01.12 Actinomyces is a Potential Cause of Perforated and Gangrenous Appendicitis

R. Patel1, S. Misra1, S. Joseph1 1Texas Tech University Health Sciences,Department Of Surgery,Odessa, TX, USA


Acute appendicitis can present with a wide range of symptoms from an indolent course to severe peritonitis and overwhelming sepsis. The patients clinical status often indicates the severity of the disease and if perforation and diffuse peritonitis is present. While there have been many attempts to identify patients who may develop sepsis and peritonitis, little has been found as to the cause of the most severe cases.

Actinomyces, a gram positive facultative anaerobe, is part of the normal flora of the mouth, GI tract, and female vagina, however when pathologic it causes severe inflammation, gangrene, perforation, and obstruction. Actinomyces can easily be identified on pathologic examination by the formation of sulfur granules. We hypothesized that Actinomyces could be a causative agent in patients who present with perforated or gangrenous appendicitis.


We did a retrospective review of the last 102 appendix specimens removed for acute appendicitis at our institution. Pathologic specimens were reviewed by a single pathologist to identify sulfur granules or actinomyces species within the specimen. Demographic data, lab value, and radiology were reviewed for all patients in the review. Appendiceal specimens were categorized as either gangrenous/perforated or acute inflammation.


There were a total of 20 cases of perforated/gangrenous appendicitis amongst our 102 cases (19.6%). For patients with gangrene/perforation (n=20) there were 7 cases of Actinomyces identified (35%). For the 82 patients with acute inflammation, Actinomyces was identified in 6 specimens (7%). p=0.0008

The average WBC level for all patients in our sample was 14.5. No clinically significant difference was found in WBC levels between gangrenous/perforated and acutely inflamed (14.4/ 14.5). However, patients with Actinomyces had a slightly higher average WBC of 15.3.


In patients with gangrenous/perforated appendicitis there is a 35% chance that Actinomyces is present in the appendix. While in patients without perforation/gangrene there is a 7% chance of identifying Actinomyces. Patients with Actinomyces were found to have a slightly higher WBC level then the patients without, however this was not statically significant.

This data suggests that Actinomyces may be a cause of gangrenous/perforated appendicitis. Since Actinomyces is best treated with a long course of Penicillin based antibiotics, patients with gangrene/perforation may benefit from penicillin based treatment for longer than the standard 2 week course. Finally, Actinomyces may account for failure of non-operative management in selected patients.