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Actinomycosis in surgical biopsies' Jennifer Dove MB BS London Hospital, London El JBB
Actinomycosis is a bacterial infection characterized by chronic granulomatous lesions with suppuration and frequently sinus formation. Aggregates of the organism responsible, which belong to the genus actinomyces and other related genera, may be found in the lesions or exudate as 'sulphur granules'. Three cases are presented in which the diagnosis of actinomycosis was made on histology of surgical material. Case reports Case I Mr P M, aged 30, presented in October 1976 with a laceration over his right knuckle after punching someone in the mouth. A piece of his opponent's tooth had been embedded in the wound. Despite antibiotic therapy he developed chronic osteomyelitis of the head of the right third metacarpal. At operation in December 1976 necrotic bone and tissue were excised and a fragment of tooth removed. He showed gradually improving function of his right hand on follow up, but developed a firm swelling over his metacarpophalangeal joint in July 1977 after jarring his hand at work. A granulomatous mass was excised in September 1977. Macroscopic examination of the tissue was unhelpful. Microscopy showed chronically inflamed granulation tissue, fibrous tissue and abscess formation around a single colony of bacteria, showing characteristic peripheral 'clubs' (Figure 1). Culture was negative. Case 2 Mrs J 0, aged 24, was seen in November 1977 with a six-month history of irregular and prolonged menstrual bleeding, general malaise and a five week history of anorexia and vomiting with a three-stone (19.05 kg) weight loss. She had had three full-term pregnancies and two terminations, the last six years previously. A Dalkon shield intrauterine contraceptive
0141-0787/00-03/SO 1.0/
Figure 1. 'Sulphur granule' surrounded by polymorphs
© 1979 Te RylScey-fMdcn
x
60)
'Paper read to Section of Pathology, 14 February 1978. Accepted 21 March 1978 0 1 41-0768/79/020106-03/$O 1.00/0
,."
1979 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 72 February 1979
107
device had been in place for five years. On examination she was pyrexial. A firm tender lower abdominal mass was felt. At laparotomy there was a large fixed pelvic mass, involving terminal ileum and omentum, containing locules of pus. Uterus, ovaries and fallopian tubes were normal. A biopsy of the pelvic mass showed only active chronic inflammatory tissue on frozen section. The intrauterine device was removed and bulky endometrial curettings sent for histology and culture. Microscopy showed fragments of endometrium, necrotic debris, polymorphs and several small colonies of bacteria, identified as Actinomyces israelii on culture (Figure 2). Case 3 Mr J R, aged 30, was seen by his GP in July 1977 complaining of a persistent cough, dyspnoea on exertion, vomiting, one stone (6.3 kg) weight loss and night sweats. He was seen again in August 1977 complaining of difficulty walking due to a persistent cramp in his right leg and a swollen right calf. In September 1977 he developed a tender fluctuant swelling of his right lower chest wall and a tender swelling of his left shin. Biopsy of his right calf in August 1977 showed a nonspecific myositis, and a chest X-ray shortly after revealed a right apical opacity. The chest wall lesion was biopsied in September 1977 but culture and histology were unhelpful. He was transferred to the London Hospital in October 1977 where his slides were reviewed and further sections cut. Deeper sections of his chest wall lesion showed a single colony of bacteria resembling actinomyces with surrounding acute inflammatory cells, and chronically inflamed fibrous tissue. The organism could not be identified, since culture was unhelpful.
Discussion A number of factors may be involved in the not infrequent delay in diagnosing actinomycosis. The infection is not rare but sufficiently uncommon for it to be on occasions forgotten in the differential diagnosis of chronic granulomatous infections. The organisms have specific growth requirements and usually require prolonged incubation. They are almost invariably present in mixed culture, which makes isolation difficult. They are susceptible to a wide variety of antibiotics. If the patient is treated prior to collection of tissue or fluid for culture, the organism may not be grown. All the organisms involved in the disease are normally present in the mouth, consequently sputum samples are unhelpful in diagnosing lung infection. In the first case the mode of infection was almost certainly directly from the tooth embedded in the wound; similar cases have been reported (Winner 1960). Almost all the organisms have been isolated from dental plaque (Slack & Gerencser 1975).
Figure 2. Endometrium containing a colony of Actinomyces israelii ( x 100)
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Journal of the Royal Society of Medicine Volume 72 February 1979
In the second case infection was associated with an intrauterine device, which is becoming an increasingly recognized problem (Schiffer et al. 1975, Lomax et al. 1976, Witwer et al. 1977). This IUCD was a Dalkon shield, a device withdrawn from the market in 1974 because of its association with septic abortion. It has a multifilament tail which is thought to provide a route for ascending infection of the endometrium (Tatum 1977). The third case was one of disseminated infection with the probable primary site in the lung and haematogenous spread to a variety of subcutaneous sites; similar cases have been reported (Varkey et al. 1974). The three cases demonstrated that actinomycosis is a chronic granulomatous infection in which the diagnosis can be made on histology alone, but further identification of the organism requires culture and investigations such as serology and gas chromatography of end products. Penicillin is the drug of choice in the treatment of actinomycosis. Prolonged therapy is usually necessary, combined with surgery when abscess formation has occurred. Characteristically, there is a rapid response to therapy which may be helpful when the diagnosis is in doubt.
References Lomax C W, Harbart G M & Thornton W N (1976) Obstetrics and Gynecology 48, 341-346 Schiffer M A, Elguezabal A, Sultana M & Allen A C (1975) Obstetrics and Gynecology 45, 67-72 Slack J M & Gerencser M A (1975) Actinomyces, Filamentous Bacteria. Biology and Pathogenicity. Burgess Publishing Company, Minneapolis; p 93 Tatum H J (1977) Fertility and Sterility 28, 3-28 Varkey B, Landis F B, Tang T T & Rose H D (1974) Archives of Internal Medicine 134, 689-693 Winner H L (1960) Journal of Clinical Pathology 13, 536 Witwer M W, Farmer M F, Wand J S & Solomon L S (1977) American Journal ofObstetrics and Gynecology 128, 913914
Journal of the Royal Society of Medicine Volume 72 February 1979
Actinomycosis in surgical biopsies' Jennifer Dove MB BS London Hospital, London El JBB
Actinomycosis is a bacterial infection characterized by chronic granulomatous lesions with suppuration and frequently sinus formation. Aggregates of the organism responsible, which belong to the genus actinomyces and other related genera, may be found in the lesions or exudate as 'sulphur granules'. Three cases are presented in which the diagnosis of actinomycosis was made on histology of surgical material. Case reports Case I Mr P M, aged 30, presented in October 1976 with a laceration over his right knuckle after punching someone in the mouth. A piece of his opponent's tooth had been embedded in the wound. Despite antibiotic therapy he developed chronic osteomyelitis of the head of the right third metacarpal. At operation in December 1976 necrotic bone and tissue were excised and a fragment of tooth removed. He showed gradually improving function of his right hand on follow up, but developed a firm swelling over his metacarpophalangeal joint in July 1977 after jarring his hand at work. A granulomatous mass was excised in September 1977. Macroscopic examination of the tissue was unhelpful. Microscopy showed chronically inflamed granulation tissue, fibrous tissue and abscess formation around a single colony of bacteria, showing characteristic peripheral 'clubs' (Figure 1). Culture was negative. Case 2 Mrs J 0, aged 24, was seen in November 1977 with a six-month history of irregular and prolonged menstrual bleeding, general malaise and a five week history of anorexia and vomiting with a three-stone (19.05 kg) weight loss. She had had three full-term pregnancies and two terminations, the last six years previously. A Dalkon shield intrauterine contraceptive
0141-0787/00-03/SO 1.0/
Figure 1. 'Sulphur granule' surrounded by polymorphs
© 1979 Te RylScey-fMdcn
x
60)
'Paper read to Section of Pathology, 14 February 1978. Accepted 21 March 1978 0 1 41-0768/79/020106-03/$O 1.00/0
,."
1979 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 72 February 1979
107
device had been in place for five years. On examination she was pyrexial. A firm tender lower abdominal mass was felt. At laparotomy there was a large fixed pelvic mass, involving terminal ileum and omentum, containing locules of pus. Uterus, ovaries and fallopian tubes were normal. A biopsy of the pelvic mass showed only active chronic inflammatory tissue on frozen section. The intrauterine device was removed and bulky endometrial curettings sent for histology and culture. Microscopy showed fragments of endometrium, necrotic debris, polymorphs and several small colonies of bacteria, identified as Actinomyces israelii on culture (Figure 2). Case 3 Mr J R, aged 30, was seen by his GP in July 1977 complaining of a persistent cough, dyspnoea on exertion, vomiting, one stone (6.3 kg) weight loss and night sweats. He was seen again in August 1977 complaining of difficulty walking due to a persistent cramp in his right leg and a swollen right calf. In September 1977 he developed a tender fluctuant swelling of his right lower chest wall and a tender swelling of his left shin. Biopsy of his right calf in August 1977 showed a nonspecific myositis, and a chest X-ray shortly after revealed a right apical opacity. The chest wall lesion was biopsied in September 1977 but culture and histology were unhelpful. He was transferred to the London Hospital in October 1977 where his slides were reviewed and further sections cut. Deeper sections of his chest wall lesion showed a single colony of bacteria resembling actinomyces with surrounding acute inflammatory cells, and chronically inflamed fibrous tissue. The organism could not be identified, since culture was unhelpful.
Discussion A number of factors may be involved in the not infrequent delay in diagnosing actinomycosis. The infection is not rare but sufficiently uncommon for it to be on occasions forgotten in the differential diagnosis of chronic granulomatous infections. The organisms have specific growth requirements and usually require prolonged incubation. They are almost invariably present in mixed culture, which makes isolation difficult. They are susceptible to a wide variety of antibiotics. If the patient is treated prior to collection of tissue or fluid for culture, the organism may not be grown. All the organisms involved in the disease are normally present in the mouth, consequently sputum samples are unhelpful in diagnosing lung infection. In the first case the mode of infection was almost certainly directly from the tooth embedded in the wound; similar cases have been reported (Winner 1960). Almost all the organisms have been isolated from dental plaque (Slack & Gerencser 1975).
Figure 2. Endometrium containing a colony of Actinomyces israelii ( x 100)
108
Journal of the Royal Society of Medicine Volume 72 February 1979
In the second case infection was associated with an intrauterine device, which is becoming an increasingly recognized problem (Schiffer et al. 1975, Lomax et al. 1976, Witwer et al. 1977). This IUCD was a Dalkon shield, a device withdrawn from the market in 1974 because of its association with septic abortion. It has a multifilament tail which is thought to provide a route for ascending infection of the endometrium (Tatum 1977). The third case was one of disseminated infection with the probable primary site in the lung and haematogenous spread to a variety of subcutaneous sites; similar cases have been reported (Varkey et al. 1974). The three cases demonstrated that actinomycosis is a chronic granulomatous infection in which the diagnosis can be made on histology alone, but further identification of the organism requires culture and investigations such as serology and gas chromatography of end products. Penicillin is the drug of choice in the treatment of actinomycosis. Prolonged therapy is usually necessary, combined with surgery when abscess formation has occurred. Characteristically, there is a rapid response to therapy which may be helpful when the diagnosis is in doubt.
References Lomax C W, Harbart G M & Thornton W N (1976) Obstetrics and Gynecology 48, 341-346 Schiffer M A, Elguezabal A, Sultana M & Allen A C (1975) Obstetrics and Gynecology 45, 67-72 Slack J M & Gerencser M A (1975) Actinomyces, Filamentous Bacteria. Biology and Pathogenicity. Burgess Publishing Company, Minneapolis; p 93 Tatum H J (1977) Fertility and Sterility 28, 3-28 Varkey B, Landis F B, Tang T T & Rose H D (1974) Archives of Internal Medicine 134, 689-693 Winner H L (1960) Journal of Clinical Pathology 13, 536 Witwer M W, Farmer M F, Wand J S & Solomon L S (1977) American Journal ofObstetrics and Gynecology 128, 913914
