The 3 major anatomic types of disease are cervicofacial, thoracic, and abdominal. Cervicofacial lesions are the most common and often occur after tooth extraction, oral surgery, or facial trauma or are associated with carious teeth. Localized pain and induration progress to "woody hard" nodular lesions that can be complicated by draining sinus tracts that usually are located at the angle of the jaw or in the submandibular region. The infection usually spreads by direct invasion of adjacent tissues. Infection also may contribute to chronic obstructive tonsillitis. Thoracic disease most commonly is secondary to aspiration of oropharyngeal secretions and occurs rarely after esophageal disruption secondary to surgery or nonpenetrating trauma or may be an extension of cervicofacial infection. Disease manifests as pneumonia, which can be complicated by abscesses, empyema, and rarely, pleurodermal sinuses. Focal or multifocal masses may be mistaken for tumors. Abdominal actinomycosis usually is attributable to penetrating trauma or intestinal perforation. The appendix and cecum are the most common sites, and symptoms are similar to those of appendicitis. Slowly developing masses may simulate abdominal or retroperitoneal neoplasms. Intra-abdominal abscesses and peritoneal-dermal draining sinuses occur eventually. Chronic localized disease often forms sinus tracts that drain a purulent discharge. Other sites of actinomycosis infection include the liver, pelvis (which, in some cases, has been linked to use of intrauterine devices), and brain. Primary cutaneous actinomycosis also has been reported.