USMLE® Step 1 style questions USMLE
A 40-year-old man presents to the clinic due to a painless jaw mass that started a few weeks ago. The mass has slowly increased in size and has recently begun producing a yellow discharge. The patient underwent molar extraction a few weeks prior to noticing the mass. Past medical history includes type 1 diabetes mellitus. Temperature is 38.0 ºC (100.4 ºF), pulse is 75/min, and blood pressure is 120/80 mmHg. Physical examination shows a painless mandibular mass with sinus tract formation and yellow purulent discharge. Gram stain and culture of the discharge shows Gram-positive bacteria with yellow sulfur granules. Which of the following is the most likely organism responsible for this patient’s condition?
Actinomyces israelii, or just A. israelii, is a gram-positive rod-shaped bacteria that causes a human infection called actinomycosis.
Calling this bug actinomyces implies that it’s morphologically similar to fungus, because both form microscopic branching filaments (or mycelium), while the word Israelii comes from James Adolf Israel, the German surgeon who first described it.
OK, A. israelii is a rod-shaped gram-positive bacteria, we’ve got that part down, but what this means is that it goes purple when gram-stained.
When there’s many of them, they arrange themselves in the shape of purple branching filaments.
They are anaerobes, meaning they grow better without oxygen, they are also non-motile, and don’t form spores.
But wait… that sounds exactly like Nocardia, another group of rod shaped, gram-positive, filamentous bacteria with a lot of other similar features.
To distinguish them, an acid-fast stain, also called Ziehl-Neelsen stain is done.
With this test, a red dye called carbon fuchsin, binds to lipids in the cell wall, coloring them red.
Then alcohol is applied to wash out any dye that hasn’t colored bacteria, and a second dye, methylene blue, is applied.
Another difference is that A. Israelii is catalase negative, so it doesn’t make an enzyme called catalase, whereas Nocardia is catalase positive.
Finally, A. israelii is cultivated on blood agar, and then incubated in anaerobic conditions.
Alright, now, A. Israelii can asymptomatically colonize the oral cavity, particularly the space between the roots and gums, as well as the pharynx, where they gather around the tonsils, and also the intestinal tract, and the urogenital tract, where they coexist with other commensal bacteria.
Another reason is poor oral hygiene, which allows the bacteria to proliferate in the oral cavity, increasing the chance of an infection.
Now, actinomycosis can present in a number of ways.
The most common form is cervicofacial actinomycosis, which affects the mouth, jaw, and neck region.
It typically starts with a breach in the oral mucosa, which can happen when there’s trauma to it, like when having dental work done, or if there’s trauma to local tissues, like after craniofacial surgery.
The bacteria can then take advantage of the injured epithelial barrier to get into deep tissues, triggering an inflammatory process, which is typically followed by formation of abscesses - pockets of pus within infected tissues.
The abscesses may fistulize, meaning they create a sinus tract, which is like a pipe that drains the pus out through the skin.
In severe cases, the infection can spread deep into jawbones resulting in osteomyelitis of the maxilla or mandible, and it can sometimes spread to the middle ear resulting in actinomycosis otitis media.