Actinomycosis (actinomycosis; Greek aktis — a beam + mykzs — a mushroom + - Usis) — the chronic infectious not contagious disease of the person and animals caused by radiant fungi.
The first instructions on communication of radiant fungi with a purulent disease at a cattle belong to Bollinger (O. of Bollinger, 1877); he offered also the modern name of a disease though colonies of radiant fungi were observed and earlier [B.Langenbeck, 1845; Leber (N. Lebert), 1848]. The culture of aerobic radiant fungi was received in 1885 [Bostr (E. W. Bostroem)], and in 1891 Mr. Izrael and Wolff (J. Israel, M. Wolff) marked out from an actinomycotic node at the person culture of an anaerobic radiant fungus.
Most of foreign authors considers the true activator of the Actinomycosis only anaerobic radiant fungi whereas domestic scientists, based on S. F's works. Dmitriyev, recognize as activators A. both aerobic, and anaerobic radiant fungi (see. Actinomycetes ).
The significant contribution to development of the doctrine about And. S.F. Dmitriyev, G. O. Suteev, D. I. Asnin, M. V. Firyukova, etc.
== Statistics and geographical distribution == introduced
the Accounting of the Actinomycosis in the USSR and abroad is not obligatory. Cases of the Actinomycosis are registered almost worldwide. Data on number of patients And. in this or that country are brought in literature on the basis of summation of the published descriptions of separate observations. G. O. Suteev (1951) explained growth And. improvement of diagnosis of a disease.
According to Institute of medical parasitology and tropical medicine of MZ USSR of E. I. Martsinovsky, in the USSR annually is registered apprx. 800 revealed cases And.
Patients And. make 2,5 — 10% among patients with chronic purulent processes of various localizations.
Men are ill And. twice more often than women. Preferential persons at the age of 21 — 40 years are surprised.
- 1 The epidemiology
- 2 A pathogeny
- 3 Pathological anatomy
- 4 The clinical picture
- 4.1 The thoracic actinomycosis
- 4.2 The abdominal actinomycosis
- 4.3 The pararectal actinomycosis
- 4.4 The actinomycosis of urinogenital bodies
- 4.5 Actinomycosis of bones
- 4.6 Actinomycosis of the central nervous system
- 4.7 The actinomycosis of skin
- 4.8 The actinomycosis of the person
- 4.9 Generalized actinomycosis
- 4.10 Complications
- 5 Diagnosis and differential diagnosis
- 6 The forecast
- 7 Treatment
the Actinomycosis develops more often in the autumn winter period that is explained by increase of catarrhal diseases as favorable background for developing of a disease.
There are no bases to consider the Actinomycosis occupational disease: distribution of patients And. by professions it is proportional to a ratio of public groups of the population in this territory. Cases And. are registered more often where medical care of the population is better developed.
Are described enzooty of the Actinomycosis at a cattle.
the Exogenous theory of infection lost to a crust, time the dominating value. According to the endogenous theory, activators of the Actinomycosis at the person are, as a rule, radiant fungi, constantly saprofitiruyushchy in an organism (an oral cavity, went. - kish. path, upper respiratory tracts, etc.).
Developing of a disease is promoted by decrease in body resistance owing to a disease (flu, tuberculosis, diabetes, etc.), overcoolings, to pregnancy and so forth. Protective function of a mucous membrane is broken by the previous local inflammatory process or the injury breaking its integrity including as a result of an operative measure. In a pathogeny And. a peculiar role is played by salivary, bilious, uric, fecal concrements: they are at the same time and the injuring factor and carriers of radiant fungi. Confirmation of the endogenous theory of infection And. development of a disease on site of the closed injury is.
Development of a disease in the field of an open injury, a skin disease is an example of exogenous genesis of the Actinomycosis (e.g., eczemas). Development And. in an urakhus, the epithelial coccygeal course, branchyogenic fistulas with the subsequent distribution on surrounding fabrics can have as endo-, and an exogenous origin.
A certain value in a pathogeny And. nonspecific microflora has; frequency of its allocation is directly proportional to prescription And. In the presence of the accompanying nonspecific microflora And. proceeds heavier, with frequent aggravations, has the expressed tendency to distribution and demands more prolonged treatment.
Around implemented into a submucosal layer or in hypodermic cellulose of a radiant fungus the specific granuloma — the actinomycoma having a characteristic structure (see below) forms. Patterns of development of an actinomycoma define ways of distribution And. in an organism of sick (fig. 1). Preferential way — contact on «the shortest straight line», irrespective of anatomic borders, from the center of the center to the periphery and towards the surface of skin. The possibility of distribution is proved And. on limf, to vessels with defeat limf, nodes. The hematogenous way of spread of an infection is very rare.
Studying of the Actinomycosis in an experiment is connected with difficulty of creation of model of a disease since. And. at laboratory animals tends to self-healing.
formation of granulomas, disintegration, their suppuration and in parallel with it fibrosis of the suppurated granulomas with formation of cicatricial, chondroid fabric is characteristic Of a gross appearance of the Actinomycosis. The last is penetrated by small multiple abscesses that gives to fabrics the spongy look reminding cells.
Around the radiant fungus which was implemented into fabric proliferative reaction develops and there is a granuloma delimiting the infectious center from surrounding fabrics. By means of microscopy find out that the cellular players of a granuloma in process of development of process are changed. While in the central part of a small knot there is a necrosis and disintegration of cells, in surrounding granulyatsionny fabric formation of fibrous structures is observed. Typically for an actinomycotic granuloma existence of ksantomny cells and process of fibrosis. Though relationship of ksantomny cells with colonies of a fungus is finally not found out, there is a certain pattern: at big accumulation of druses of a fungus of ksantomny cells it is not enough, in the absence of them — there is a lot of. Degree of manifestation of fibrosis is various and depends on reaction of an organism.
Distinguish two options of a structure of an actinomycotic granuloma — destructive and destructive and productive. The first (an initial stage) is characterized by availability of the granulyatsionny fabric consisting preferential of young connective tissue cells and polymorphonuclear leukocytes with tendency to disintegration and suppuration; the second option (the second stage) is characterized by motley composition of granulyatsionny fabric in which, except above-stated, there are epithelial, lymphoid, plasmatic, ksantomny cells, hyaline spheres, collagenic fibers and existence of the hyalinized hems and different size of abscesses is noted. In diagnosis And. along with studying of fabric reactions also detection of druses of actinomycetes (fig. 2) is of great importance.
In cuts of fabric druses of actinomycetes of various sizes (from 20 to 320 microns) meet. They consist of a texture of fine ends of a mycelium with a diameter of 0,4 — 0,7 microns, have uneven, the lobular structure is more often. The ends of the threads of a mycelium which are located radially are represented kolbovidno reinforced. In the center of druse the mycelium of a rod form without swelling on the ends is found sometimes. Consider that druses with «flasks» are formed by an anaerobic form of an actinomyce. It is characteristic that in cases of «flask», heavy on a clinical current, as a rule, are not formed. True actinomycotic Druses in cuts of fabric need to be differentiated from the druzopodobny accumulations formed by microbes and other fungi. It is reached, in addition to coloring of cuts of fabric hematoxylin-eosine, by use of various modifications of colourings with a methylrosanilinum chloride, coloring, across Tsil — to Nelsen and use of PAS reaction. The specified techniques allow to find actinomycetes even then when threads of a mycelium break up to separate short fragments.
Druses of actinomycetes are most often observed in the central parts of granulomas and are surrounded with a zone of leukocytic infiltration. At dying off of a mushroom this zone is represented more rarefied. Around the leukocytes surrounded in turn with epithelial cells it is possible to observe colossal cells of foreign bodys quite often.
Along with detection of druses it is necessary to estimate their condition, a cut depends on fabric reaction. Change of druses in fabric can be divided into four groups: 1) a lysis (it is expressed in regional or total dissolution of druses); 2) calcification of druses; 3) absorption of druse colossal cells (fig. 3); 4) transformation of druses into vitreous amorphous masses. Phagocytosis of druses and the phenomenon of a lysis demonstrate increase in immune forces of an organism. Comparison of fabric reaction and a condition of druses especially important at assessment of efficiency of the applied methods of treatment, so far as concerns a pathomorphism And.
At one of the most frequent localizations And. in the field of an ileocecal corner distinguish two forms: the first when on a mucous membrane grayish plaques from colonies of a fungus which separate threads carry out intestinal glands, and the second (fabric) at which the main defeat is observed in a submucosa and a muscular coat where small knots are formed are visible. Upon transition of process to an abdominal wall typical actinomycotic granulomas are formed. Damage of a liver is expressed in development of one or several abscesses consisting of the mass of the cells divided by layers of connecting fabric.
In lungs of change are presented by the dense nodes consisting of granulyatsionny fabric, squeezing and destroying tissue of lungs. At damage of a brain around the abscesses surrounded with a layer of vaskulyarizirovanny connecting fabric it is noted umenypeny quantities of nervous cells, swelled also increase in a microglia. At damage of bones multiple cavities which walls consist of granulyatsionny fabric are formed. On the periphery the sclerosis of a bone tissue is noted.
The clinical picture
Lack of uniform classification of the Actinomycosis creates considerable difficulties for its registration, the account and studying.
The offered options of classifications are applicable only for certain localizations of the Actinomycosis or reflect separate lines of this peculiar process. Clinical characteristic and assessment And. shall be based on results of a research of process from the points of view: 1) localizations of process; 2) period of development (initial, chronic, recovery); 3) the forms (localized, extended, disseminated); 4) stages of a disease.
An incubation interval at And. varies from several days to many years.
The thoracic actinomycosis
the Thoracic actinomycosis makes 10 — 20% among other localizations of this disease. Most often meets And. lungs.
At localization of primary center in the central sites of a lung the beginning And. remains usually imperceptible. In the anamnesis note catarrhal and respiratory diseases. Later dull aches in a breast join.
The actinomycosis of a top of a lung is followed by non-constant brachialgias, shovels.
At subpleural localization primary And. develops sharply, is followed by dry painful cough, quickly accruing pains amplifying at breath and the movement. The thorax on the party of defeat lags behind at breath, the pleural rub sometimes is defined.
The ampere-second preferential localization in soft tissues of a chest wall is clinically characterized by development of extensive infiltrate with sites of abscessing, narrowing of intercostal spaces, often at the same time takes place And. edges. In a stage of abscessing the disease has all signs of ostrovospalitelny and even septic process. The break of abscess in a large bronchial tube is followed by an otkhozhdeniye of a significant amount of a purulent phlegm. In process of progressing of process the condition of patients worsens, weakness increases, appetite goes down, weight loss up to a cachexia progresses. Discrepancy between weight of process and a small amount of a mucous or mucopurulent phlegm with streaks of blood pays attention.
In recent years cases when began to meet And. lungs it is limited to defeat of one of segments of a lung, without tendency to distribution of process that is explained by early use of antibacterial therapy.
Perkutorno over the center of defeat can be defined a dullness. In the field of the center breath, scattered non-constant wet rattles is noted weakened, with a rigid shade, the strengthened bronchophony, the weakened voice trembling is more often small-bubbling.
At primary aerogenic And. lungs upper right and lower left shares of lungs most often are surprised. Secondary pulmonary And. at spread of an infection from an abdominal cavity in overwhelming number of cases strikes the lower shares, is more often right.
And., localized in a pleural cavity, is followed by formation of the cavities limited to connective tissue partitions containing dense pus and connected among themselves by the fistular courses.
Damage of a mammary gland at And. usually primary, limited to limits of gland. Secondary And. a mammary gland develops as a result of distribution from lungs, a mediastinum. Clinically And. a mammary gland proceeds as chronic purulent mastitis (see).
One of complications thoracic And. — specific damage of heart.
The abdominal actinomycosis
the Abdominal actinomycosis makes 10 — 20% among other localizations of this disease. In most cases abdominal And. develops in a caecum that speaks stazy fecal masses in this piece of a digestive tract. The important role of a worm-shaped shoot in a pathogeny abdominal is proved And.: in 60,3% of cases from the shoots removed concerning an acute inflammation the culture of an anaerobic radiant fungus is distinguished; in 10,8% — the fabric form (druse of a radiant fungus) at different stages of their formation is histologically found.
The disease begins sharply, is shown by strong skhvatkoobrazny or constant abdominal pains of the kolikoobrazny, stupid or cutting character, high temperature. Pains can irradiate to the area of a bladder, a rectum, hip joints. Sometimes dispeptic join these symptoms, the peritoneal phenomena are more rare.
Much more rare entrance gate And. the stomach, a duodenum is; even more rare — the colon (ascending, cross, descending, sigmoid); very seldom — actively peristaltiruyushchy small bowel. At the women suffering abdominal And., specific defeat of internal generative organs often comes to light.
Progressing of process at abdominal And. it is expressed in increase in infiltrate and extraordinary extensive development of the commissures combining actually actinomycotic infiltrate and the nearest bodies and fabrics in the general conglomerate that can lead to development of an adhesive desease. The mucous membrane of intestines remains intact even at the considerable sizes of the center And. and prelum of a gleam of a gut. More rare abdominal And. proceeds in the form of abscessing with clinic of interintestinal abscess or with formation of sclerous process in an intestinal wall.
Most often And. from the place of primary affect extends towards a front abdominal wall, creating in it the abscessing infiltrate which is opened with fistula on the surface of skin.
Direction of distribution, the second for frequency, And. from a caecum — in retroperitoneal cellulose (fig. 4) — retroabdominal A. Retroabdominalny A. is characterized by diffusion infiltration of cellulose, unusual to this infection, lack of a clear boundary of the center, considerable hypostasis of surrounding fabrics, purulent fusion as phlegmon and often is complicated by an amyloidosis of internals. One of the most constant clinical symptoms at retroabdominal And. — psoitis (see).
From retroperitoneal cellulose A. can extend to a backbone, a thorax, bones of a small pelvis, the lower extremities. Complication abdominal And. there can be a damage of a liver, solitary at contact distribution, disseminated — at hematogenous.
The pararectal actinomycosis
the Pararectal actinomycosis (a paraproctitis actinomycotic) is characterized by emergence in cellulose of dense motionless infiltrate with rather clear boundary. The arisen infiltration extends on cellulose, abscesses, forming the characteristic tuberosity squeezing a rectum, sometimes to full obturation. Opening of pararectal abscesses at And. occurs, as a rule, on skin, it is extremely rare — in a gleam of a gut. Small puffiness of a mucous membrane of a rectum, a symptom of piloting — protrusion of dense infiltrate in a gleam of a gut comes to light, is more rare — bleeding of a mucous membrane. Patients note tenesmus, locks. At a fistulografiya the network of the anastomosing fistular courses in a pararectal fat comes to light.
Primary And. a rump can develop on site a bruise, an injection of medicinal substance. And. sacral area proceeds, as a rule, from an epithelial coccygeal cyst. From pararectal or buttock fat A. can extend to a crotch, urinogenital bodies.
The actinomycosis of urinogenital bodies
the Actinomycosis of urinogenital bodies develops as a result of distribution of process on contact or gematogenno.
And. kidneys it is shown by local pains, sometimes in the form of renal colic, the palpated infiltrate, a hamaturia. If center And. it is localized in cortical substance of a kidney, even at its big size it can not have messages with a cavity of a pelvis. The arrangement of the center in a medulla leads to rather early dysfunction of a kidney. At a piyelografiya in these cases defect of filling of a renal pelvis is observed. At distribution of process to pararenal cellulose the phenomena of a paranephritis, retroabdominal develop And. From a kidney distribution And. perhaps on the descending urinary tract, and also in other kidney.
Defeat of ureters is characterized by their deformation, «izjedennost», a crenation of walls, narrowing of a gleam that well comes to light at contrast X-ray inspection.
Primary And. a bladder meets seldom and it is connected usually with foreign bodys. And. a bladder it is shown by the painful and speeded-up urination, a hamaturia and proceeds further as ulcer and hemorrhagic or fibrinous and filmy cystitis (see). On a tsistogramma defect of filling can be defined, at a tsistoskopiya «tumor» with rare and rather broad polypostural educations is visible.
And. external genitals at men and women develops usually as a complication of an injury, is more rare — as a result of distribution of process of pelvic cellulose or urinary tract. And. external genitals at women usually is followed by purulent discharges from fistulas, and at men it is characterized by development of dense, low-painful infiltrate that conducts, especially at localization at a root of a penis or on a crotch, to a dysuria. Abscessing And. is followed by severe pains and comes to the end with burrowing.
Feature And. a penis — multiple fistulas on skin and hl. obr. on a head where «ulcers» are formed not as a result of a necrosis and rejection of fabrics, and owing to merge of close located mouths of fistulas. These fistulas are periodically closed, unlike uric which function constantly because of permanent cicatricial deformation of an urethra. A part of urine gets and impregnates cellulose of a crotch, a scrotum, a basin, cavernous bodies of a penis that considerably worsens a condition of patients and facilitates accession of consecutive infection. The case is described And. a penis, ended with gangrene of the last.
And. scrotums it is characterized by multiple fistulas, a lymphostasis up to its elephantiasis. Skin of a scrotum is thickened and condensed, its striation becomes rough. It is possible to palpate testicles and appendages hardly. Decrease in sexual function, as a rule, is not noted.
Isolated cases are described And. prostate, testicles and appendages, periurethral glands.
And. internal generative organs at women it is characterized the considerable sizes by the center of defeat which is going beyond a small pelvis; unions with intestines and an epiploon are formed. The vagina is narrowed so that vaginal examonation becomes impossible or sharply complicated. Most often appendages are surprised, is more rare — a uterus.
Fistulas can open on skin of a front abdominal wall, a hip, to the area of external genitals of a crotch, lumbar and buttock areas, in a vagina, a rectum, a bladder, etc.
Some patients at the beginning of a disease from a genital tract have allocations of white color or putreform, the number of allocations sometimes reaches 1 l a day. Disturbance of a menstrual cycle, acyclic bleedings are sometimes noted.
Actinomycosis of bones
Actinomycosis of bones. Changes in bones at And. have various character and depend on ways of penetration of an infection, dominance of one of at the same time proceeding processes (destructive, osteomiyelitichesky and productive, sclerous).
At a contact way of distribution And. first of all the periosteum, then cortical substance of a bone and, at last, spongy is surprised. The periosteum is thickened, condensed. Further can obyzvestvlyatsya (an ossifying periostitis). Calcification of intervertebral sheaves causes deformation of a backbone in the form of a bamboo stick.
At a hematogenous way the center And. reminds the central bone abscess, differing from the last in a zone of a sclerosis around, edges it can be hardly noticeable or sharply expressed. Expressiveness and increase in a zone of a sclerosis around the center And. in a bone — a favorable predictive sign. The sizes of the centers of destruction vary: the solitary center has usually rather big sizes, multiple — smaller.
And. does not strike cartilaginous tissue and, as a rule, joints. Apparently, for this reason And. the backbone even at extensive defeat is not complicated by its curvature.
A peculiar clinicoradiological picture is observed at defeat of foot (see. Madura foot ).
Actinomycosis of the central nervous system
Actinomycosis of the central nervous system. And. a brain, developed as a result of spread of an infection kontaktno or on limf, to ways from the center on a face and a neck, in retropharyngeal cellulose, proceeds as purulent, is more often than basilar meningitis, an encephalomeningitis, solitary abscess which can reach the considerable sizes in this or that part of a brain, as defines clinic of a disease. Hematogenous And. a brain it is characterized by multiple scattered actinomycomas in brain fabric and in covers of a brain that is clinically shown as encephalitis, dakhileptomeningit. The combination of contact and hematogenous ways of penetration of an infection into a brain is possible.
And. a spinal cord can develop as a result of contact penetration of an infection from a mediastinum through intervertebral foramens, an epidural space and it is clinically shown as radikulomeningit, acute purulent meningitis. The metastatic centers in a spinal cord meet extremely seldom. A spinal cord at And. suffers more often from a prelum, than from a direct injury. There are descriptions of distribution And. on covers at first a head, then spinal cord with clinic of cerebrospinal meningitis.
Center And. the central nervous system can latentno exist for many years.
The actinomycosis of skin
the Actinomycosis of skin can be primary and secondary. Primary And. skin develops as a result of penetration of aktinomipet from the outside at injuries, wounds. Secondary And. skin it is observed more often, it develops owing to spread of an infection from primary center in internals.
Distinguish the following clinical forms A. skin.
Knotty form. At primary And. skin — dense or dense and elastic slow-moving painless infiltrate in deep layers of skin the size 3×4 of cm and more. Increasing, infiltrate acts over the level of surrounding skin, edges are got by dark red color with a violet shade (tsvetn. tab., fig. 7 and 8). Near the main center quite often develop new, affiliated, evolution their same. At secondary And. skin nodes are larger, lie more deeply, being accustomed to drinking with surrounding fabrics. Nodes abscess and are opened with formation of several fistulas — a gummous form of an actinomycosis of skin.
In purulent separated fistulas it is often possible to find yellowish grains — druses of an actinomyce. A part of fistulas cicatrizes, but soon there are new. This form should be differentiated with syphilitic and tubercular gummas, new growths, a chronic pyoderma.
The grumous form usually develops at primary And. skin in the form of small (0,5×0,5 cm), not merging among themselves, dense, painless, semi-spherical, dark red hillocks. The most part abscesses them, being opened with allocation of a drop of pus. Later the fistulas which are periodically becoming covered by crusts of brown-yellow color are formed. Process tends to strike a hypodermic fatty tissue and to extend to the neighboring topographical areas. Sometimes deeply lying hillocks pustulizirutsya (a grumous and pustular form A.), reminding grumous syphilis.
The ulcer form usually arises at the weakened patients on site of the abscessing infiltrates. Edges of ulcers soft, subdug, uneven, skin around them bluish color. The bottom of ulcers is covered with nekrotizirovanny fabrics, sluggish granulations. Ulcers arise more often in places where there is a friable hypodermic cellulose (over - and subclavial areas, axillary hollows, etc.).
The atheromatous form arises at children more often. Infiltrate of rounded shape, to 5 cm in the diameter, (pseudofluctuation), with a clear boundary, reminds an elastic consistence a true atheroma; in the subsequent infiltrate abscesses with release of pus and burrowing.
And. skin can have features depending on localization. At And. skin of proctal area are formed the multiple fistulas surrounded with vegetations around mouths.
At And. skin of sacral area dense infiltrate with single fistulas is often formed. And. skin of buttocks it is localized in a hypoderma. Process takes the surface of both buttocks and extends to the neighboring areas, forming a set of the painless merging infiltrates with fistulas.
Regional limf. nodes at And. skin are involved in process seldom, usually only at maxillofacial And.
The actinomycosis of the person
the Actinomycosis of the person is observed approximately at 58% of total number of patients And. and almost at 6% of the patients addressing to medical institutions concerning inflammatory diseases of jaws and areas of the person.
Actinomycetes, being residents of an oral cavity, are in a dental plaque, pathological dentogingival pockets, in carious cavities of teeth, make the main stroma of a dental calculus.
Such inflammatory processes as periodontosis, a pericoronitis, dontogenous inflammatory process, tonsillitis, a sialodochitis and others, and also injuries of a mucous membrane of a mouth promote
A. A. development persons is characterized hron. a current, however the great influence on a clinical picture is exerted by accession of a consecutive pyogenic infection. It aggravates and considerably changes character of a course of a disease; and aggravations are observed repeatedly.
At And. faces it is advisable to distinguish the following clinical forms (fig. 5 — 7): skin, hypodermic, hypodermic and intermuscular (deep), And. limf, nodes, primary And. jaws, And. bodies of an oral cavity — sialadens, language, almonds (T. G. Robustov). Most often hypodermic and hypodermic and intermuscular forms meet, and also And. limf, nodes.
The skin form is observed seldom, pathological process is usually localized in buccal, submaxillary and mental areas (tsvetn. tab., fig. 9). It is characterized by existence on skin of pustules or hillocks, and also their combination creating the separate small or merging infiltrates towering over surrounding not affected areas. Often process extends to the neighboring sites of skin.
At a hypodermic form there is a limited infiltrate in hypodermic cellulose, in close proximity to the site of fabrics which was entrance infection atriums. At this form A., the most often localized in buccal area, at the level of upper or a mandible, and also in submandibular area in one cases the prevalence of exudative processes, in others — proliferative is observed. Distribution on an extent and formation of the new centers is quite often noted.
Hypodermic and intermuscular form. The beginning of a disease and a clinical picture are various. Emergence of inflammatory hypostasis of soft tissues with their subsequent consolidation is characteristic.
At localization of process in parotid and chewing and temporal areas, a retromandibular pole, in alate and maxillary space, an infratemporal pole the resistant inflammatory contracture of a mandible of the II—III degree is observed. It can be one of early symptoms of a disease.
Quite often for weeks and months the slow, sluggish disease which is not followed by a pain syndrome and temperature increase is noted. Further there comes the gradual softening of infiltrate in one or several sites and abscessing. It is followed by emergence of pains, rise in temperature to 38 — 39 °. In the subsequent perhaps gradual rassasyvaniye of infiltrate or its distribution on the next fabrics with formation of the new centers, involvement in process of a bone tissue of a jaw.
At this form A. influence of the joined consecutive pyogenic infection is most brightly shown that does the course of a disease more acute and rough and usually promotes distribution of process on an extent.
Actinomycosis of lymph nodes. Involvement limf, nodes, contrary to the statement that the adenoid tissue is not surprised this pathological process [F. Trauner], at maxillofacial And. meets quite often. Most often are surprised limf, nodes of submandibular area, buccal, supramaxillary and cervical. The disease differs in a slow and sluggish current. It is shown more often in the form of the abscessing lymphadenitis, sometimes hyperplastic lymphadenitis and an adenoflegmona with involvement in process of surrounding cellulose.
Actinomycosis of a bone tissue of a jaw. A specific place is held by primary defeat And. a bone tissue of a jaw, proceeding as destructive or productive and destructive process. On a clinical and X-ray pattern the disease reminds development of a dontogenous tumor or a malignant new growth.
At destructive process one or several merging centers of destruction of a bone with the indistinct, and sometimes sharply outlined borders are noted. More often the mandible is surprised though cases of damage of an upper jaw [Yarmer, by Thomas (are described To. Jarmer, K.H.Thoma)].
Productive and destructive process is observed at defeat And. a mandible at children, teenagers or young people [Vassmund (M. Wassmund)]. It is characterized by a considerable thickening of affected areas of a bone.
The actinomycosis of bodies of an oral cavity (language, sialadens, almonds) is observed rather seldom. By considerable variety of manifestations it is characterized And. language that depends on localization of a specific granuloma in its fabrics. Process can strike superficial departments of language, be located in the thickness of muscular tissue of a back or a tip of language in the form of limited infiltrates; also diffusion defeats reminding banal abscess and phlegmon of the basis of language are observed.
In some cases And. for the second time strikes a mandible, is more rare upper, seldom malar and temporal bones. At the same time there is a picture of an extensive ossifying periostitis, sometimes in combination with a row uzur cortical substance of a bone, the progressing destruction of its considerable sites is sometimes noted. In cases of accession of a purulent infection there can occur necrosis of cortical sites of a jaw with the subsequent their sequestration (a picture of cortical osteomyelitis). It is the indication to an operative measure — a sequestectomy.
Generalized actinomycosis. Cases of multiple hematogenous innidiation And. in various bodies and fabrics in a crust, time almost do not meet. In a number of works (B. L. Ospovat, 1963, etc.) it is claimed that for hematogenous dissimination And. the break of a specific granuloma in a gleam of a blood vessel suffices. However the data which are available in modern literature call into question absoluteness of this statement: even germination of an actinomycoma in a gleam of the lower vena cava and formation of blood clot, considerable on extent, from specific granulations not always causes hematogenous dissimination. Apparently, conditions under which there can come hematogenous dissimination are necessary.
Clinical picture generalized And. reminds sepsis with metastasises in various bodies where the specific centers which then pass usual for were created And. stages of development. Initial (primary) center And. it can be localized in any body or body tissue of the patient.
Complications. Inherent And. snowballing of connecting fabric can lead to cicatricial deformation of the body involved in process and disturbance of its function (e.g., a prelum of ureters, a gleam of a gut). It is long the existing center And. can undergo blastomatous transformation, cause development of an amyloidosis of internals.
Diagnosis and differential diagnosis
Recognition And. remains a difficult task: frequency of wrong diagnoses is big and causes late diagnosis, the beginning of rational treatment detains, considerably extends its terms. For timely diagnosis And. the comprehensive examination of the patient including clinical, radiological and laboratory methods of a research is necessary. And. it is necessary to differentiate with the processes caused by banal pyogenic flora, new growths, tuberculosis. And. a worm-shaped shoot can simulate an acute appendicitis. Appendectomy at the same time is quite justified.
Unlike the abscess caused by banal pyogenic flora, the center And. is not exposed to total purulent fusion, tends to distribution on surrounding fabrics; after opening of specific abscess the fistula going to depth of fabrics comes to light (except cases primary And. skin).
The wrong diagnosis of a new growth of this or that genesis is made at the considerable sizes of the center And., inefficiencies of antibacterial therapy. Unlike malignant tumors, at And. ulcers are not formed (except very rare primary And. skin), are not surprised, as a rule, regional limf, nodes; pains develop only in initial stages of a disease. At high-quality new growths, unlike And., abscessing of the center of defeat is not observed.
The diagnosis of tuberculosis is mistakenly made to a thicket at patients pulmonary And., usually in connection with the pneumopathy which is not giving in to antibacterial therapy. Unlike And., tuberculosis organotropen, whereas at And. the hl is surprised. obr. cellulose around body.
Radiodiagnosis of an actinomycosis
Radiodiagnosis of an actinomycosis. X-ray inspection at And. shall depending on localization and the corresponding indications to include all available complex of modern methods.
At primary And. lungs in case of an aerogenic way of infection the focal and infiltrative forms of a disease often similar to tubercular infiltrates both on a clinical picture, and on radiological signs are observed. Further at similar type of defeat there is a peribronchitis and a perivasculitis, in a root of a lung there are increased limf, nodes connected with availability of mycotic infiltrate. For And. early involvement in process of pleural leaves (a thickening of a pleura in the form of rough shvart), and also edges (fig. 8) is characteristic. At an adverse current share defeats with large and small cavities of disintegration, involvement in process of cellulose of a mediastinum, a gullet, with formation of internal and outside fistulas develop. The existence of massive defeat of a lung lobe which is followed by increase limf of nodes of the corresponding root and a mediastinum, forces to suspect cancer of a lung first of all. But at And., unlike a tumor, share borders are not an initial barrier to distribution of process. The tomography and a bronchography confirm lack of the major symptom of bronchopulmonary cancer — a bronchostenosis — and existence of large and small cavities of destruction against the background of an extensive peri-and an endobronchitis. A valuable diagnostic character are the accompanying changes in edges in the form of diffusion, is more rare than local ossifluence, an osteosclerosis and periosteal stratifications that distinguishes And. from a picture of germination and innidiation of cancer of lung in edges (destruction of a bone tissue).
At more favorable (preferential productive) type of a current And. lungs there is a X-ray pattern very similar with hron. intersticial pneumonia up to cirrhosis of a lung. There come the shift of a mediastinum, narrowing of mezhreberiya and other signs of a fibrothorax.
And. tracheobronchial and bronkho-pulmonic limf, nodes radiological it is shown by intensive blackout with polycyclic outlines in a radical zone of a lung.
In rare instances A. E. Prozorov observed a picture primary and miliary And. lungs. Unlike miliary tuberculosis, intersticial changes at this type A. lungs have more rough character, the centers are more dense, tyazhisty consolidations of a stroma of a lung clearly are directed to a root. Along with rough intersticial changes in a zone of the greatest defeat at And. in earlier phases also gentle linear shadows of a peribronchitis both in related departments of the affected lung, and on the healthy party can be observed. At success of treatment such changes disappear first of all.
At secondary And. lungs distribution of process from cellulose of a mediastinum to the periphery is observed. At the same time are defined: 1) expansion of roots of lungs and mediastinum; 2) massive mediastinal and kostalny shvarta; 3) the rough tyazhistost which is radially extending from the increased roots of lungs to the periphery; 4) the centers and infiltrates on the course formed by tyazhy. During the contrasting of a gullet its deformations and narrowings, and sometimes fistulas come to light. Almost always there are rather characteristic changes in edges, is frequent with fistulas.
At And. a skeleton secondary changes owing to distribution of process from soft tissues are observed considerably more often than primary. Distinctions in a X-ray pattern between primary and secondary And. are essential. At primary defeat on roentgenograms the picture of a so-called actinomycotic gumma, i.e. the center (centers) of ossifluence of a rounded or oval shape with a zone moderate comes to light, but is more often than the expressed sclerosis on the periphery. Periosteal stratifications and fistulas are frequent. A characteristic sign — lack of narrowing of an adjacent joint crack, and also sequesters if there is only no secondary infection. Primary And. a backbone leads to considerable destructions of bodies of vertebrae and intervertebral disks, extends to arches and shoots of vertebrae (fig. 9). Unlike a tubercular spondylitis, considerable sclerous reactions and ossification of sheaves, and contrary to a coccal spondylitis — much slower and hidden current, despite existence of fistulas are observed. At secondary And. a skeleton damages of a jaw at cervical and front localization of primary process are most frequent. Damages of a backbone are less often observed at mediastinal And., and also distribution And. abdominal organs on walls of a basin and lumbar vertebrae. It is characteristic: 1) early involvement of a periosteum with its ossification; 2) formation of the small centers of ossifluence with a reactive osteosclerosis; 3) lack of sequesters. At damage of jaws there are both massive hyperostoses up to a picture of a pseudoneoplasm, and preferential osteolytic forms. The widespread tendovaginitis at damage of a backbone can simulate a picture of a disease of Bekhterev if not to take into account the centers of ossifluence in bodies of vertebrae and their arches. At fistulas the fistulografiya specifies distribution of process in soft tissues, and the tomography reveals existence of the small centers of ossifluence in a bone.
Radiodiagnosis And. internals (a stomach, intestines, urinogenital system) presents great difficulties. At the most frequent localizations in the field of ileocecal transition and in a rectum the X-ray patterns very similar to infiltrative cancer, tuberculosis, a disease Krone and even with severe forms of amoebic dysentery are described. Sometimes reveal small stepped appearance of a wall of an affected area («a symptom of a saw»).
Emergence not only internal, but also outside fistulas, and also formation of extensive infiltrates is characteristic.
Endoscopic methods of a research
Endoscopic methods of a research at And. are a little productive since from a mucous membrane pathology does not come to light, and from a serous cover the center of defeat masks commissural process.
Laboratory methods of a research
Laboratory methods of a research. By the most widespread method of a laboratory research at And. the microscopy of pus, a phlegm, etc., carried out for the purpose of detection in pathological material of colonies (druses) or a mycelium of radiant fungi is. Allocation of culture of radiant fungi significantly supplements microscopic diagnosis (see. Actinomycetes ). At assessment of results of a microbiological research it must be kept in mind constant presence of radiant fungi at an organism of healthy people, and also a possibility of formation of various druzopodobny educations, e.g. colonies of causative agents of other deep mycoses, accumulations of stafilokokk (staphylococcal aktinofitoz), crystals of fatty acids, etc.
And reliable the patogistologichesky method of a research which purpose consists not only in search of druses of radiant fungi, but also in identification of characteristic structure of an actinomycoma is important.
Immunological reactions at And. have approximate value.
All laboratory researches A. are quite available and can be executed in the conditions of usual laboratory.
At timely begun rational treatment the forecast at And. it is necessary to consider favorable. After the first course of treatment patients usually are returned to work, continuing treatment in out-patient conditions. During aggravations hospitalization is shown. The persons occupied with hard physical work are transferred temporarily to easier work. In most cases the disease recovers completely. At a small number of patients after treatment from And. the residual phenomena connected with development of cicatricial fabric in the field of the center of a disease remain: in lungs — fibrosis with bronchiectasias and cysts, in an abdominal cavity — adhesive desease (see), etc.
the Large number of the means and methods offered for treatment of patients And., considerably confirms their insufficient efficiency and need of complex treatment of patients, the basis to-rogo is made by an immunotherapy. Antibacterial drugs, excitants, surgical treatment can be in addition used.
The specific immunotherapy is carried out by domestic drugs — aktinolizaty, the actinomyce polyvalent vaccine (APV). Aktinolizat represents a filtrate of bouillon culture of spontaneously lysing strains of aerobic radiant fungi; APV is produced from sporiferous strains of aerobic radiant fungi. Introduction of an aktinolizat is carried out by intradermal (according to D. I. Asnin) or intramuscular (according to G. O. Suteev) injections. Intradermal injections: in thickness of skin of a flexion surface of a forearm the drug is administered in the raising doses from 0,5 to 2 ml: 0,5 — 0,7 — 0,9 — 1,0 — 1,1 — 1,2 etc. to 2 ml. No more than 0,5 ml so since the 14th injection aktinolizat it is entered into 4 points are entered into each point (on 2 on each hand). Intramuscular injections: aktinolizat it is entered into thickness of an upper outside quadrant of a gluteus on 3 ml. By both methods of an injection of drug are made twice a week. Duration of one course — 3 months; an interval between courses — 1 month.
The method of intramuscular injections is simpler, intradermal — is more economic and, on a nek-eye to data, is more effective.
After clinical recovery are obligatory 1 — 2 antirecurrent a course of an immunotherapy and control observation within 2 — 3 years.
APV is entered vnutrikozhno into thickness of flexion surfaces of forearms daily in gradually increasing doses, since 0,1 ml, then 0,2 — 0,3 — 0,4 ml etc. to 1,0 ml. No more than 0,1 ml so since the 10th injection of APV it is entered into 10 points are entered into each point of APV in cultivation of 1 billion, microbic bodies in 1 ml on an optical turbidity standard. Duration of one full course of treatment of APV — 3 months, intervals between courses — 1 month. The published data demonstrate that in some cases APV is more effective, than aktinolizat.
Antibacterial drugs (antibiotics, streptocides) influence not only the accompanying microflora, but also a radiant fungus. Reasonablly therefore to define sensitivity to these drugs of the accompanying microflora and radiant fungi from the center in the beginning And. The picked-up drugs are used according to the existing schemes. As clinical indications for use of antibiotics and streptocides serve the frequent aggravations which are followed by abscessing of the center, especially on new sites; existence of constantly functioning fistulas with purulent discharges.
The stimulating treatment consists hl. obr. from courses of hemotransfusions in the small, gradually raising doses: once a week on 50 — 75 — 100 — 125 — 150 — 175 — 200 ml; in total on a course depending on indications — 4 — 6 hemotransfusions. The stimulating therapy is carried out at reduced reactivity of an organism of the patient.
The question of need and the nature of surgical treatment is solved as follows. Radical operations with the purpose of excision of the center of defeat (in one stage or step by step) are made when all complex of conservative means is insufficient and the center of defeat is delimited, and also in cases of development And. from anatomic anomalies. The purpose of palliative operations — removal of accumulation of pus or a foreign body from the center of defeat, a sequestrotomy, etc. The section of fistulas and their curettage are useless.
A roentgenotherapy and drugs of iodine in treatment And. have limited use.
Combination of these or those remedies A. shall be selected individually depending on a condition of the patient, localization and the nature of a disease.
Bibliography: Asnin D. I. Immunodiagnosis of an actinomycosis, M., 1956, bibliogr.; Mashkilleyson L. N. Treatment and prevention of skin diseases, M., 1964, bibliogr.; Minsker O. B. Pathogeny, clinic and treatment of an actinomycosis, Surgery, No. 11, page 130, 1971, bibliogr.; To base B. L. Aktinomikoz of lungs, M., 1963, bibliogr.; Spasokukotsky S. I. An actinomycosis of lungs, M. — L., 1940; Suteev G. O. Actinomycosis, M., 1951, bibliogr.; Hauf U., Heinrich S. u. Legler F. Untersuchungen uber die Empfindlichkeit des Erregers der Aktinomycose gegen Antibiotica (Penicillin, Streptomycin, Aureomycin, Chlormycetin, Terramycin) und Methylenblau, Arch. Hyg. (Berl.), Bd 137, S. 527, 1953, Bibliogr.; Hylton R. P., Samuels H. S. and. Oatis G. W. Actinomycosis, Oral Surg., v. 29, p. 138, 1970; Krankheiten durch Aktinomyzeten und verwandte Erreger, hrsg. v. H. I. Heite, V., 1967, Bibliogr.; Lungenmykosen, hrsg. v. H. Bartsch, Stuttgart, 1971.
Pathological anatomy A. — Zhgenti V. K. and Tatishvili I. Ya. Materials for studying of morphology of an actinomycosis at the person, Works Vsesoyuzn. konf. patologoanat.v Leningrad, page 191, M., 1956; Minsker O. B. and Egorov T. P. Pathological anatomy of an actinomycosis, Arkh. patol., t. 29, No. 12, page 3, 1967, bibliogr.; The multivolume guide to pathological anatomy, under the editorship of A. I. Strukov, t. 9, page 624, M., 1964; Talalayeva L. V. and Asnin D. I. To diagnosis of an actinomycosis in fabrics, Arkh. patol., t. 26, No. 11, page 71, 1964, bibliogr.
And. persons — Robustova T. G. Actinomycosis of maxillofacial area and neck, M., 1966, bibliogr.; The guide to surgical stomatology, under the editorship of A. I. Evdokimov, page 204, M., 1972; Bethmann W. u. Pape K. Erkrankungen der Kieferknochen, Bd 1, S. 53, V., 1965, Bibliogr.; Smith A. F. J. Actinomycosis of the body of the mandible, J. roy. nav. med. Serv., v. 56, p. 279, 1970.
Radiodiagnosis A. — Altshuller E. N. Efficiency of additional methods of X-ray inspection at an actinomycosis of lungs, Vestn. rentgenol. and radio-gramophones., No. 2, page 27, 1969, bibliogr.; Prozorov A. E. and Tager I. L. X-ray inspection at some infections, page 5, M., 1950; Sobolev V. I. To radiodiagnosis of an actinomycosis of lungs, Vestn. rentgenol. and radio-gramophones., No. 5, page 47, 1955, bibliogr.; Tokareva S. V. An actinomycosis of a backbone in the radiological image, in the same place, No. 3, page 10, 1969, bibliogr.
O. B. Minsker; G. A. Vasilyev, T. G. Robustova (ostomies.); B. M. Leshchenko (dermas.), I. L. Tager (rents.), O.K. Khmelnytsky (stalemate. An.).