Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Actinomycosis


Related Terms

  • Abdominal Actinomycosis
  • Actinomycotic Infection
  • Cervicofacial Actinomycosis
  • Lumpy Jaw
  • Thoracic Actinomycosis

Differential Diagnosis

Specialists

  • Dermatologist
  • General Surgeon
  • Gynecologist
  • Infectious Disease Internist
  • Internal Medicine Physician
  • Neurosurgeon
  • Orthopedic (Orthopaedic) Surgeon
  • Pulmonologist

Comorbid Conditions

Factors Influencing Duration

Length of disability may be influenced by severity of the infection, location of infection, progression of disease before diagnosis, speed of treatment, response to antibiotic therapy, extent of surgical intervention, and postoperative complications.

Medical Codes

ICD-9-CM:
039.0 - Actinomycotic Infection; Cutaneous, Erythrasma, Trichomycosis Axillaris
039.1 - Actinomycotic Infection; Pulmonary, Thoracic Actinomycosis
039.2 - Actinomycotic Infection, Abdominal
039.3 - Actinomycotic Infection, Cervicofacial
039.4 - Actinomycotic Infections; Madura Foot
039.8 - Actinomycotic Infections, Other Specified Sites
039.9 - Actinomycosis Infections, Unspecified Site; Actinomycosis NOS, Maduromycosis NOS, Nocardiosis NOS

Overview

Actinomycosis is an infection caused by the bacterium Actinomyces israelii, which normally is a harmless inhabitant of the gums, teeth, and tonsils. The bacterium also is present in lesser numbers in the membranes lining the gastrointestinal and female genital tracts (Okulicz). Actinomyces bacteria can be harmful, however, if they are moved into other body tissues through trauma, infection in which the soft tissues are broken or inflamed, general surgery, or dental surgery. Once inside the tissue, actinomyces can cause infection resulting in accumulations of white blood cells and breakdown products from dying tissues (pus). These localized collections of pus (abscesses) can develop channels (fistulae) that allow pus to drain through the skin or that extend into other body spaces and internal organs.

The most common form of actinomycosis (about 50% to 70%) occurs in the head and neck (cervicofacial actinomycosis or "lumpy jaw"). Thoracic or pulmonary actinomycosis is a less common form (about 15% to 20%); it starts in the lungs after inhaling secretions containing the bacterium or spreads to the lungs from untreated actinomycosis in the head or neck. Abdominal or pelvic actinomycosis (10% to 20% of cases) spreads throughout the abdomen from a trauma such as a recent bowel surgery or prolonged placement of an intrauterine contraceptive device (IUD) (Okulicz). The infection also can spread via the bloodstream to other organs, including the skin, liver, kidneys, ureters, ovaries, uterus, vertebrae, and brain (generalized actinomycosis).

Incidence and Prevalence: Actinomycosis is uncommon and is estimated to occur in no more than 1 in 300,000 population per year (Okulicz).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Actinomycosis is 3 times more common in men than in women, except in the case of pelvic actinomycosis, which affects women more frequently (Okulicz). The condition can occur in people of all ages, but most often develops in adults aged 20 to 50 (Okulicz).

Source: Medical Disability Advisor



Diagnosis

History: In cervicofacial actinomycosis the individual may report a history of recent oral surgery or oral trauma, poor general health, poor oral hygiene, periodontal disease, or a history of aspiration. The individual may report pain at the site of infection, pus-filled lumps in the mouth, neck, or below the jaw, and difficulty chewing. Symptoms of thoracic actinomycosis may include cough with phlegm (sputum), shortness of breath, chest pain, fever, fatigue, and weight loss. Abdominal actinomycosis often is associated with a history of abdominal surgery, ingestion of a foreign body (e.g., chicken or fish bones), low-grade fever, fatigue, abdominal pain, vomiting, diarrhea or constipation, and severe weight loss. Pelvic actinomycosis usually is seen in women with IUDs; typically they have had the IUD place for an average of 8 years (Okulicz). These women may report lower abdominal pain and abnormal vaginal discharge or bleeding. Symptoms of generalized actinomycosis also may include weight loss, weakness, fever, night sweats, and an overall feeling of illness (malaise).

Physical exam: With cervicofacial actinomycosis, examination of the face or upper neck may reveal swelling, multiple small lumps, and oozing sores, typically located high in the neck near the angle of the jaw. The lumps are hard, red to reddish-purple, and not particularly tender when touched (palpated). Pus draining to the skin's surface may contain yellow bacterial elements called sulfur granules. The signs of thoracic actinomycosis include abnormal breath sounds and coughing up blood (hemoptysis). Additionally there may be drainage of pus from sinus tracts in the chest wall. In abdominal actinomycosis, hard masses may be palpated, often in the right lower quadrant of the abdomen, or less frequently in the left lower quadrant. Pus may drain through fistulae connecting the masses to the skin. In the case of pelvic actinomycosis, a hard pelvic mass also may be felt.

Tests: After using ultrasound to locate an abscess, the abscess is drained (needle aspiration). This fluid is then grown (cultured) in the laboratory to determine if the infection is caused by actinomyces. Actinomyces is a bacterium that grows in the absence of oxygen (anaerobic bacterium). The culture protocol for suspected actinomyces infection must be for microorganisms that can live without oxygen (anaerobic culture). In some cases, the abscess must be surgically removed (excised) and examined with a microscope to reveal the characteristic appearance of the bacteria and associated sulfur granules.

Blood tests may reveal anemia and elevated erythrocyte sedimentation rate (ESR) and C-reactive protein levels. A chest x-ray may reveal a mass. Although a computed tomography (CT) scan of the neck usually shows a lump that may have a visible rim when contrast dye is given, this also can be seen in other conditions including tumors and cysts and is not definitive. In the case of pelvic actinomycosis, a Pap test may be done, but since 7% of Pap tests will be positive for the bacterium in absence of infection, the test is not diagnostically useful in individuals without concomitant symptoms (Okulicz).

Source: Medical Disability Advisor



Treatment

If the mass is accessible or is obstructing nearby structures (e.g., intestines, ureters), abscesses may be aspirated or surgically excised. Antibiotic therapy begins with high doses of antibiotics, typically penicillin, injected directly into a vein through a peripherally inserted central catheter (PICC line) for the first 2 to 6 weeks (Lentino). After that, oral antibiotics are taken for an additional 6 to 12 months depending on the severity of the infection (Lentino). This two-stage therapy usually is effective; injected antibiotics reach the invading bacteria rapidly and in high concentrations while follow-up oral antibiotics protect against recurrence. In order to be effective, however, treatment must be continued for the entire recommended period even after symptoms have completely disappeared. When diagnosed in the early stages, surgery may not be necessary, and the infection may be treated entirely with antibiotics.

Respiratory therapy may be prescribed for individuals with pulmonary actinomycosis depending on the severity of the respiratory symptoms.

Individuals are instructed in maintaining good oral hygiene, and advised to seek regular dental care. Women may be advised to discontinue or avoid using an IUD due to infection risk.

Source: Medical Disability Advisor



Prognosis

Because actinomycosis is progressive, prognosis depends on the stage at which the infection is diagnosed and treated. Although improvement is slow and involves months of antibiotic therapy and possible surgery, most individuals do recover. Cervicofacial actinomycosis is the most easily treated. The prognosis is less encouraging for thoracic and abdominal actinomycosis or when the infection is generalized.

If the infection is not completely eliminated, the individual is at risk for the disease to recur in a more severe form. Untreated infection may cause extensive tissue injury or death.

Source: Medical Disability Advisor



Complications

Actinomyces can enter the bloodstream and spread throughout the body, causing infection in the blood (sepsis), in the coverings of the brain and spinal cord (bacterial meningitis), within the brain (brain abscess), or in the liver. Although rare, these complications often are rapidly fatal. Actinomycosis involving the face or neck may spread to the gums, jawbone, middle ear (otitis media), ribs, or spine (osteomyelitis). Pulmonary actinomycosis can cause pneumonia.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Work restrictions and accommodations depend on the location and extent of surgery. Individuals with a peripherally inserted central catheter (PICC line) will need to keep the area protected, dry, and clean. If breathing is difficult for the individual with pulmonary actinomycosis, walking may need to be limited or avoided. The individual may need time off from work for follow-up care.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Did individual have history of recent oral surgery or trauma, poor general health, poor oral hygiene, or aspiration?
  • Were weight loss, weakness, fever, night sweats, and an overall feeling of illness (malaise) present?
  • Did individual have pain at the site of infection, and pus-filled lumps in the mouth, neck, or below the jaw? Did pus contain sulfur granules?
  • Was there cough with phlegm (sputum), shortness of breath, and chest pain?
  • Did individual have fever, abdominal pain, vomiting, diarrhea or constipation, and severe weight loss?
  • If individual is female, was an IUD present? Were there menstrual irregularities or abnormal vaginal discharge?
  • What type of culture was performed?
  • How far had the infection spread?
  • Were other conditions that cause similar abscesses ruled out?
  • How was diagnosis of actinomycosis confirmed?

Regarding treatment:

  • In what part of the body was the infection located and treated?
  • Is the infection responding to antibiotic therapy? If not, were bacteria cultured from the removed material tested and sensitivity testing done to determine what antibiotics would be the most effective?
  • Did individual receive antibiotics by intravenous catheter before starting oral antibiotic therapy?
  • Is individual capable of and committed to following the treatment plan?
  • Has individual continued antibiotic therapy for entire prescribed period?
  • If not responding to antibiotic therapy, should abscess(es) be surgically removed?

Regarding prognosis:

  • Does individual have a coexisting condition, such as alcoholism, diabetes, immune system disorders, or cancer that may affect recovery?
  • Is disease generalized?
  • Is disease recurrent?
  • Can employer accommodate return to work restrictions?

Source: Medical Disability Advisor



References

Cited

Lentino, Joseph R. "Actinomycosis." The Merck Manual of Diagnosis and Therapy. Eds. Robert S. Porter, et al. 18th ed. Whitehouse Station, NJ: Merck and Company, Inc., 2008. Merck Manual of Diagnosis and Therapy. Merck & Co., Inc. 12 Nov. 2009 <http://www.merck.com/mmpe/sec14/ch178/ch178b.html>.

Okulicz, Jason F., Hari Polenakovik, and Sylvia Polenakovik. "Actinomycosis." eMedicine. Eds. Daniel R. Lucey, et al. 24 Feb. 2009. Medscape. 28 Sep. 2009 <http://emedicine.medscape.com/article/211587-overview>.

General

Fort, Glenn G., and Dennis J. Mikolich. "Actinomycosis." Ferri’s Clinical Advisor. Ed. Fred Ferri. 1st ed. Elsevier, Inc., 2010. MD Consult. Elsevier, Inc. <http://www.mdconsult.com/das/book/body/162839795-4/894761023/2088/24.html#4-u1.0-B978-0-323-05609-0..00010-1--sc0085_377>.

Source: Medical Disability Advisor






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