Actinomycosis differential diagnosis: Difference between revisions

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__NOTOC__
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{{Actinomycosis}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Actinomycosis]]
{{CMG}}
{{CMG}}; {{AE}}{{ADG}}
 
==Overview==
==Overview==
The differential diagnosis of actinomycosis consists of [[blastomycosis]], [[brain abscess]], [[colon cancer]], [[crohn disease]], [[diverticulitis]], [[liver abscess]], [[lung abscess]], [[lymphoma]], [[nocardiosis]], [[pelvic inflammatory disease]], [[pneumonia]], [[tuberculosis]] and [[uterine cancer]].
Based on the organ system involved and duration of symptoms, differential diagnosis of [[actinomycosis]] consists of [[blastomycosis]], [[brain abscess]], [[colon cancer]], [[crohn disease]], [[diverticulitis]], [[liver abscess]], [[lung abscess]], [[lymphoma]], [[nocardiosis]], [[pelvic inflammatory disease]], [[pneumonia]], [[tuberculosis]] and [[uterine cancer]].


==Differential Diagnosis==
==Differential Diagnosis==
Actinomycosis should be differentiated from other conditions with similar presentation:<ref name="pmid17560191">{{cite journal| author=Yiğiter M, Kiyici H, Arda IS, Hiçsönmez A| title=Actinomycosis: a differential diagnosis for appendicitis. A case report and review of the literature. | journal=J Pediatr Surg | year= 2007 | volume= 42 | issue= 6 | pages= E23-6 | pmid=17560191 | doi=10.1016/j.jpedsurg.2007.03.057 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17560191  }} </ref><ref name="pmid19149697">{{cite journal |vauthors=Hasper D, Schefold JC, Baumgart DC |title=Management of severe abdominal infections |journal=Recent Pat Antiinfect Drug Discov |volume=4 |issue=1 |pages=57–65 |year=2009 |pmid=19149697 |doi= |url=}}</ref><ref name="pmid15342974">{{cite journal |author=Lederman ER, Crum NF |title=A case series and focused review of nocardiosis: clinical and microbiologic aspects |journal=Medicine (Baltimore) |volume=83 |issue=5 |pages=300–13 |year=2004 |month=September |pmid=15342974 |doi= 10.1097/01.md.0000141100.30871.39|url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0025-7974&volume=83&issue=5&spage=300}}</ref>
*[[Actinomycosis]] is a chronic [[pyogenic]] [[bacterial infection]] caused by [[Actinomyces]]species and most commonly involves orocervicofacial region
*It rarely infects other organ systems. If involved it has a wide variety of presentation.
*Most common symptoms of actinomycosis includes [[abscess]] with draining [[sinus]] tracts.
*Other symptoms are mostly non-specific for actinomycosis.
*Based on the organ system involved and duration of symptoms it should be differentiated from other conditions:<ref name="pmid17560191">{{cite journal| author=Yiğiter M, Kiyici H, Arda IS, Hiçsönmez A| title=Actinomycosis: a differential diagnosis for [[appendicitis]]. A case report and review of the literature. | journal=J Pediatr Surg | year= 2007 | volume= 42 | issue= 6 | pages= E23-6 | pmid=17560191 | doi=10.1016/j.jpedsurg.2007.03.057 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17560191  }} </ref><ref name="pmid19149697">{{cite journal |vauthors=Hasper D, Schefold JC, Baumgart DC |title=Management of severe abdominal infections |journal=Recent Pat Antiinfect Drug Discov |volume=4 |issue=1 |pages=57–65 |year=2009 |pmid=19149697 |doi= |url=}}</ref><ref name="pmid15342974">{{cite journal |author=Lederman ER, Crum NF |title=A case series and focused review of nocardiosis: clinical and microbiologic aspects |journal=Medicine (Baltimore) |volume=83 |issue=5 |pages=300–13 |year=2004|pmid=15342974 |doi= 10.1097/01.md.0000141100.30871.39|url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0025-7974&volume=83&issue=5&spage=300}}</ref><ref>{{cite book | last = Hoffman | first = Barbara | title = Williams gynecology | publisher = McGraw-Hill Medical | location = New York | year = 2012 | isbn = 9780071716727 }}</ref><ref name="Humes2006">{{cite journal|last1=Humes|first1=D J|title=Acute appendicitis|journal=BMJ|volume=333|issue=7567|year=2006|pages=530–534|issn=0959-8138|doi=10.1136/bmj.38940.664363.AE}}</ref><ref name="pmid20375357">{{cite journal |vauthors=Saccente M, Woods GL |title=Clinical and laboratory update on blastomycosis |journal=Clin. Microbiol. Rev. |volume=23 |issue=2 |pages=367–81 |year=2010 |pmid=20375357 |pmc=2863359 |doi=10.1128/CMR.00056-09 |url=}}</ref><ref name="Kim2014">{{cite journal|last1=Kim|first1=Eun Ran|title=Colorectal cancer in inflammatory bowel disease: The risk, pathogenesis, prevention and diagnosis|journal=World Journal of Gastroenterology|volume=20|issue=29|year=2014|pages=9872|issn=1007-9327|doi=10.3748/wjg.v20.i29.9872}}</ref><ref name=Hanauer>{{cite journal | last = Hanauer | first = Stephen B. | year = 1996 | title = Inflammatory bowel disease | journal = New England Journal of Medicine | volume = 334 | issue = 13 | pages = 841-848 | id = PMID 8596552 | url = http://content.nejm.org/cgi/content/extract/334/13/841 | accessdate = 2006-11-10}}</ref><ref name="pmid26366400">{{cite journal |vauthors=Kuhajda I, Zarogoulidis K, Tsirgogianni K, Tsavlis D, Kioumis I, Kosmidis C, Tsakiridis K, Mpakas A, Zarogoulidis P, Zissimopoulos A, Baloukas D, Kuhajda D |title=Lung abscess-etiology, diagnostic and treatment options |journal=Ann Transl Med |volume=3 |issue=13 |pages=183 |year=2015 |pmid=26366400 |pmc=4543327 |doi=10.3978/j.issn.2305-5839.2015.07.08 |url=}}</ref> <ref name="pmid20664404">{{cite journal |vauthors=Soper DE |title=Pelvic inflammatory disease |journal=Obstet Gynecol |volume=116 |issue=2 Pt 1 |pages=419–28 |year=2010 |pmid=20664404 |doi=10.1097/AOG.0b013e3181e92c54 |url=}}</ref>
 
 
 
{| class="wikitable"
{| class="wikitable"
!System involved
!Disease
!Disease
!Differentiating signs/symptoms
!Differentiating signs/symptoms
!Differentiating tests
!Differentiating tests
|-
|-
| rowspan="5" |Abdomen
|'''Abdominal Abscess'''
|'''Abdominal Abscess'''
|Features of sepsis and signs of an acute abdomen are generally prominent
|Features of [[sepsis]] and signs of an [[acute abdomen]] are generally prominent
|Histology and culture for actinomycetes are negative.
|Histology and culture for [[actinomycetes]] are negative.


Blood or site cultures identify etiologic organism.
[[Blood cultures]] positive for the [[organism|causative organism]].
|-
|-
|'''[[Nocardiosis]]'''
|'''[[Appendicitis]]'''
|Immunocompromised host
|Rapid onset of symptoms
 
Positive for signs of [[appendicitis]]
|[[Ultrasound]] shows [[Appendicitis|inflammation of appendix]]


Predominant pulmonary
Negative [[blood culture]]
|Modified acid-fast staining of biopsy tissue or other samples allows distinction between Nocardia and Actinomyces
|-
|-
|'''[[ovarian cancer|Ovarian/Oviductal tumor]]'''
|'''[[Colon cancer]]'''
|Systemic findings like weight loss ,night sweats present
|Systemic findings like [[weight loss]], [[night sweats]] present


No leukorrhea
[[Anemia]]
|Histopathology shows malignancy.


Blood loss in [[stools]]
|[[Colonoscopy]] identifies the lesions, [[histopathology]] confirms the presence of the [[Cancer cells|malignant cells]].
|-
|-
|'''[[Appendicitis]]'''
|'''[[Whipple disease]]'''
|Rapid onset of symptoms
|An acute GI illness, with [[fever]], [[diarrhea]], and [[weight loss]]
 
[[Malabsorption]] such as [[steatorrhea]].


Positive for signs of appenidicitis
[[Abdominal]] [[lymphadenopathy]] and [[abdominal pain]].
|Ultrasound shows inflammation of appendix


Negative blood culture
Joint problems
|-
|'''[[Blastomycosis]]'''
|Self limited


Cutaneous manifestations along with lung involvement.
[[Anemia]].
|[[Tropheryma whipplei|Anti-Tropheryma whipplei-positive macrophage (Tropheryma whipplei)]].


Endemic to Mississippi and Ohio river valley
[[PCR]] testing of duodenal biopsies positive for [[Tropheryma whipplei|T whipplei]]
|Sputum smear and culture using KOH preparations or specific stains can confirm diagnosis
|-
|-
|'''[[Colon cancer]]'''
|'''[[Crohn disease|Inflammatory bowel disease]]'''
|Systemic findings like weight loss, night sweats present
|[[Dysentery]]


Anemia
[[Weight loss]]
|[[Colonoscopy]] identifies the ulcerative [[lesions]]
|-
| rowspan="4" |Pulmonary
|'''[[Nocardiosis]]'''
|[[Immunocompromised]] host


Blood loss in stools
Predominant [[pulmonary]]
|Colonoscopy identifies the lesions ,histopathology confirms the presence of the malignant cells.
|Modified [[acid-fast]] staining of biopsy tissue or other samples allows distinction between [[Nocardia]] and [[Actinomyces]]
|-
|-
|'''[[Crohn disease|Inflammatory bowel disease]]'''
|'''[[Blastomycosis]]'''
|Dysentery
|Self-limited
 
[[Cutaneous]] manifestations along with [[lung]] involvement.


Weight loss
Endemic to Mississippi and Ohio river valley
|Colonoscopy identifies the ulcerative lesions
|[[Sputum]] smear and culture using [[KOH test|KOH]] preparations or specific stains can confirm diagnosis
|-
|-
|'''[[Lung abscess]]'''
|'''[[Lung abscess]]'''
|Risk of aspiration
|Risk of [[aspiration]]


Cough with foul smelling sputum
[[Cough]] with foul smelling sputum
|Polymicrobial infection
|Polymicrobial [[infection]]  
|-
|'''[[Pelvic inflammatory disease]]'''
|History of recent sexual contact or a sexually transmitted infection in the partner,
 
Past history of PID.
|laparoscopy with biopsy sampling followed by histology.
|-
|-
|'''[[Pulmonary tuberculosis]]'''
|'''[[Pulmonary tuberculosis]]'''
|Cough >2 weeks
|[[Cough]] >2 weeks


Hemoptyisis
[[Hemoptysis]]


Night sweats, weight loss
[[Night sweats]], [[weight loss]]
|Acid fast bacilli positive on sputum examination  
|[[Acid-fast-bacilli|Acid fast bacilli]] positive on sputum examination  


Tuberculin skin testing positive. 
[[Tuberculin skin test|Tuberculin skin]] testing positive.  
|-
|-
|'''[[Whipple disease]]'''
| rowspan="2" |Uro-genital system
|An acute GI illness, with fever, diarrhea, and weight loss  
|'''[[ovarian cancer|Ovarian/Oviductal tumor]]'''
|Systemic findings like [[weight loss]] ,[[night sweats]] present


Malabsorption such as steatorrhea.
No [[leukorrhea]]
|Histopathology shows [[malignancy]].
|-
|'''[[Pelvic inflammatory disease]]'''
|History of recent sexual contact or a [[STD|sexually transmitted infection]] in the partner,


Abdominal lymphadenopathy and abdominal pain.
Past history of [[PID]].
 
|[[Laparoscopy]] with [[biopsy]] sampling followed by histology.
Joint problems
 
Anemia.
|Anti-Tropheryma whipplei-positive macrophage.
 
PCR testing of duodenal biopsies positive for T whipplei
|}
|}
* The clinical manifestations of actinomycosis and nocardiosis are similar. The following table helps in differentiating actinomycosis from nocardiosis.<ref name="pmid20463251">{{cite journal| author=Sullivan DC, Chapman SW| title=Bacteria that masquerade as fungi: actinomycosis/nocardia. | journal=Proc Am Thorac Soc | year= 2010 | volume= 7 | issue= 3 | pages= 216-21 | pmid=20463251 | doi=10.1513/pats.200907-077AL | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20463251  }} </ref><ref name="pmid8821161">{{cite journal| author=Warren NG| title=Actinomycosis, nocardiosis, and actinomycetoma. | journal=Dermatol Clin | year= 1996 | volume= 14 | issue= 1 | pages= 85-95 | pmid=8821161 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8821161  }} </ref>
* The clinical manifestations of actinomycosis and [[nocardiosis]] are similar. The following table helps in differentiating actinomycosis from [[nocardiosis]].<ref name="pmid20463251">{{cite journal| author=Sullivan DC, Chapman SW| title=Bacteria that masquerade as fungi: actinomycosis/nocardia. | journal=Proc Am Thorac Soc | year= 2010 | volume= 7 | issue= 3 | pages= 216-21 | pmid=20463251 | doi=10.1513/pats.200907-077AL | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20463251  }} </ref><ref name="pmid8821161">{{cite journal| author=Warren NG| title=Actinomycosis, nocardiosis, and actinomycetoma. | journal=Dermatol Clin | year= 1996 | volume= 14 | issue= 1 | pages= 85-95 | pmid=8821161 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8821161  }} </ref>
* Differentiation of actinomycosis from nocardiosis is very important in selection of appropriate antimicrobial therapy.<ref name="pmid3317731">{{cite journal| author=Smego RA| title=Actinomycosis of the central nervous system. | journal=Rev Infect Dis | year= 1987 | volume= 9 | issue= 5 | pages= 855-65 | pmid=3317731 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3317731  }} </ref>
* Differentiation of actinomycosis from nocardiosis is very important in selection of appropriate [[Antimicrobial drug|antimicrobial therapy]].<ref name="pmid3317731">{{cite journal| author=Smego RA| title=Actinomycosis of the central nervous system. | journal=Rev Infect Dis | year= 1987 | volume= 9 | issue= 5 | pages= 855-65 | pmid=3317731 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3317731  }} </ref><ref name="pmid22223997">{{cite journal |vauthors=Bassiri-Jahromi S, Doostkam A |title=Actinomyces and nocardia infections in chronic granulomatous disease |journal=J Glob Infect Dis |volume=3 |issue=4 |pages=348–52 |year=2011 |pmid=22223997 |pmc=3249989 |doi=10.4103/0974-777X.91056 |url=}}</ref>


{| class="wikitable"
{| class="wikitable"
!Actinomycosis
![[Actinomycosis]]
!Nocardiosis
![[Nocardiosis]]
|-
|-
|Gram positive anaerobic species
|[[Gram positive]] [[anaerobic]] species
|Gram positive aerobe
|[[Gram positive]] [[aerobe]]
|-
|-
|Decreasing incidence
|Decreasing [[incidence]]
|Increasing incidence
|Increasing [[incidence]]
|-
|-
|Occurs primarily in immunocompetent host
|Occurs primarily in [[immunocompetent|immunocompetent host]]
|Occurs primarily in immunocompromised host
|Occurs primarily in [[immunocompromised host]]
|-
|-
|Predominant cervicofacial
|Predominant cervicofacial
|Predominant pulmonary
|Predominant [[pulmonary]]
|-
|-
|Chest wall involvement and bony erosions are common
|[[Chest wall]] involvement and bony erosions are common
|Chest wall involvement is uncommon
|Chest wall involvement is uncommon
|-
|-
|Granuloma formation and intense fibrosis are common. Form characteristic sulfur granules
|[[Granuloma]] formation and intense [[fibrosis]] are common. Form characteristic sulfur granules
|Granuloma formation and fibrosis are uncommon
|Granuloma formation and fibrosis are uncommon
|-
|-
|Spread by direct invasion
|Spread by direct invasion
|Metastatic spread is common (especially to brain)
|[[Metastatic]] spread is common (especially to [[brain]])
|-
|-
|Diagnosis is made through cytologic or histologic examination
|Diagnosis is made through cytologic or histologic examination
|Diagnosis is made through BAL (bronchoalveolar lavage),
|Diagnosis is made through [[Bronchoalveolar lavage|bronchoalveolar lavage (BAL).]]
sputum, or pleural fluid culture
sputum, or [[pleural]] [[fluid]] culture
|-
|-
|Treatment: Penicillin
|Treatment: [[Penicillin]]
Treatment with antibiotics alone
Treatment with [[antibiotics]] alone
|Treatment: Sulfonamides
|Treatment: [[Sulfonamides]]
Often need surgical drainage
Often need surgical drainage
|}
|}
Line 156: Line 165:
[[Category:Bacterial diseases]]
[[Category:Bacterial diseases]]
[[Category:Disease]]
[[Category:Disease]]
[[Category:Infectious disease]]
 
[[Category:Overview complete]]
[[Category:Overview complete]]
[[Category:Dermatology]]
[[Category:Dermatology]]

Latest revision as of 22:19, 21 February 2019

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]

Overview

Based on the organ system involved and duration of symptoms, differential diagnosis of actinomycosis consists of blastomycosis, brain abscess, colon cancer, crohn disease, diverticulitis, liver abscess, lung abscess, lymphoma, nocardiosis, pelvic inflammatory disease, pneumonia, tuberculosis and uterine cancer.

Differential Diagnosis

  • Actinomycosis is a chronic pyogenic bacterial infection caused by Actinomycesspecies and most commonly involves orocervicofacial region
  • It rarely infects other organ systems. If involved it has a wide variety of presentation.
  • Most common symptoms of actinomycosis includes abscess with draining sinus tracts.
  • Other symptoms are mostly non-specific for actinomycosis.
  • Based on the organ system involved and duration of symptoms it should be differentiated from other conditions:[1][2][3][4][5][6][7][8][9] [10]


System involved Disease Differentiating signs/symptoms Differentiating tests
Abdomen Abdominal Abscess Features of sepsis and signs of an acute abdomen are generally prominent Histology and culture for actinomycetes are negative.

Blood cultures positive for the causative organism.

Appendicitis Rapid onset of symptoms

Positive for signs of appendicitis

Ultrasound shows inflammation of appendix

Negative blood culture

Colon cancer Systemic findings like weight loss, night sweats present

Anemia

Blood loss in stools

Colonoscopy identifies the lesions, histopathology confirms the presence of the malignant cells.
Whipple disease An acute GI illness, with fever, diarrhea, and weight loss

Malabsorption such as steatorrhea.

Abdominal lymphadenopathy and abdominal pain.

Joint problems

Anemia.

Anti-Tropheryma whipplei-positive macrophage (Tropheryma whipplei).

PCR testing of duodenal biopsies positive for T whipplei

Inflammatory bowel disease Dysentery

Weight loss

Colonoscopy identifies the ulcerative lesions
Pulmonary Nocardiosis Immunocompromised host

Predominant pulmonary

Modified acid-fast staining of biopsy tissue or other samples allows distinction between Nocardia and Actinomyces
Blastomycosis Self-limited

Cutaneous manifestations along with lung involvement.

Endemic to Mississippi and Ohio river valley

Sputum smear and culture using KOH preparations or specific stains can confirm diagnosis
Lung abscess Risk of aspiration

Cough with foul smelling sputum

Polymicrobial infection
Pulmonary tuberculosis Cough >2 weeks

Hemoptysis

Night sweats, weight loss

Acid fast bacilli positive on sputum examination

Tuberculin skin testing positive.

Uro-genital system Ovarian/Oviductal tumor Systemic findings like weight loss ,night sweats present

No leukorrhea

Histopathology shows malignancy.
Pelvic inflammatory disease History of recent sexual contact or a sexually transmitted infection in the partner,

Past history of PID.

Laparoscopy with biopsy sampling followed by histology.
Actinomycosis Nocardiosis
Gram positive anaerobic species Gram positive aerobe
Decreasing incidence Increasing incidence
Occurs primarily in immunocompetent host Occurs primarily in immunocompromised host
Predominant cervicofacial Predominant pulmonary
Chest wall involvement and bony erosions are common Chest wall involvement is uncommon
Granuloma formation and intense fibrosis are common. Form characteristic sulfur granules Granuloma formation and fibrosis are uncommon
Spread by direct invasion Metastatic spread is common (especially to brain)
Diagnosis is made through cytologic or histologic examination Diagnosis is made through bronchoalveolar lavage (BAL).

sputum, or pleural fluid culture

Treatment: Penicillin

Treatment with antibiotics alone

Treatment: Sulfonamides

Often need surgical drainage

References

  1. ↑ Yiğiter M, Kiyici H, Arda IS, Hiçsönmez A (2007). "Actinomycosis: a differential diagnosis for [[appendicitis]]. A case report and review of the literature". J Pediatr Surg. 42 (6): E23–6. doi:10.1016/j.jpedsurg.2007.03.057. PMID 17560191. URL–wikilink conflict (help)
  2. ↑ Hasper D, Schefold JC, Baumgart DC (2009). "Management of severe abdominal infections". Recent Pat Antiinfect Drug Discov. 4 (1): 57–65. PMID 19149697.
  3. ↑ Lederman ER, Crum NF (2004). "A case series and focused review of nocardiosis: clinical and microbiologic aspects". Medicine (Baltimore). 83 (5): 300–13. doi:10.1097/01.md.0000141100.30871.39. PMID 15342974.
  4. ↑ Hoffman, Barbara (2012). Williams gynecology. New York: McGraw-Hill Medical. ISBN 9780071716727.
  5. ↑ Humes, D J (2006). "Acute appendicitis". BMJ. 333 (7567): 530–534. doi:10.1136/bmj.38940.664363.AE. ISSN 0959-8138.
  6. ↑ Saccente M, Woods GL (2010). "Clinical and laboratory update on blastomycosis". Clin. Microbiol. Rev. 23 (2): 367–81. doi:10.1128/CMR.00056-09. PMC 2863359. PMID 20375357.
  7. ↑ Kim, Eun Ran (2014). "Colorectal cancer in inflammatory bowel disease: The risk, pathogenesis, prevention and diagnosis". World Journal of Gastroenterology. 20 (29): 9872. doi:10.3748/wjg.v20.i29.9872. ISSN 1007-9327.
  8. ↑ Hanauer, Stephen B. (1996). "Inflammatory bowel disease". New England Journal of Medicine. 334 (13): 841–848. PMID 8596552. Retrieved 2006-11-10.
  9. ↑ Kuhajda I, Zarogoulidis K, Tsirgogianni K, Tsavlis D, Kioumis I, Kosmidis C, Tsakiridis K, Mpakas A, Zarogoulidis P, Zissimopoulos A, Baloukas D, Kuhajda D (2015). "Lung abscess-etiology, diagnostic and treatment options". Ann Transl Med. 3 (13): 183. doi:10.3978/j.issn.2305-5839.2015.07.08. PMC 4543327. PMID 26366400.
  10. ↑ Soper DE (2010). "Pelvic inflammatory disease". Obstet Gynecol. 116 (2 Pt 1): 419–28. doi:10.1097/AOG.0b013e3181e92c54. PMID 20664404.
  11. ↑ Sullivan DC, Chapman SW (2010). "Bacteria that masquerade as fungi: actinomycosis/nocardia". Proc Am Thorac Soc. 7 (3): 216–21. doi:10.1513/pats.200907-077AL. PMID 20463251.
  12. ↑ Warren NG (1996). "Actinomycosis, nocardiosis, and actinomycetoma". Dermatol Clin. 14 (1): 85–95. PMID 8821161.
  13. ↑ Smego RA (1987). "Actinomycosis of the central nervous system". Rev Infect Dis. 9 (5): 855–65. PMID 3317731.
  14. ↑ Bassiri-Jahromi S, Doostkam A (2011). "Actinomyces and nocardia infections in chronic granulomatous disease". J Glob Infect Dis. 3 (4): 348–52. doi:10.4103/0974-777X.91056. PMC 3249989. PMID 22223997.

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