A 51-year-old man comes to the physician because of persistent swelling over the left mandible for the last 3 months. The swelling initially responded to antibiotics prescribed to him 2 months ago; however, it subsequently returned. His other medical problems include a history of poorly controlled type 2 diabetes mellitus and hypertension. His medications include metformin, glyburide, and lisinopril. He denies tobacco, alcohol, or illicit drug use.
His temperature is 37 C (98.6 F), blood pressure is 130/80 mm Hg, and respirations are 12/min. Eye examination reveals intact ocular movements. There is no nasal discharge or sinus tenderness. Palpation over the jaw reveals a 4 cm mass extending from the mandible that is raised, non-tender, and firm. There is a sinus tract extending to the skin with purulent and blood-tinged drainage. No erythema or fluctuance is noted. Examination of the oral cavity shows poor dentition with gingivitis, but no open lesions. There is neither anterior nor posterior cervical lymphadenopathy. The remainder of the physical examination is within normal limits.
Laboratory results are as follows:

Which of the following is the most effective treatment for this patient's condition?

Question

A 51-year-old man comes to the physician because of persistent swelling over the left mandible for the last 3 months.  The swelling initially responded to antibiotics prescribed to him 2 months ago; however, it subsequently returned.  His other medical problems include a history of poorly controlled type 2 diabetes mellitus and hypertension.  His medications include metformin, glyburide, and lisinopril.  He denies tobacco, alcohol, or illicit drug use.
His temperature is 37 C (98.6 F), blood pressure is 130/80 mm Hg, and respirations are 12/min.  Eye examination reveals intact ocular movements.  There is no nasal discharge or sinus tenderness.  Palpation over the jaw reveals a 4 cm mass extending from the mandible that is raised, non-tender, and firm.  There is a sinus tract extending to the skin with purulent and blood-tinged drainage.  No erythema or fluctuance is noted.  Examination of the oral cavity shows poor dentition with gingivitis, but no open lesions.  There is neither anterior nor posterior cervical lymphadenopathy.  The remainder of the physical examination is within normal limits.
Laboratory results are as follows:

Which of the following is the most effective treatment for this patient's condition?

Quizplus · Accepted Answer

11ec193a_984a_f770_853d_754781e7b853_MD0002_00 This patient's presentation is consistent with likely cervicofacial actinomycosis, which is most commonly seen in the mandibular region. Actinomyces is an anaerobic, gram-positive, and filamentous branching bacteria that colonizes the oral cavity. Patients with poor oral hygiene are more likely to develop infection. Patients typically present with a slowly growing, non-tender, and indurated mass that can form abscesses, fistulas, or draining sinus tracts. The organisms also form characteristic sulfur granules in the infected tissue and extend locally through tissue planes instead of lymphangitic or hematologic spread. Actinomycosis can mimic other conditions, such as malignancy or granulomatous disease (e.g., TB, sarcoid). Diagnosis is confirmed by tissue culture, but Actinomyces are fastidious organisms that can take up to 3 weeks to grow in culture. Intravenous penicillin for 4-6 weeks is preferred initially, followed by 6 to 12 months of oral penicillin. For patients with penicillin allergy, clindamycin is a reasonable alternative. Surgical excision may be required for more severe cases. (Choice A) Chemotherapy would treat malignancies (e.g., lymphoma) that can mimic this patient's presentation. However, malignant lesions typically do not decrease and then increase in size or form sinus tracts. (Choice B) Levofloxacin is a fluoroquinolone with activity against gram-negative infections, some gram-positive infections (e.g., streptococci), and drug-resistant tuberculosis. Although TB causes cervical lymphadenitis, it does not typically form sinus tracts as seen in this patient. (Choice C) Metronidazole is effective for many anaerobic and parasitic infections, but is not effective for actinomycosis. This patient's sinus tracts in the mandible region are more consistent with actinomycosis. (Choice E) Prednisone is used to treat a variety of autoimmune conditions and malignancy, but is not effective for actinomycosis. This patient's lack of other systemic symptoms makes autoimmune disease less likely. Educational objective: Cervicofacial actinomycosis most commonly presents in the mandibular region as a slowly growing, non-tender mass with characteristic sulfur granules. The infection can extend through tissue planes and form abscesses, fistulas, and draining sinus tracts. Diagnosis is confirmed by culture, and penicillin for 6-12 months is the preferred therapy. __________ References: Cervicofacial actinomycosis and mandibular osteomyelitis. (http://www.ncbi.nlm.nih.gov/pubmed/17561082) Actinomyces: A Great Pretender (http://www.ncbi.nlm.nih.gov/pubmed/18164641)

A 51-Year-Old Man Comes to the Physician Because of Persistent