A 38-year-old woman presents to the emergency department with difficulty eating. Over the past week, she has had increasing difficulty chewing her food and progressive pain in the left side of her jaw. This morning, she was unable to close her mouth for several minutes after taking a bite of her breakfast. Two months ago, the patient had a root canal on a left molar. Her medical history is significant for hyperlipidemia, mild intermittent asthma, and type 2 diabetes mellitus. She has never smoked and has 10-15 alcoholic drinks per week. She works as an aide at a nursing home. Her temperature is 100.8°F (38.2°C), blood pressure is 133/74 mmHg, pulse is 105/min, and respirations are 14/min. On physical exam, there is a bluish hue to the skin on the lower left side of the patient’s face. A 3x4 cm non-tender mass can be palpated inferior to the angle of the left mandible. Thick exudate is draining from an opening in the skin. The gram stain of the exudate can be seen in Figure A. Which of the following is the most appropriate treatment for this patient?
Trimethoprim-sulfamethoxazole
Penicillin
Clindamycin
Amphotericin B
Penicillin
This patient presents with fever, trismus, and cutaneous drainage of sulfur granules in the setting of a recent dental procedure, which points to a diagnosis of cervicofacial actinomycosis. The most appropriate treatment for this disease is penicillin.

Actinomyces is a gram-positive, filamentous rod that causes a cervicofacial infection after direct inoculation during a dental procedure or trauma. It typically presents in an indolent fashion over a time course of weeks to months in which a hard, indurated mass evolves into multiple abscesses that drain through sinus tracts through the skin. The exudate is classically thick with small yellow “sulfur” granules, although it may also be serosanguinous. Since the infection spreads by direct extension, patients may complain of pain when the infection infiltrates or compresses nearby structures. Trismus may occur for the same reasons. The treatment of choice is penicillin.

Valour et al. review the evidence regarding the treatment of Actinomyces infection. They discuss how prolonged (6- to 12-month) high-dose penicillin or amoxicillin is required for the treatment of this disease. They recommend preventive measures such as improvement of dental hygiene to prevent this disease.

Figure/Illustration A demonstrates the histologic appearance of a basophilic “sulfur granule” (red circle). These granules are found in the draining exudate in patients with actinomycosis.

Incorrect Answers:
Answer A: Amphotericin B is the treatment of choice for fungal infections such as mucormycosis. This disease generally presents with a rapidly progressive soft tissue infection that can be fatal if left untreated. Patients would present with black fungal lesions generally in immunocompromised or diabetic hosts.

Answer B: Clindamycin may be used in the treatment of empyema as it has activity against many anaerobes. Although this patient has a substantial weekly alcohol intake and has a chief complaint of “difficulty eating,” she has no true pulmonary symptoms and her presentation is more likely related to her recent dental procedure.

Answer C: Metronidazole may be used in the treatment of empyema. Although this patient has a substantial weekly alcohol intake and has a chief complaint of “difficulty eating,” she has no true pulmonary symptoms and her presentation is more likely related to her recent dental procedure.

Answer E: Trimethoprim-sulfamethoxazole is the treatment of choice for Nocardiosis, which may cause cutaneous lesions in immunocompromised hosts. This disease more commonly causes pulmonary or central nervous system disease. Nocardia would not explain the granule seen in histology.

Bullet Summary:
Actinomyces is a gram-positive anaerobic rod that presents as an indurated mass with draining sinus tracts and should be treated with penicillin.