CHAPTER I
Actinomycosis
David T. Smith, M.D.
Actinomycosis was of minor importance in World War II. The annual admission rate per 1,000 average strength was about 0.01 and remained remarkably constant in the continental United States and in the various theaters of operations overseas. There were no epidemics or seasonal variations in the incidence of the disease. Sample tabulations of individual medical records for the years 1942-45 indicate that in the total U.S. Army there were about 230 cases of actinomycosis as compared to the approximately 200 cases of tularemia, the estimated 1,150 cases of trachoma, and the 1,200 cases of undulant fever (brucellosis). There were four deaths due to actinomycosis, all occurring among troops in the United States.
The rate of occurrence of actinomycosis in military personnel was certainly not higher, and was probably lower, than that in the civilian population during the same period of years. The only available data for the occurrence of this disease in the civilian population come from Duke Hospital, Durham, N.C., where 71 cases were found in 250,000 admissions.1
Organisms belonging to two different genera are responsible for the clinical syndrome known as actinomycosis. Most cases are caused by the anaerobic organism known as Actinomyces bovis, but some are produced by members of the aerobic genus Nocardia, especially the acid-fast Nocordia asteroides. The source of A. bovis is the patient's own mouth, and soldiers with clean teeth and healthy gums would harbor the organism in a smaller percentage than would civilians who as a group practice poorer oral hygiene. The source of N. asteroides is the soil, and exposure would be less general among properly clothed and booted soldiers than among civilians. None of these organisms spread directly from patient to patient (fig. 1). Therefore, the crowding in Army camps and in field maneuvers would have no effect in increasing the rate of infection.
Although no statistics have been published concerning the case fatality rates for actinomycosis before the introduction of sulfonamides and antibiotics, the mortality in cervicofacial actinomycosis is estimated by the writer to have been about 25 percent, that in pulmonary actinomycosis 50 percent, and that in abdominal actinomycosis 99 percent. Only 4 deaths among approximately
1Smith, D. T.: Fungous Infections in the United States. J.A.M.A. 141: 1223-1226, December 1949.
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230 cases, or a case fatality rate of about 1.7 percent, represents a remarkable triumph for military medicine. Sulfadiazine, penicillin, iodides, and surgical procedures were used in various combinations in individual cases. Early cases of cervicofacial actinomycosis usually respond to medical therapy with sulfonamides, penicillin, or both, without the necessity for surgery. Pulmonary actinomycosis usually requires chest-wall excisions or lobectomy, as well as antibiotic and iodide therapy. Abdominal actinomycosis usually requires a series of operations and prolonged treatment with antibiotics and iodides.
Actinomycosis caused by the aerobic N. asteroides does not respond to penicillin and other antibiotics but may be cured with sulfadiazine or other sulfonamides.
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