A 78-Year-Old Man With a Lingual Ulcerative Lesion

Talib A. Najjar, DMD, MDS, PhD; Prabhjot Singh, DDS

Disclosures

July 21, 2016

Discussion

The diagnosis of actinomycosis was made on the basis of the patient's physical examination as well as the histologic and microbiologic evaluation. The wedge biopsy demonstrated marked acute inflammation, microabscess formation, and visible organisms morphologically consistent with actinomycosis (Figure 3).

Figure 3.

This case is an atypical presentation of actinomycosis of the head and neck. A more common presentation consists of chronic submandibular swelling, usually brawny induration with fistula formation and purulent drainage. The presentation of actinomycosis on the tongue itself is also unusual. Firm masses with associated ulceration on the lateral border of the tongue in the presence of a significant tobacco and alcohol history are usually associated with cancer, typically squamous cell carcinoma.

Although the presence of a chronic, firm swelling is consistent with actinomycosis infection, cancer must also be considered. Therefore, in addition to the microbiologic analysis, an incisional biopsy of the lesion must be obtained.

No evidence suggested other cervicofacial, abdominal, pelvic, or pulmonary actinomycosis in this patient. The frequency of cervicofacial, abdominal/pelvic, and pulmonary actinomycosis is 55%, 25%, and 15%, respectively; subcutaneous actinomycosis as well as actinomycosis at other sites accounts for the remaining 5% of cases.

Although the pathogenesis is unclear, the two primary predisposing factors for development of an actinomycosis infection are the presence of an introductory pathway into the tissue, and a suitable environment for the bacteria to thrive. Trauma seems to play an important role in most cases by initiating the portal of entry for the organism. In this case, trauma associated with the blade implant may have been involved. Some investigators have proposed that other microorganisms, such as Staphylococcus aureus, act in a synergistic fashion to create an anaerobic environment for the Actinomyces organisms to multiply.

In the cervicofacial area, the infection is frequently of odontogenic origin and can be the result of oromaxillofacial trauma, dental intervention, or poor oral hygiene. Actinomyces israelii reproduces easily in the presence of necrotic tissue and can lead to clinical emergence of the disease. The presence of dental or periodontal disease and devitalized tissue after trauma or surgery provides an adequate environment for Actinomyces species to flourish.

Actinomyces require the presence of many other types of bacteria to proliferate; the specific ecosystem thus formed has a low oxidoreduction potential that is favorable to anaerobic growth. This ecosystem is formed with polymicrobic "associate" flora working in a synergistic fashion. It destroys local tissue, which is highly vascularized and aerobic, and replaces it with poorly vascularized granulomatous tissue, thereby permitting development of an anaerobic milieu that is essential to Actinomyces growth.[1,2,3,4]

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