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Actinomycosis of the hand: A case report
Actinomycosis of the hand: A case report G. J. Southwick, F.R.A.C.S., and G. D. Lister, F.R.C.S., Louisville, Ky.
Actinomyces israelii is a commensal organism of the oral cavity. When introduced into a microaerophilic environment in the deeper tissues of the body, it can produce a chronic suppurative infection which is difficult to eradicate. Actinomycosis can follow any human bite which penetrates the skin. We present such a case occurring in the hand.
Case report A 31-year-old black male plasterer was examined on Sep tember I, 1978, for a swollen left hand. On February 14, 6 1h months previously, he had been involved in a fight in which he struck a man in the mouth with a closed left fist. Immedi ately after the fight he noticed teeth marks and a superficial abrasion over the head of the left second metacarpal. The abrasion healed rapidly, but 4 days later the area began to swell, and the swelling persisted. There was minimal pain and tenderness, and the swelling did not interfere with the normal use of his hand. He was right handed and an otherwise fit man. Initial examination revealed moderate swelling of the left hand in the region of the second metacarpal and extending into the first interosseous space. There was mild tenderness only and otherwise the hand was normal. He was afebrile, and no lymphadenopathy in the relevant lymph drainage areas was detected. Radiological examination of the cut hand with routine views showed erosion of bone on the radial side of the neck of the second metacarpal. A Brewerton view markedly im proved the delineation of the extent of bone erosion (Fig. 1). This is in keeping with other reports on the use of the Brewer ton view in detecting changes in the metacarpal head and bone.t. 2 Hematological examination showed a mild monocytosis (10%, normal values are I% to 79c), but an otherwise normal profile. The Mantoux test was positive, but Reiter protein complement fixation and fluorescent treponema antibody tests were negative. At this stage a definitive diagnosis had not been made and it was decided to explore the swelling. On September 2, 1978, under left axillary block and tour niquet control, an incision was made over the dorsum of the second metacarpal. The tissues were edematous. The first Received for publication Dec. 16, 1978. Reprint requests: G. D. Lister, F.R.C.S., Doctors' Office Bldg., 250 E. Liberty St., Louisville, KY 40202.
360
THE JOURNAL OF HAND SURGERY
Fig. I. Brewerton-view roentgenogram of the left hand clearly delineates the degree of bone erosion on the radial side of the neck of the second metacarpal. dorsal interosseous muscle was exposed and appeared to be normal. An area of indurated subcutaneous tissue was located around the radial side of the neck of the second metacarpal and was firmly adherent to the bone. It also was difficult to dissect from the overlying dermis. This tissue was excised along with the involved bone, and the wound was closed in layers with a Penrose drain left in situ. Section of the tissue revealed multiple small abscesses which extruded straw-colored fluid containing many white, 1 mm-sized nodules, suggestive of "sulphur granules." His tological examination disclosed chronic inflammatory tissue with multiple abscess formation consistent with actinomy cosis infection (Fig. 2). Specimens submitted for bacteriology examination showed that the organism was not acid fast and
Vol. 4, No.4 July, 1979
Fig. 2. A low-power hematoxylin and eosin section shows a sulphur granule contained in an abscess cavity. that the sulphur granules were gram positive; Wright's fungal stain showed multiple branching filaments. The organism grew in colonies slowly on chocolate agar in carbon dioxide and brain-heart infusion with blood in an anaerobic envi ronment. Intravenous crystalline penicillin in a dose of I 2 million units was given in six divided doses daily. This regime was continued for I week while he was in the hospital and then continued on an outpatient basis with phenoxymethyl penicil lin ( 4 gm/day orally in divided doses) supplemented with probenecid (2 gm/day). In the postoperative period he remained afebrile; however, there was partial wound breakdown which was treated by careful irrigation and saline gauze packs. The wound healed well by secondary intention.
Comment. Actinomycosis is a chronic infection caused by Actinomyces israelii. This organism is an intermediary between bacteria and fungi and exists both as a gram-positive bacillary form and as a fungal filamentous form. It is a facultative anaerobe and is not acid fast, which differentiates it from the related Nocardia, which is aerobic and acid fast. 3 • 4 The organism forms part of the normal flora of the
Actinomycosis of hand
361
Fig. 3. Gram stain reveals gram-positive bacillary form of Actinomyces israelii.
oral cavity and is found especially in carious teeth and tonsillar crypts. Following a human bite or, as in our case, a hand wound contaminated with oral cavity flora, the seeds are sewn for the development of an infection. A microaerophilic environment is provided by traumatized tissue, and a chronic inflammatory reaction develops with extensive necrosis. 3 - 7 If the infection is not checked, the inflammatory reaction continues and results in destruction of all local tissues, including bone. Eventually drainage to the sur face occurs via multiple sinuses. Eventually hematoge nous spread will occur in most body tissues, and in the preantibiotic era the patient's demise soon followed. Lymphatic spread almost never occurs, and hence lymphadenopathy is most unusual. Examination of the involved tissue reveals multiple small abscesses con taining masses of intertwined mycelial filaments, commonly referred to as "sulphur granules." These are diagnostic, measure from 0.5 to 3 mm, and can be crushed between slides to reveal the filamentous or ganism on microscopic examination (Fig. 3). Radiating from this tangled mass of threads are club-shaped fila
362
The Journal of HAND SURGERY
Southwick and Lister
ments which on low-power microscopy produce a sun ray effect. At the present time, serological tests are of no diagnostic help. 3 • 4 The presence of a mild monocytosis was noted in our patient, but reference to this in other case reviews was not found. The treatment to eradicate the infection includes ef fective drainage of the involved area and administration of antibiotics. In 1943 Florey and Florey8 reported on two cases of actinomycosis treated by penicillin with out apparent effect. In 1947 Nichols and Herrell 9 used higher doses effectively in 46 patients who were fol lowed from 1 to 5 years after apparent cure. They rec ommended at least a 6 week treatment program. Eastridge 10 reviewed 24 cases over 24 years and rec ommended 2 to 5 million units of penicillin a day for a variable period, depending on clinical response, but suggested that treatment should continue for 3 months after all evidence of infection has disappeared. The organism also is sensitive to sulphonamides, tetracy cline, erythromycin, and lincomycin. 11 Our patient re ceived 12 million units of penicillin parenterally per day for 1 week and then 4 gm of oral penicillin sup plemented with probenecid to increase the effective blood, and hence tissue, levels of penicillin. This reg imen was continued for 3 months after full clinical response was apparent. The partial wound breakdown in the postoperative period suggests that it may have been wiser to leave the wound open and allow it to heal by secondary inten tion. However, there is no doubt that surgical interven tion was important for both diagnosis and treatment. It may be that the role of antibiotic therapy may not be so important if excision of the infected area is car ried out, as was done in our case. Linscheid and Dobyns 5 reported a case of Nocardia infection, similar to actinomycosis, which was excised. However, recur rence developed requiring sulphonamide therapy to control it. An extensive search of the literature revealed two case reports similar to ours. 6 • 12 In 1915 Cope and in 1917 Me Williams presented case reports of hand in fections following human tooth trauma to the hand. In the latter case amputation of the involved middle finger was performed following a diagnosis of sarcoma;
pathological findings, however, confirmed the diag nosis of actinomycosis. In summary, the diagnosis of actinomycosis of the hand should be entertained when human tooth trauma to the hand is followed several months later by a rela tively painless, nontender, swelling. Surgical explora tion may reveal the sulphur granules, but if not, mi croscopy and bacteriological staining and culture will confirm the diagnosis. A rigid antibiotic regime will aid eradication of the disease. With the wide use of antibiotics the incidence of this infection in its classical cervicofacial, pulmonary, and intestinal forms now is uncommon. However the astute physician should be aware of its existence, as this po tentially severe infection is readily treated. We appreciate the help given by the Department of Pathol ogy and Bacteriology at the Jewish Hospital, Louisville, Ky.
REFERENCES I. Lane CS: Detecting occult fractures of the metacarpal head: The Brewerton view. J HANDSURG 2:131-3, 1977 2. Kaye J, Lister GD: Another use for the Brewerton view (letter). J HAND SURG 3:603, 1978 3. Harrison TR: Principles of internal medicine, ed 7. New York, 1974, McGraw Hill Book Co, pp 937-9 4. Robbins SL: Pathological basis of disease. Philadelphia, 1974, WB Saunders Co, pp 442-4 5. Linscheid RL, Dobyns JH: Common and uncommon in fections of the hand. Orthop Clin North Am 6: I 100, 1975 6. Cope VZ: A clinical study of actinomycosis, with illus trative cases. Br J Surg 3:55-81, 1915-16 7. Robinson RA: Actinomycosis of the subcutaneous tissue of the forearm secondary to a human bite. JAMA 142:1049-51, 1945 8. Florey ME, Florey HW: General and local administration of penicillin. Lancet I: 387-97, I943 9. Nichols DR, Herrell WE: Penicillin in the treatment of actinomycosis. J Lab Clin Med 33:521-5, 1948 10. Eastridge CE: Actinomycosis: A 24 year experience. South Med J 65:839-43, 1972 II. Goodman LS, Gillman A: The pharmacological basis of therapeutics, ed 4. Toronto, 1970, The MacMillan Co, p 1235 12. McWilliams CA: Actinomycosis of phalanx of finger, Ann Surg 66: I 17-8, 1917
Actinomyces israelii is a commensal organism of the oral cavity. When introduced into a microaerophilic environment in the deeper tissues of the body, it can produce a chronic suppurative infection which is difficult to eradicate. Actinomycosis can follow any human bite which penetrates the skin. We present such a case occurring in the hand.
Case report A 31-year-old black male plasterer was examined on Sep tember I, 1978, for a swollen left hand. On February 14, 6 1h months previously, he had been involved in a fight in which he struck a man in the mouth with a closed left fist. Immedi ately after the fight he noticed teeth marks and a superficial abrasion over the head of the left second metacarpal. The abrasion healed rapidly, but 4 days later the area began to swell, and the swelling persisted. There was minimal pain and tenderness, and the swelling did not interfere with the normal use of his hand. He was right handed and an otherwise fit man. Initial examination revealed moderate swelling of the left hand in the region of the second metacarpal and extending into the first interosseous space. There was mild tenderness only and otherwise the hand was normal. He was afebrile, and no lymphadenopathy in the relevant lymph drainage areas was detected. Radiological examination of the cut hand with routine views showed erosion of bone on the radial side of the neck of the second metacarpal. A Brewerton view markedly im proved the delineation of the extent of bone erosion (Fig. 1). This is in keeping with other reports on the use of the Brewer ton view in detecting changes in the metacarpal head and bone.t. 2 Hematological examination showed a mild monocytosis (10%, normal values are I% to 79c), but an otherwise normal profile. The Mantoux test was positive, but Reiter protein complement fixation and fluorescent treponema antibody tests were negative. At this stage a definitive diagnosis had not been made and it was decided to explore the swelling. On September 2, 1978, under left axillary block and tour niquet control, an incision was made over the dorsum of the second metacarpal. The tissues were edematous. The first Received for publication Dec. 16, 1978. Reprint requests: G. D. Lister, F.R.C.S., Doctors' Office Bldg., 250 E. Liberty St., Louisville, KY 40202.
360
THE JOURNAL OF HAND SURGERY
Fig. I. Brewerton-view roentgenogram of the left hand clearly delineates the degree of bone erosion on the radial side of the neck of the second metacarpal. dorsal interosseous muscle was exposed and appeared to be normal. An area of indurated subcutaneous tissue was located around the radial side of the neck of the second metacarpal and was firmly adherent to the bone. It also was difficult to dissect from the overlying dermis. This tissue was excised along with the involved bone, and the wound was closed in layers with a Penrose drain left in situ. Section of the tissue revealed multiple small abscesses which extruded straw-colored fluid containing many white, 1 mm-sized nodules, suggestive of "sulphur granules." His tological examination disclosed chronic inflammatory tissue with multiple abscess formation consistent with actinomy cosis infection (Fig. 2). Specimens submitted for bacteriology examination showed that the organism was not acid fast and
Vol. 4, No.4 July, 1979
Fig. 2. A low-power hematoxylin and eosin section shows a sulphur granule contained in an abscess cavity. that the sulphur granules were gram positive; Wright's fungal stain showed multiple branching filaments. The organism grew in colonies slowly on chocolate agar in carbon dioxide and brain-heart infusion with blood in an anaerobic envi ronment. Intravenous crystalline penicillin in a dose of I 2 million units was given in six divided doses daily. This regime was continued for I week while he was in the hospital and then continued on an outpatient basis with phenoxymethyl penicil lin ( 4 gm/day orally in divided doses) supplemented with probenecid (2 gm/day). In the postoperative period he remained afebrile; however, there was partial wound breakdown which was treated by careful irrigation and saline gauze packs. The wound healed well by secondary intention.
Comment. Actinomycosis is a chronic infection caused by Actinomyces israelii. This organism is an intermediary between bacteria and fungi and exists both as a gram-positive bacillary form and as a fungal filamentous form. It is a facultative anaerobe and is not acid fast, which differentiates it from the related Nocardia, which is aerobic and acid fast. 3 • 4 The organism forms part of the normal flora of the
Actinomycosis of hand
361
Fig. 3. Gram stain reveals gram-positive bacillary form of Actinomyces israelii.
oral cavity and is found especially in carious teeth and tonsillar crypts. Following a human bite or, as in our case, a hand wound contaminated with oral cavity flora, the seeds are sewn for the development of an infection. A microaerophilic environment is provided by traumatized tissue, and a chronic inflammatory reaction develops with extensive necrosis. 3 - 7 If the infection is not checked, the inflammatory reaction continues and results in destruction of all local tissues, including bone. Eventually drainage to the sur face occurs via multiple sinuses. Eventually hematoge nous spread will occur in most body tissues, and in the preantibiotic era the patient's demise soon followed. Lymphatic spread almost never occurs, and hence lymphadenopathy is most unusual. Examination of the involved tissue reveals multiple small abscesses con taining masses of intertwined mycelial filaments, commonly referred to as "sulphur granules." These are diagnostic, measure from 0.5 to 3 mm, and can be crushed between slides to reveal the filamentous or ganism on microscopic examination (Fig. 3). Radiating from this tangled mass of threads are club-shaped fila
362
The Journal of HAND SURGERY
Southwick and Lister
ments which on low-power microscopy produce a sun ray effect. At the present time, serological tests are of no diagnostic help. 3 • 4 The presence of a mild monocytosis was noted in our patient, but reference to this in other case reviews was not found. The treatment to eradicate the infection includes ef fective drainage of the involved area and administration of antibiotics. In 1943 Florey and Florey8 reported on two cases of actinomycosis treated by penicillin with out apparent effect. In 1947 Nichols and Herrell 9 used higher doses effectively in 46 patients who were fol lowed from 1 to 5 years after apparent cure. They rec ommended at least a 6 week treatment program. Eastridge 10 reviewed 24 cases over 24 years and rec ommended 2 to 5 million units of penicillin a day for a variable period, depending on clinical response, but suggested that treatment should continue for 3 months after all evidence of infection has disappeared. The organism also is sensitive to sulphonamides, tetracy cline, erythromycin, and lincomycin. 11 Our patient re ceived 12 million units of penicillin parenterally per day for 1 week and then 4 gm of oral penicillin sup plemented with probenecid to increase the effective blood, and hence tissue, levels of penicillin. This reg imen was continued for 3 months after full clinical response was apparent. The partial wound breakdown in the postoperative period suggests that it may have been wiser to leave the wound open and allow it to heal by secondary inten tion. However, there is no doubt that surgical interven tion was important for both diagnosis and treatment. It may be that the role of antibiotic therapy may not be so important if excision of the infected area is car ried out, as was done in our case. Linscheid and Dobyns 5 reported a case of Nocardia infection, similar to actinomycosis, which was excised. However, recur rence developed requiring sulphonamide therapy to control it. An extensive search of the literature revealed two case reports similar to ours. 6 • 12 In 1915 Cope and in 1917 Me Williams presented case reports of hand in fections following human tooth trauma to the hand. In the latter case amputation of the involved middle finger was performed following a diagnosis of sarcoma;
pathological findings, however, confirmed the diag nosis of actinomycosis. In summary, the diagnosis of actinomycosis of the hand should be entertained when human tooth trauma to the hand is followed several months later by a rela tively painless, nontender, swelling. Surgical explora tion may reveal the sulphur granules, but if not, mi croscopy and bacteriological staining and culture will confirm the diagnosis. A rigid antibiotic regime will aid eradication of the disease. With the wide use of antibiotics the incidence of this infection in its classical cervicofacial, pulmonary, and intestinal forms now is uncommon. However the astute physician should be aware of its existence, as this po tentially severe infection is readily treated. We appreciate the help given by the Department of Pathol ogy and Bacteriology at the Jewish Hospital, Louisville, Ky.
REFERENCES I. Lane CS: Detecting occult fractures of the metacarpal head: The Brewerton view. J HANDSURG 2:131-3, 1977 2. Kaye J, Lister GD: Another use for the Brewerton view (letter). J HAND SURG 3:603, 1978 3. Harrison TR: Principles of internal medicine, ed 7. New York, 1974, McGraw Hill Book Co, pp 937-9 4. Robbins SL: Pathological basis of disease. Philadelphia, 1974, WB Saunders Co, pp 442-4 5. Linscheid RL, Dobyns JH: Common and uncommon in fections of the hand. Orthop Clin North Am 6: I 100, 1975 6. Cope VZ: A clinical study of actinomycosis, with illus trative cases. Br J Surg 3:55-81, 1915-16 7. Robinson RA: Actinomycosis of the subcutaneous tissue of the forearm secondary to a human bite. JAMA 142:1049-51, 1945 8. Florey ME, Florey HW: General and local administration of penicillin. Lancet I: 387-97, I943 9. Nichols DR, Herrell WE: Penicillin in the treatment of actinomycosis. J Lab Clin Med 33:521-5, 1948 10. Eastridge CE: Actinomycosis: A 24 year experience. South Med J 65:839-43, 1972 II. Goodman LS, Gillman A: The pharmacological basis of therapeutics, ed 4. Toronto, 1970, The MacMillan Co, p 1235 12. McWilliams CA: Actinomycosis of phalanx of finger, Ann Surg 66: I 17-8, 1917