Case study(Actinomyces israeliiand)

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Actinomyces Israeli Prepared by : Mohammed A Qazzaz

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Thoracic Vertebral Actinomycosis : Actinomyces israelii and Fusobacterium nucleatum Case study

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ABSTRACT Actinomyces spp. are considered rare pathogens in today's medicine, especially with thoracic vertebral involvement. Classic actinomycosis (50%) presents as an oral- cervicofacial (“lumpy jaw”) infection. This report describes a case of spinal cord compression caused by Actinomyces israelii with the coisolation of Fusobacterium nucleatum . There are limited numbers of similar cases. محمد عدنان القزاز

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The case described here involves a 43-year-old Filipino man who presented to a medical center emergency department with a chief complaint of acute lower back pain and urinary incontinence. He had been in his usual state of health until approximately 3 days prior to admission Case report محمد عدنان القزاز

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Case report con. when he first noticed a gradual onset of bilateral lower-extremity weakness, followed by difficulty with walking and, finally, the inability to arise from bed. In addition, the patient stated that he had been experiencing low-grade fevers and progressive weight loss over the past several months. محمد عدنان القزاز

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Case report con. His medical history was unremarkable and did not include any recent trauma. The patient had emigrated from the Philippines to Hawaii about 20 years earlier. However, he denied any history of exposure to tuberculosis or any recent travel back to the Philippines or Southeast Asia. محمد عدنان القزاز

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Case report con. In the emergency room, the patient appeared to be disoriented, although he was able to follow simple commands. His vital signs included a temperature of 97.8°F, blood pressure of 121/75 mm Hg, a heart rate of 116 beats/min, and mild tachypnea, with an O 2 saturation of 99% on room air. محمد عدنان القزاز

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Case report con. On physical examination, he was noted to have poor dentition and evidence of multiple previous dental extractions. A neurological examination revealed significant bilateral lower-extremity weakness (two of five) with brisk deep-tendon reflexes, positive ankle clonus, and a positive Babinski sign, as well as diminished rectal tone. محمد عدنان القزاز

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Case report con. Laboratory blood findings were significant for leukocytosis (22.0 × 10 9 /liter) with 87% segmented neutrophils, an elevated platelet count of 722 × 10 6 /liter, and an erythrocyte sedimentation rate of 84 mm/h. محمد عدنان القزاز

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Case report con. A screen for human immunodeficiency virus type 1 and 2 antibodies was negative. The remaining laboratory findings were noncontributory. A chest X ray showed a left-lower-lobe infiltrate with minimal pleural effusion. محمد عدنان القزاز

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Case report con. Because of the possibility of spinal cord compression and injury, the patient was admitted to the medical intensive care unit for further workup and management. محمد عدنان القزاز

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Case report con. This included magnetic resonance imaging of the spine, which showed an abnormal signal intensity involving the thoracic vertebrae from T5 through T8 and an abnormal soft tissue mass enhancement consistent with an apparent abscess that involved the left posterior chest wall and ribs and that extended to the thoracic vertebral column and into the epidural space , with apparent spinal cord compression محمد عدنان القزاز

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Case report con. A computed tomography scan of the chest revealed similar abnormal findings involving the left posterior chest wall and ribs as well as a collapsed left lower lobe with minimal pleural effusion. A bone scan also showed increased activity within the thoracic vertebrae and left ribs but with no mention of bony erosion. محمد عدنان القزاز

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Case report con. The patient was started empirically on intravenous ( i.v. ) antibiotics, consisting of ceftriaxone at 2 g every 24 h and vancomycin at 1 g every 12 h, as well as dexamethasone. This was followed immediately by an emergent thoracic laminectomy and debridement of the epidural abscess. محمد عدنان القزاز

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Case report con. Very thick fibrinous material was present overlying the dura , and several pockets of gross purulence were seen from T5 to the superior aspect of T9. There was a well-organized abscess running over the entire extent of exposure and tapering at the rostral and caudal ends. محمد عدنان القزاز

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Case report con. Abscess fluid samples for aerobic and anaerobic culture were obtained intraoperatively , placed in a BBL Port-A- Cul envelope (221607; BD), and transported to the Microbiology Laboratory. The wound was then irrigated with a copious volume of antibiotic-containing saline and closed. محمد عدنان القزاز

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Case report con. The culture was positive for both Actinomyces spp. and Fusobacterium spp. Blood and urine cultures showed no growth. Stains for acid-fast bacilli and mycobacterial cultures were also negative. محمد عدنان القزاز

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Case report con. The patient's antibiotic regimen was changed to i.v. penicillin G at 2 × 10 6 units every 4 h and clindamycin at 600 mg every 6 h. Postoperatively, the surgical wound healed well without the expression of purulence. The patient's bilateral lower-extremity motor strength improved markedly during his remaining hospital course. However, residual bowel and urinary dysfunction still persisted محمد عدنان القزاز

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Case report con. He was subsequently transferred to a rehabilitation center for 6 weeks of i.v. antibiotic therapy consisting of penicillin G and clindamycin. This was followed by 12 months of oral amoxicillin at 500 mg three times a day. محمد عدنان القزاز

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MATERIAL AND METHODS A Gram stain was used to identify the microscopic morphology of the isolates. Culture was performed with brucella agar as the primary anaerobic medium. The Rapid ANA II system (API) was used for the biochemical identification of the anaerobe. Culture isolation and microscopy . محمد عدنان القزاز

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Actinomyces israelii “molar tooth” appearance on sheep blood agar and microscopic morphology showing branching gram-positive bacilli ; Fusobacterium nucleatum ( larger colony) and A. israelii ( smaller colony) colony morphology on محمد عدنان القزاز

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MATERIAL AND METHODS PCR and sequencing. The identity of the isolate was confirmed by 16S rRNA gene sequencing. A fragment of the 16S rRNA gene was amplified from DNA extracted from the bacterial isolate by PCR with Pfu DNA polymerase, a PCR mixture, and universal eukaryotic primers 27F and 1492R. محمد عدنان القزاز

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MATERIAL AND METHODS PCR and sequencing con. The thermal cycling conditions consisted of denaturation at 94°C for 3 min, followed by 30 cycles at 94°C for 45 s, 55°C for 45 s, and 72°C for 90 s. A final extension was carried out at 72°C for 7 min, followed by cooling to 4°C. The PCR product was then purified with a Qiagen PCR purification kit and sequenced with the following primers: 27F (AGAGTTTGATCMTGGCTCAG), 530R (GTA TTA CCG CGG CTG CTG), 981R (GGG TTG CGC TCG TTG CGG G), and 1492R (TACGGYTACCTTGTTACGACTT). محمد عدنان القزاز

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DNA sequencing was performed with a BigDye Terminator cycle sequencing kit (version 3.1), and the sequence was resolved on an ABI 3730XL DNA analyzer (Applied BioSystems , Foster City, CA). The full 16S rRNA gene sequences were then assembled by use of the Seqman program ( DNAStar ). Sequence analysis was performed with the ChromasPro program (version 1.33; Technelysium Pty. Ltd.) and a search with the BLAST program MATERIAL AND METHODS PCR and sequencing con. محمد عدنان القزاز

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Reference ( www.ncbi.nlm.nih.gov/BLAST/BLAST.cgi ). 1. Apotheloz , C., and C. Regamey . 1996. Disseminated infection due to Actinomyces meyeri : case report and review. Clin . Infect. Dis. 22 621-625. [ PubMed ] 2 . Bennhoff , D. F. 1984. Actinomycosis : diagnostic and therapeutic considerations and a review of 32 cases. Laryngoscope 94 1198-1217. [ PubMed ] 3. Birley , H. D., E. L. Teare , and J. A. Utting . 1989. Actinomycotic osteomyelitis of the thoracic spine in a penicillin-sensitive patient. J. Infect. 19 193-194. [ PubMed ] 4 . Cendan , I., A. Klapholz , and W. Talavera. 1993. Pulmonary actinomycosis . A cause of endobronchial disease in a patient with AIDS. Chest 103 1886-1887. [ PubMed ] 5 . Chao, D., and A. Nanda. 2002. Spinal epidural abscess: a diagnostic challenge. Am. Fam. Physician 65 1341-1346. [ PubMed ] محمد عدنان القزاز

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