(Actinomycosis of the skin; Lumpy-jaw)
Definition – A chronic, parasitic disease, due to the ray fungus and characterized by deep tumors and swellings which have a tendency to break down and suppurate.
The condition known as lumpy-jaw and osteosarcoma of the jaw in cattle or other animals has been known for many years, but is is only since 1977, when Bollinger demonstrated the fungus in these lesions, which Harz termed the ray fungus, that interest as regards its relation to the human disease has been aroused. It is to Israel and Ponfick that we owe our original knowledge concerning the identity of this disease in animals and man.
Symptoms – The common situation of actinomycosis of the skin is about the lower jaw, neck and face. The fungus gains access to the tissues in nearly all cases through the mouth, usually to the jaw through a decayed tooth. Rarely it may find entrance through the respiratory and digestive tracts, later showing on the surface, or the skin may be affected from without through some break in its surface. The onset as well as the course of the disease is slow and insidious, only occasionally rapid, for usually months must elapse before the involvement is extensive. Sooner or later deep subcutaneous tumors develop covered by dark red or livid skin which, as it becomes more involved, bursts at one or more points and gives outlet to a thick, purulent discharge which later becomes serosanguineous. Sometimes as the tumor-like swelling becomes soft, burrowing of its contents takes place and an opening in the skin may occur followed by a discharge at some distance from the tumor. Short or long fistulous tracts are thus formed similar to those in scrofuloderma. The special feature of the discharge is the presence of numerous, minute, yellowish bodies from pin-head to a hemp-seed in size, consisting of massed mycelium of the pathogenic fungus. The course of the disease is invariably chronic, slowly but steadily invading new tissue, with a mingling of red and purple, hard and soft, cutaneous and subcutaneous nodules, some of them situated about the orifice of the sinuses. Very rarely the indurations remain persistently hard and may subside without cutaneous rupture and discharge, or an opening may occur in a blood vessel and the infecting element is transported in the blood to internal organs, particularly to the lungs. The disease in internal organs may or may not lead to a fistulous opening on the surface. Secondary infection of the lesion with pus cocci may occur, in which cases swelling of the lymphatic glands may follow and extensive suppuration and pyemia ensue, but unmixed actinomycotic infection does not tend to involve the lymphatics.
Fig. 165 & 166 – Actinomycosis of the skin. The left hand illustration shows the disease in an active state presenting nodules, sinuses, ulcers and pustules. The right hand cut shows the same view seven years later after the lesions had been healed for five years.
Fig. 167 – Actinomycosis, presenting a different view of the same patient as depicted in Fig. 165. Duration of disease at this time, eighteen months. Mode of infection, from a horse afflicted with lumpy-jaw. Actinomyces easily demonstrated.
Fig. 168 – The same view as Fig. 167, taken seven years later, showing extensive pigmented areas and scars. Cured in two years with potassium iodid in large doses and Calcarea fluo. 6x as an intercurrent remedy. Hydrogen peroxid was used locally.
Etiology and Pathology – This rare disease, due to ray fungus, is contagious by inoculation. Some break in the continuity of the mucous or cutaneous surface probably presents the necessary entrance to the fungus. It is commonly contracted from cattle and horses, rarely other animals, and naturally is most often seen among those who handle animals. One of my own cases was in a physician who attended to his own horse, and another occurred in a dairyman. Corn, straw and other grain may harbor the fungus, so that those chewing such substances might easily become inoculated through the mouth. The actinomyces or ray fungi may be seen as yellowish bodies visible to the eye in the discharges from the active lesions. They are best stained by the Gram method, and under the microscope are seen to consist of mycelia which interlace centrally and give off threads which radiate therefrom and expand at their distal ends into the club-like enlargements which are thought to be the spores or fructifying parts of the fungus. This organism is found throughout the tumor mass as well as in the discharge.
Fig. 169 – Actinomyces, showing the ray arrangement and the club-shaped ends of the mycelial threads (diagrammatic after Ponfick).
Diagnosis – Although it may be necessary to distinguish carcinoma, sarcoma, syphilis, tuberculosis cutis, mycetoma and dental abscesses or sinuses from this disease, the presence of the typical yellowish masses in the discharge should be sufficient evidence. Its common location about the lower jaw, neck and cheeks in those who have to do with animals and grain products, plus careful and repeated examination for the fungus will determine the disease without any question.
Prognosis – Schlange and others are inclined to believe that all forms of this disease, except those involving the internal organs, have a decided tendency toward spontaneous recovery. Although I believe that actinomycosis of the skin is usually a curable disease, there is always the chance of deeper involvement with pyemic symptoms and fatal results. When the orbit, upper jaw or viscera are extensively involved the prognosis is naturally poor.
Treatment is usually surgical and antiparasitic. Complete removal in suitable cases is ideal, but it is usually not possible when sinuses and cavities have developed, for these need to be curretted and treatment anti-septically. Among antiparasitic measures for intertissue treatment of the growths either before or after external rupture, the electrochemic method of Gautier should be mentioned. This consists in inserting two platinum needles into the tumor and passing a current of fifty milliamperes through its substance, injecting at the same time a few drops of a 10 per cent. solution of potassium iodid. Nascent iodin is set free in the tissues, and the treatment can be kept up in different parts of the growth for about twenty minutes. It is too painful to be employed without an anesthetic but most satisfactory results have been reported by Gautier, Darier and others. Usually a successful treatment consists in the administering of moderate or large doses of potassium iodid, together with thorough local antiparasitic or cleansing treatment, such as injections into the growth of dilute tincture of iodin, or the persistent use of hydrogen peroxid.
In my own cases I have made frequent use locally of the X-rays, high-frequency sparking and mild fulguration, and have invariably prescribed the indicated remedy during the periods of remission from the iodid treatment. I have observed four cases, the first two to be mentioned being in men and the last two in women. One involving a large part of both legs (see illustrations) was completely cured in a year’s time by the use of potassium iodid in gradually increasing doses with Calcarea fluorica 6x, as an intercurrent remedy. Dilute hydrogen peroxid was injected twice daily into all openings. The second case involving the neck and jaw was cured in three months with the same methods. The third case involving the palm of one hand was cured in two months with the same methods, with the addition of Hepar sulphur 3x. The fourth case presented lesions on the right cheek and jaw and was cured in six months by the iodids, X- rays and fulguration. The ray fungus was found microscopically in the first three cases without any difficulty. Physiological methods are always indicated. Kali brom. and Silicea have been used to advantage in addition to the drugs mentioned.