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CASE REPORT Table of Contents   
Year : 2009  |  Volume : 52  |  Issue : 1  |  Page : 115-116
Osteomyelitis of the mandible due to Aggregatibacter (Actinobacillus) actinomycetemcomitans


1 Department of Microbiology, Sri Siddhartha Medical College, Tumkur, India
2 Department of Maxillofacial Surgery, Sri Siddhartha Medical College, Tumkur, India

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   Abstract 

Aggregatibacter (Actinobacillus) actinomycetemcomitans is a capnoic gram negative coccobacilli known to produce juvenile periodontitis. This organism was isolated in pure culture from an unusual case of osteomyelitis of the mandible. The patient was treated with tetracycline, which is the drug of choice for A. actinomycetemcomitans and the clinical response improved. From our limited review of the literature, it appears that this is the first case of osteomyelitis due to A.actinomycetemcomitans reported in India.

Keywords: A. actinomycetemcomitans, osteomyelitis

How to cite this article:
Antony B, Thomas S, Chandrashekar S C, Kumar M S, Kumar V. Osteomyelitis of the mandible due to Aggregatibacter (Actinobacillus) actinomycetemcomitans. Indian J Pathol Microbiol 2009;52:115-6

How to cite this URL:
Antony B, Thomas S, Chandrashekar S C, Kumar M S, Kumar V. Osteomyelitis of the mandible due to Aggregatibacter (Actinobacillus) actinomycetemcomitans. Indian J Pathol Microbiol [serial online] 2009 [cited 2017 Jun 25];52:115-6. Available from: http://www.ijpmonline.org/text.asp?2009/52/1/115/44994



   Introduction Top


Aggregatibacter (Actinobacillus) actinomycetemocomitans is a commensal of the human oral cavity. It is currently implicated as a significant pathogen in juvenile periodinititis and in rapidly destructive periodontal disease in adults. [1],[2] This organism is also associated with non oral infections. Only very few reports are available from India regarding the pathogenicity of this bacterium. [3],[4],[5] We report here an unusual case of osteomyelitis of the mandible due to  A.actinomycetemcomitans Scientific Name Search  . To the best of our knowledge, this is the first case of osteomyelitis due to A.actinomycetemcomitans reported in India.


   Case Report Top


A 38-year-old male with a complaint of pus discharge from the lower part of the right side of the mandible came to the department of Maxillofacial Surgery, a tertiary care center in Tumkur. The patient gave a history of trauma 2 months earlier. In spite of the severe pain and the difficulty in chewing, he did not seek any medical attention. Twenty days before coming to the hospital, he noticed a swelling on the right side of the lower jaw, which eventually ruptured with pus discharge.

On examination, step deformity of the mandibular occlusion plane in relation to the mandibular right canine and premolar mobility of fragments were observed in the same region. Multiple abscesses were drained with a frank yellowish purulent discharge. A radiograph revealed a fracture of the body of mandible with osteomyelitis in the fractured region, i.e., a moth-eaten appearance of both proximal and distal fragments.

The abscess site was cleaned and the frank pus dripping out of the abscess was collected and cultured for aerobes, anaerobes and capnoic organisms in the department of Microbiology. The patient was advised to take ampicillin (250 mg q.i.d) and metronidazole (400 mg t.i.d) as empirical treatment.

No aerobic or anaerobic bacteria were grown; however, the Brain Heart Infusion Agar and Trypticase Soy Bacitracin Vancomycin (TSBV) Agar [6],[7] incubated in the candle jar as per routine for oral pathogens showing minute translucent colonies in pure culture. On gram stain, they were gram negative coccobacilli and when observed under the low power objective of the microscope, the colonies revealed a central star shaped configuration with 4 to 6 pointed arms. [7] Hence, they were presumptively identified as A. actinomycetemcomitans . [Figure 1] Biochemically, the organism was catalase positive and oxidase negative. It reduced nitrate, produced acid from glucose and maltose, but not fermented lactose and sucrose, confirming the identification as A. actinomycetemcomitans . Antimicrobial susceptibility testing was performed by Kirby- Bauer's disc diffusion technique and the organism was found to be sensitive to tetracycline, streptomycin, chloramphenicol, ciprofloxacin and moderately sensitive to ampicillin.

Treatment with ampicillin resulted in the reduction of the number of colonies but symptoms still persisted. Based on the antibiogram, the treatment regimen was changed to tetracycline (1 gm given daily in divided doses for 20 days), which is the drug of choice for A. actinomycetemcomitans . The clinical response improved, the pain and the difficulty in chewing subsided gradually and the further cultures were sterile for A. actinomycetemcomitans . The patient was advised to have the fixation of fracture and surgical treatment for osteomyelitis.


   Discussion Top


A. actinomycetemcomitans is a capnoic, non motile, gram negative coccobacilli that produces characteristic star-like configurations in the center of the colony. [7] Phylogenitic similarity between Actinobacillus actinomycetemcomitans , Haemophilus aphrophilus,. H para aphrophilus and  H.segnis Scientific Name Search  assigned them to a new genus Aggregatibacter, recently. [8] This organism is found to inhabit dental plaques, periodontal pockets and buccal mucosa of about 36% of the population. [9] Human infection with A.actinomycetemocomitans was first recognized in association with Actinomyces israelii . [9] A review of literature has revealed that A.actinomycetemcomitans has been implicated as a sole pathogen from more than 100 cases, 55 of which had endocarditis, 45 had actinomycosis and the rest of the cases had various abscesses. [9]

Osteomyelitis due to A. actinomycetemcomitans is very rare in its occurrence and the only reported case is a vertebral osteomyelitis due to hematogenous spread. [10] No reports were available from India regarding this aspect. There is no doubt that the proximity to the oral cavity and the negligence to seek medical treatment had predisposed the patient to infection by A. actinomycetemcomitans in this case. The present case report and other studies emphasize the need for including routine culture techniques for A. actinomycetemcomitans , especially lesions with proximity to the oral cavity.

 
   References Top

1.Eisenmann AC, Eisenmann R, Sousa O, Slots J. Microbiological study of localized juvenile periodontitis in Panama. J Periodontol 1983;54:712-3.  Back to cited text no. 1  [PUBMED]  
2.Ebersole JL, Taubman MA, Smith DJ, Genco RJ, Hanuman FDE. Immune responses to oral micro organisms: Association of localized juvenile periodontitis (LJP) with serum antibody responses to A. actinomycetemcomitans . Clin Experimental Immunol 1982;47:43-52.  Back to cited text no. 2    
3.Turner P, Kallat C, Mathur M, Mehta A, Shankwalkar G. Bacterial microflora associated with chronic periodontal disease in Indian patients. JIDA 1991;62:147-9.  Back to cited text no. 3    
4.Beena A, Rajesh K, Faizal M, Varma BR, Shivananda PG. Actinobacillus actinomycetemcomitans and anaerobes in periodontitis. Indian J Med Microbiol 1997;15:73-6.  Back to cited text no. 4    
5.Saini S, Aparna, Gupta N, Mahajan A, Arora DR. Microbial flora in orodental infections. Indian J Med Microbiol 2003;21:111-4.  Back to cited text no. 5  [PUBMED]  Medknow Journal
6.Slots J. Selective medium for isolation of A. actinomycetemcomitans. J Clin Microbiol 1982;15:606-9.  Back to cited text no. 6    
7.Garcia LS, Procop GW, Roberts GD, Thomson RB. Actinobacillus , kingella, cardiobacterium, capnocytophaga and similar organisms: Chapter 42. In: Forbes BA, Sahm DF, Weissfeld AS editors. Bailey and Scott's Diagnostic Microbiology; 10 ed. Mosby Inc. St. Louis; 1998. p. 547-54.  Back to cited text no. 7    
8.Norskov-Lauritsen N, Kilian M. Reclassification of A. actinomycetemcomitans, H. aphrophilus, H. para aphrophilus and H. segnis as Aggregatibacter to include V factor dependant and V factor independent isolates. Int J Syst Evol Microbiol 2006;56:2135-46.   Back to cited text no. 8    
9.Zambon JJ. A. actinomycetemcomitans in periodontal disease. J Clin Periodontol 1985;12:1-20.  Back to cited text no. 9    
10.Muhle I, Rau J, Rauskin J. Vertebral osteomyelitis due to Actinobacillus actinomycetemcomitans . J Am Med Assoc 1979;241:1824-5.   Back to cited text no. 10    

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Correspondence Address:
Beena Antony
Department of Microbiology, Fr. Muller Medical College, Kankanady, Mangalore, Karnataka - 575 002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.44994

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