higher amounts than what is typically found in foods.

• Lavender: Early laboratory studies suggest that lavender oils may have topical antibiotic activity. However, this has not been well tested in human studies.

• Avoid if allergic or hypersensitive to lavender. Avoid with a history of seizures, bleeding disorders, eating disorders (such as anorexia or bulimia), or anemia (low levels of iron). Avoid if pregnant or breastfeeding.

• Propolis: Propolis is a natural resin created by bees to make their hives. Propolis is made from the buds of conifer and poplar trees and combined with beeswax and other bee secretions. Animal and laboratory studies suggest that propolis may be a beneficial treatment for various types of bacterial infections. Additional research is needed to confirm these findings.

• Avoid if allergic or hypersensitive to propolis, black poplar (Populus nigra), poplar bud, bee stings, bee products, honey, or balsam of Peru. Severe allergic reactions have been reported. There has been one report of kidney failure with the ingestion of propolis, which improved upon discontinuing therapy and deteriorated with re-exposure. Avoid if pregnant or breastfeeding, because of the high alcohol content in some products.

• Seaweed, kelp, bladderwrack: Bladderwrack (Fucus vesiculosus) is a brown seaweed found along the northern coasts of the Atlantic and Pacific oceans and North and Baltic Seas. Another seaweed that grows alongside bladderwrack is Ascophyllum nodosum, and it is often combined with bladderwrack in kelp preparations. Laboratory research suggests that bladderwrack may have antibacterial activity. However, reliable human studies to support this use are currently lacking in the available literature.

• Avoid if allergic or hypersensitive to Fucus vesiculosus or iodine. Avoid with a history of thyroid disease, bleeding, acne, kidney disease, blood clots, nerve disorders, high blood pressure, stroke, or diabetes. Avoid if pregnant or breastfeeding.

• Selenium: Selenium is a mineral found in soil, water, and some foods. Preliminary research reports that selenium may be beneficial in the prevention of several types of infection, including recurrence of erysipelas (bacterial skin infection associated with lymphedema) or Mycoplasma pneumonia. Further research is needed to confirm the effects of selenium for infection prevention.

• Avoid if allergic or hypersensitive to products containing selenium. Avoid with a history of nonmelanoma skin cancer. Selenium is generally regarded as safe for pregnant or breastfeeding women. However, animal research reports that large doses of selenium may lead to birth defects.

• Sorrel: There is currently not enough evidence on the proposed antibacterial effects of sorrel. More research is needed.

• Avoid large doses of sorrel, because there have been reports of toxicity and death. This may be because of the oxalate found in sorrel. Many sorrel tinctures contain high levels of alcohol and should be avoided when driving or operating heavy machinery. These sorrel formulations may cause nausea or vomiting when taken with the prescription drugs metronidazole (Flagyl®) or disulfiram (Antabuse®). Avoid if pregnant or breastfeeding.

Prevention

• Regular dental checkups can help prevent cervicofacial actinomycosis. Some cases of thoracic and abdominal actinomycosis can be prevented by avoiding swallowing items such as fish or chicken bones with sharp edges. Women who use an intrauterine device (IUD) for birth control should have a regular pelvic examination.

Research

• One focus of current research is in the area of monoclonal antibodies. Monoclonal antibodies are protein structures that can attach to bacteria such as Actinomyces spp. and inactivate them. These antibodies can also be used for specific identification of the bacteria's DNA. Monoclonal antibodies are usually produced in a laboratory by injecting mice with a bacterium such as Actinomyces species; the mice then make antibodies against the bacterium, which are then harvested and used as a drug.

• Studies have used monoclonal antibodies for Tropheryma whipplei, which belongs to the actinomyces group of bacteria. Mice were injected with two different strains of the bacteria. The monoclonal antibodies produced by the mice were used to identify the bacterium in stool samples.

• Another study used adhesive fimbria of the bacterium to produce monoclonal antibodies. Adhesive fimbria are hair-like structures on the surface of the bacterium that allow it to attach to specific structures in the host organism; for example, adhesive fimbria allows Tropheryma whipplei to attach to intestinal cells. The researchers reported that the identification of the genetic structure of the fimbria may lead to better understanding of how the bacterium produces an infection. This further understanding may lead to improved treatments.

Future Research

• Future research will focus in the same areas as current research. Genomics will be used to further define the genetic makeup of Actinomyces spp. This further understanding will aid in the diagnosis and treatment of the disease.

Author Information

• This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. For comprehensive information about alternative and complementary therapies on the professional level, go to www.naturalstandard.com. Selected references are listed below.

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