mykosen 21 (7) 223-235 0 Grosse Verlag 1978

Eingang 14. Dezember 1937 Angenommen 15. Marz 1978

Clinical Section (Head: 0. B. MINSKER, Doctor of Medical Sciences) of the Decp Mycoses Department (Head: T. G. SUTEEVA, Candidate of Medical Sciences), Martsinovsky-Institute of Medical Parasitology and Tropical Medicine (Director: K. P. CHAGIN,Corresponding Member of the USSR Academy of Medical Sciences, Professor), Moscow, USSR

Actinomycosis ,of Lymphatic Nodes 0. B. MINSKER and L. B. GOLOV

Summary Lymph node actinomycosis is still a rarely diagnosed, insufficiently investigated disease. The lymphatic nodes of the neck a n d head are most frequently affected. As in actinomycosis of other localization, identifications of the stage and form of the process develo ment according to the particular classification enables a complete characterization o the process, with an optimum treatment and prognosis of its course. A complex examination of the patients, including clinical, microbiological, pathomorphological, cytological, radiological and immunological investigations is necessary for diagnosis of lymph node actinomycosis. Early diagnosis and early rational treatment (conservative, surgical) make prognosis in lymph node actinomycosis quite favourable a t present. The paper introduces detailed information on results of ahe complex diagnostics and combined treatment of 161 patients with lymph node actinomycosis.

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Zusammenfassung Die Lymphknotenaktinomykose ist immer noch eine seltene und ungeniigend untersuchte Krankheit. I n der Regel sind die Lymphknoten sdes Kopf- und Halsbereiches befallen. Wie au& bei der Aktinomykose anderer Lokalisationen, sind Bestimmungen des Grades und der Form der Krankheitsentwicklung, besonders in Beziehung zum klinischen Bild, erforderlich, was eine vollstandige Charakterisierung des Prozesses mit einer optimalen Behandlung und einem Prognoseverlauf erm6glicht. Eine griindliche Durchuntersuchung der Patienten, die klinische, mikrobiologische, pathomorphologische, zytologische, radiologische und immunologische Untersuchungen einschlieflt, ist fur die Diagnose der Lymphknotenaktinornykose erforderlich. Eine fruhe Diagnose und somit eine fruhe optimale Behandlung (konservativ, chirurgisch) ergeben jetzt eine gunstige Prognose dieser Krankheit. Hier werden die Ergebnisse einer umfangreichen Diagnostik und einer kombinierten Behandlung von insgesamt 161 Patienten mit einer Lymphknotenaktinomykose eingehend geschildert.

I n the problem of actinomycosis the lesions of the lymphatic nodes have remained so far least investigated. The symptomatology of this disease is not sufficiently know to the general medical profession, thus resulting in late diagnosis and longer terms of treatment. The rarity of diagnosing this pathological condition has ma,de some authors (BERDYGAN 1960; TOMM e t al. 1972) reject the possibility of actinomycotic lesions in the lymphatic system. BERESTNEV (1897) was t h e first to describe actinomycosis of a lymphatic node. By 1931 in the world literature there had been reports “on less than 10 cases of lymphatic 1931). nodes actinomycosis confirmed morphologically an,d microbiologically” (SCHWARZ Key words: Lymph node actinomycosis, Actinornyces israeli, infiltration stage, abscess stage,

immunotherapie.

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Fig. 1: Patiect E.: A.ctinon'K' :osis cf bur cal lymphatic node; In itial period of infiltrationI stage of the

lesion.

At present due to growing interest in actino:nycosis and improved diagnosis of this condition, the number of such abservations has largely increased. The number of patients with lymphatic node lesions in relation to all the patients with actinomycosis o f this localization ranges between 1,21 % (SUTELV1951) and 20,97 % (BARDYSHLVA 1972). The most frequently involved lymphatic nodes are: those of the submaxillary triangle, cervical nodes, submental nodes, less frequently - buccal nodes (ASNIN1956; ROBU+ TOVA 1962; MINSKER et a]. 1968; DIMENTSHTEIN 1973). There have been reported some unusual case:, such as ac:inomycosis of the lymphatic nodes of the root of the tongue (MINSKERand ROBUSTOVA 1969), of those of the mcdiastinum (HARRISand PRIESTLEY 1944; PROSOROV 1950; SOBOLEV 1955), of the bifurcational and paratracheal nodes (SHLAPOBERSKY 1927), of the hilus of the lung (GERMANOVSKY and LIBERMAN 1938; BERTA and KULKA1971), of the mesenteric nodes (BERESTNEV 1897; HARVEY e t al. 1957; SERRANO-RIOS et al. 1969), of those of t h e groin RAUBER1925; SUTEEV1951; GORBUNOV 1970; HASSAN and ELSHAHH 1972) and of t h e axillary nodes (HARRIS and PRIESTLEY 1944). Within the period of 1946 to 1974 in the Department of Deep Mycoses of the Martsinovsky-Institute of Medical Parasitology and Tropical Medicine (DDM IMPaTM) there have been encountered 161 patients with actinomycosis of the lymphatic nodes. Among them there were 111 males and 50 females, the age groups being from 2 to 70 years (the average age - 29.3). Duration of the condition ranged from 7 days to 16 years; most patients (92 of them) were admitted to DDM IMPaTM 1 - 2.5 months after the onset of the disease. During this period they were followed up in different hospitals and medical institutions for common lymphadenitis, sialoadenitis, tuberculosis, abscesses, phlegmon, neoplasms. Only in 21 patients actinomycosis was suspected before their admission to DDM IMPaTM (involvement of the lymphatic nodes was thought t o be the case in 8 of them). These patients were admitted a t early stages of the disease mykosen 21, Heft 7 (1975)

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Fig. 2 : Patiect G.: Actinomycosis

of submaxillary lymph nod?; t h e chronic period of lesion, abscension stage.

Fig. 3 : Parirnf E.: Acrinomycosis of submental lymph node; chronic period of the lesion, fistula stage.

without previous treatment. I n 154 out of 161 patients the actinoniycotic process had localized in the lymphatic nodes of the head and neck; submaxillary lymphatic nodes being involved in 84 patients, cervical (45), submental (12), masseterial ( 6 ) , the buccal nodes (5), parotic ( 2 ) . Besides, 3 patients had lesions in the groin lymphatic nodes, two in the axillary ones, one patient had those lesions in the mesentery nodes and one in the supraclavicular nodes (secondary to the involvement of the forearm lymphatic nodes). 77 patients had a rightsided localization of the process, 68 Ieftsided, 13 median, and 3 bilateral (Figs. 1, 2 , 3 ) . mykosen 21, H e f t 7 (1978)

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Actinomycosis of the lymphatic nodes may be either primary or secondary. As primary actinomycosis w e consider those cases (48 patients), when the pathological process developed originally in a lymphatic node either without any lesion a t the site of infection entry or the lesion could not be detected or when it was impossible to reveal any relation of rhe dimsease TO the supposed causes from the case history. Most of the patients under our care had secondary actinomycosis of the lymphatic nodes with a primary focus a t the site of infection invasion, the lymphatic node being involved due to lymphogenic or contact distribution of the process. A relation to stomatogenic, odontogenic and other causes was revealed in 113 out of 161 patients: dental caries (53), difficult dentition of the third molars (12), exposure to cold (lo), sore throat (8), catarrh of the upper respiratory tract (7), influenza (6), fracture of the mandible (5), chronic tonsillitis (4), disturbance of the oral mucosa with dental prosthesis (3), pathologic gum cavities (4, tonsillectomy ( 2 ) , an’d inflammation of the middle ear in 1 patient. The secondary character of lymphatic node actinomycosis was confirmed by lymphangitis observed in 24 patients: in 5 patients with lesions of the buccal lymphatic nodes and in 19 patients with lesions in the submaxillary nodes; from the site of entry of infection there ran a band with signs of acute inflammation. To the secondary lymphatic node actinomycosis we also refer 6 cases in which actinomycosis had appeared against underlaying coninion inflammatory process; it was diagnosed by repeated diagnostic punctures and subsequent cytologic investigations. I n 38 patients the lymphatic nodes were involved secondarily as a result of distribution of the actinomycotic process from the surrounding tissues. Association of secondary actinomycosis with exposure to cold and frequent colds is confirmed by a certain seasonal character of the disease: 56 patients fell ill in winter, 41 in autumn, 32 in spring, and 29 in summer. In 4 patients the exact period of onset of the disease had not been ascertained. In 43 out of 161 patients observed the illness began with the appearance of a solid, rather painless, movable infiltration in the areas of anatomical arrangement of the lymphatic nodes. The patients referred to it as a “ball” or “swollen gland” etc. D a t a on the onset of the disease (the infiltration stage of inlitial period) could only be obtained from the patients themselves, as at that time they usually did not consult a doctor. The remaining 118 patients did not point out changes a t the early stage of the disease; they considered the first manifestation of its development to be the beginning. With the progress of the pathologic process the infiltration was noticed to enlarge and t o be moderately painful on palpation; mobility of the lesion being restricted due to distribution of the process outside the connective tissue capsule of the lymphatic node. On admission of the patients for examination at this period (duration of the disease 1 - 1.5 month) it was difficult to ascertain the real character of the lesion: in 8 patients enlarged, solid, slightly movable lymphatic nodes were detected only on resolution of the infiltration after some specific immunotherapy. I n 7 of 43 patients we have observed transition of t h e process from the infiltration stage into the abscess stage. A t the abscess stage there were admitted f o r investigation 79 patients (1.5 - 2.5 months after the onset of the disease). A solid, oval infiltration with uneven raised surface joined with the surrounding tissues, the colour of the skin above the focus was changing from normal to a purple-cyanotic. Further, the skin in the centre of the abscess area became thin; in 16 patients before ejection of pus it became slightly protruted over the rest of the skin surface. The border between the area of fluctuation and the solid part of the infiltration was distinct with fragmented ends. On puncturing the abscess area, were obtained from some drops to 3-5 ml of bloody-purulent, odorless material in which microscopically there were seen mykosen 21, Heir 7 (1978)

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small whitish o r whitish-yellow grains of the size of a manna grain (“sulfur granules”). I n 39 patients we had observed the undulatory course of the process in this stage. Some inflammatory signs, with subsequent deterioration of general condition, febrile temperature, painful infiltration and its enlargement to 6 x 10 cm (and difficulties i n opening the mouth in 10 patients) were followed by improvement in general condition, diminished inflammatory changes and decreased size of the infiltration. There were admitted for investigation and treatment a t the fistula stage 29 patients. T h e patients of this group appeared to have the longest duration of the disease (about 4.5 monts), many of t h m having been treated surgically before coming to the D D M IMPaTM. I n 19 patients this resulted in rapid progress of the process and its transition into the fistula stage, since the fistula in these patients appeared immediately after surgery and localized in the postoperative scar. The outer opening of the fistula, formed a t the site of the operation or spontaneously (in 10 patients), was surrounded by thickened bright pink o r red granulations. I n 1 patient the mouth of the fistula after applying Vishnevsky-ointment became open and resembled an ulcer with a diametr of 0.5 cm. The walls of the fistulas were solid and easily bled on probing. At the fistula stage the lymphatic node remained solid, its borders - indistinct, the size ranging between 1.5 x 2 cm and 2.5 x 3.5 cm. The skin over the affected zone was either of a normal colour o r slightly cyanotic, the skin around the fistula mouth was hyperemic and macerated. The size of the lesion decreased or increased with periodic opening and closing of the fistula mouth; exacerbations of the inflammatory process alternating as well. Discharges in most cases were scanty-serous or seropurulent, occasionally bloodypurulent. The diagnostic complex comprised immunological, microbiological, morphological and radiological techniques of investigation. Skin-test with actinolysate” as antigen was carried out in 140 patients; positive findings were obtained in 129 patients (92 %). Complement fixation test with actinolysate as antigen was performed in 60 patients; positive findings being obtained in 52 patients (86 %). O n microscopic examination of the direct preparations of sulfur granules, colonies of actinomycetes (druses) were found in 56 patients as soon as 1 o r 2 hours after the pus had been taken from the lesion. Besides, in Gram-stained preparations from 19 patients there were obtained colonies of actinomycotic filaments; from 12 patients Actinomyces israeli were cultured (according to classification of KRASSILNIKOV 1949 - Proactinomyces israeli). Under pathomorphological examination of the affected lymphatic nodes extracted a t operation we had detected thickening and hyalinization of the lymph node connective tissue capsule; vegetations of connective tissue bundles in the node proper as well as focal or diffusibly infiltrated lymphoid-histiocytic elements and plasmatic cells. Two patients had obliterated patterns of the lesion due to hyperplasia of the lymphoid and reticular cells and atrophy of the follicles. In 3 cases there were detected microabscesses with actimycotic druses in the centre. I n 1 patient we had found accumulations of amorphous necrotizing tissue, impregnated with calcium salts, which resembled druses of actinomycetes. Since 1972 a t DDM IMPaTM cytological investigation has been introduced as a component in the complex of diagnostic techniques; since it produces negligible trauma of the surrounding tissues. Cytological investigation makes it possible to detect elements of the actinomycotic process agents as well as the tissue reaction to this agent in the lesion

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actinolysate - a Soviet specific immunopreparation

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Fig. 4 : Actinomycosis of thc lymph node. Cytologic exam ination. Primary alteration of thc tissue: aster-like format-ion. RoMANovsxY-staining (x 140).

focus, which is important for determining the character of the lesion, the stage of the process and reactivity of the body. I n addition, this technique is advantageous because of its technical simplicity and the possibility of obtaining results in 10-15 minutes after puncture. 72 out of 161 patients with actinomycosis of the lymphatic nodes had undergone cytological investigation. 52 patients had a diagnostic puncture to investigate into the lesion focus under the intact skin or mucosa. As actinomycotic infiltrations are usually solid, we used 20 ml capacity syringes for obtaining specimens. I n 20 patients we carried out cytological investigation of the fistula discharges. Multiple signs of common inflammatory process made diagnosis difficult in such cases because of the associated nonspecific microflora. Therefore the purulent masses from the outer sections were removed initially and specimens taken from the deeper sections of the fistula. Curettage of fistulas was carried out with a n ophthalmic Folkman spoon o r ordinary grooved probe. I n case of narrow fistula openings in 4 patients w e aspirated the pathological material from the fistula by syringes with blunt needles of 10-15 cm long. I n 52 out of 72 patients elements of actinomycetes were found in cytologic preparations. Accumulations of filaments were detected in 18 patients, - scattered threads of mykosen 21, Hefr 7 (1978)

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Fig. 5: Actinomycosis of the lymph node. Cytologic examination. Development of cellular granuloma; the epithelioid cell next to rhe collection of actinomycotic filamenir. R@MANOVSKY-Stalning(X 630).

filaments extra- and intracellularly - in 34. I n 22 patients there were long filaments threads (to 30-50 mk); in 7 - accumulations of finely fragmented filaments resembling a collection of small cocci. I n 3 patients w e noted the presence of highly branched Mwooly’’filaments. O n staining with azur-eosine (ROMANOVSK-staining), actinomycete filaments usually turned into violet colour, but in 8 patients separate filaments were coloured blue with red impregnations, situated 1-3 mm from one another. I n 4 patients we found gray a n d blue triangle or droplike particles of 3 x 10-15 mk, which we considered to be “flasks”, situated along the periphery of the actinomycetes druses. Except actinomycetes filaments in 6 cases on puncture a n d in 4 cases on investigation of the fistula contents, we had found coccal flora, in 2 cases - spirochetes, morphologically resembling Spirochaeta buccalis; in 2 - amoebas, considered by us as E n t a m o e b a gingiwalis. I n these cases on puncture there was obtained copious, purulent material not characteristic of actinomycosis. Formation of specific granuloma in different infections has a similar biological basis as it is stimulated by the immune powers of the organism (DAVYDOVSKY 1969). This explains the fact that in various diseases the organism builds granulomas from one and the same elements. However, quantitative relationship of these cellular elements in the granuloma makes it practically possible to differentiate the nature of the disease. The cellular structure revealed under cytological investigation does not allow to establish complete identity of the developmental stages of specific granuloma (DAVYDOVSKY 1969) and developmental stages of actinomycotic lesion foci (MINSKER1971, 1974). Considering characteristics of the pathological process in actinomycosis we associated this with formation of “daughter” granulomas (MINSKER1971 ; EGOROVA1973, MINSKER and EGOROVA 1974), developing along the periphery of already existing “mother” granulomas which have respectively earlier stages of development. This explains why some cytological preparations display simultaneously the cells of different stages of granulomatous process. mykosen 21, Heft 7 (1978)

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Fig. 6 : Actinomycosis of the lymph node. Cytologic examination. Destruction of granuloma cel!s; the xanthomatous cell next to the collcction of actinomycotic filaments. ROMANOVSKYstaining (x 140).

Cytologically revealed primary alteration of the tissue corresponded to clinical infiltrative stage of the primary period of lesion focus development; though discovery of active pus elements i n 7 patients testified to presence of an abscess (a microabscess). The elements discovered at this stage are characteristic for any inflammatory process. These are - neutrophiles and macrophages. I n 2 of them alongside with confused arrangement of the cells we have noticed “aster-like” formations, in the centres of which on x 600-900 magnification there were seen threads of actinomycetes, “the petals” of which consisted of neutrophiles and macrophages (Fig. 4 ) . I n direct preparations these formations looked like fine druses with obvious stellates but without flasks. Development of the cellular granuloma (the abscess a n d fistula stages in the clinic) could be seen in the preparations taken from 50 patients due to appearance of specific granuloma cells a t the background of the elements of the previous stage ( F i g . 5 ) : lymphoid elements (in 40 patients), eosinophiles (in 12), plasmatic cells (in 24), multinuclear cells o r “the foreign body cells” (in 13). This colour variation of the picture was accentuated b y the cells of epithelioid type (in 6 patients) and PIROGOV-LANGHANS cells (in 4). No assotiation with other specific disease, tuberculosis in particular, was found. Destruction of granuloma cells (more frequently in abscess and fistula stages) was quite characteristic and manifested by formation of cells with copious, vacuolated cytoand BERKMAN1952; OSPOVAT 1963 ; plasm - “xanthomatous cells” (ALTGAUSEN GRACHEV 1965), which we have discovered in 26 patients. I n 14 patients we had noticed transformation of macrophages, plasmatic and reticular cells into xanthomatous cells (Fig. 6 ) . In 6 patients we had found macrophages with blue impregnations in the cytoplasm. I n the same preparations we had discovered the blue filaments described above o r mykosen 21, H e f t 7 (1978)

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Fig. 7: Actinomycosis of the lymph node. Cytologic examination. Residual sclerosis; layers of reticulohistiocytic cells and poliblasts. ROMANOVSKY-staining (x 140).

the flasks of actinomycetes. I t is possible, that actinomycetes filaments and flasks phagocytosed by macrophages through lysis (DMITRIEV 1947) or fatty degeneration participate in formation of cellular cytoplasm of the xanthomatous cells. Residual sclerosis as the final stage of granulomatous process in actinomycosis is cytologically manifested in 2 ways. I n 34 patients (abscess and fistula stages in the clinic) the onset of sclerosis was indicated by a collection of reticulo-histiocytic elements and fibroblasts, composing in a number of preparations cellular layers ( F i g . 7), resembling and Mathose in granulation of wounds healing by secondary intention (POKROVSKAJA XAROV 1942; MINSKERet al. 1973). In the scar stage of the lesion focus there were registered single fibroblastic elements against thc background of blood. Differential diagnosis had to be carried out first of all with cutaneous and subcutaneous actinomycosis, for with completely developed disease a n d distribution of the process outside the capsule of the lymphatic node with involvement of the surrounding tissues it is possible to reveal the elements of the lymphatic node only b y means of pathomorphological and cytological investigations. I t is also possible to reveal histologically the above described changes in the lymphatic nodes which made the diagnosis difficult. I n 2 patients remnants of the lymphoid tissue in t h e form of small islets had been discovered in the scar tissue only after examination of numerous sections. Considerable changes of the lymphatic nodes had been confirmed by isotope scanning in 5 of the patients examined. I t indicated a sharp decrease in the isotope storage in comparison to symmetrical lymphatic nodes of the intact side. A solid oedema, developed around the lesion, makes diagnosis quite difficult too. I t may be account of lymphostasis. The latter and lymphoid infiltration make the cytological diagnosis of lymph node actinamycosis diffioult though lymphocytes and lymphopoetic cells are encountered rare in this case. Localization of the process in the areas of lymphatic node distribution, complete anamnesis and repeated examinations of the lesion focus when there is resolution of the oedema under treatment facilitate correct diagnosis. 390 patients referred to the D D M IMPaTM in whom actinomycosis of the lymphatic nodes was suspected had undergone cytological investigation and the results were as follows: 71 patients had nonspecific inflammation (including nonspecific lymphadenitis - 21), 28 - tuberculosis (including 15 with tuberculosis of the lymphatic nodes), 11 mykosen 21, H e f t 7 (1978)

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hyperplasia of the lymphatic nodes, 8 - neoplasms (including 4 with metastases of cancer into the lymph node, 2 - lymphogranulomatosis, 2 - malignant lymphomas). Besides, there were diagnosed some conditions simulating lesions of the lymphatic nodes. Those were: sialadenitis in 7 patients, dermoid cysts - in 3, malerb epithelioma - in 2 , adenolymphoma - in 2 , miscellaneous tumor of the salivary gland - in 1, aberrating stroma of the thyroid - in I, basalioma - in I. The clinical picture of a nonspecific phlegmon or an abscess - tenderness, hyperemia, glassy skin over the lesion, oedema of the surrounding tissues - made the diagnosis difficult in exacerbations associated primarily with activation of the secondary (nonspecific) flora, lasting in the chronic stage of the disease from 4 days to 2 weeks. Continuance of the process, slow distribution of the solid-elastic infiltration into the surrounding soft tissues, relatively distinct borders of the lesion facilitated differential diagnosis. I n the abscess stage the actinomycotic infiltration retained considerable density; softening not involving the whole surface but a small area only; a dense infiltration surrounded the fluctuacion a r m . The pus in lymphatic node actinomycosis was odorless, most often of a creamy-colour, with admixture of blood, thick and of small amount (0.5-1.5 ml), except when associated with trivial flora. I n nonspecific lymphadenitis contrary to lymph node actinomycosis, the onset of the process was noticed to be acute, with pains, softening of the whole surface followed by rapid purulent liquefaction of the lymphatic node. In the development of the disease there was early involvement of the lymphatic nodes of the adjacent groups; abscess formation did not complete with fistula formation. Correct differential diagnosis of the nonspecific lymphadenitis was facilitated by microbiological and cytological investigation of the pus, obtained on puncture of the abscess area. I t was relatively easy to differentiate tuberculosis lymphadenitis, when a separate lymphatic node grew the size of a hen‘s egg: its surface was smooth, i t had a n elastic consistency, fistulas did not form. I t was much more difficult to diagnose when the process extended outside the node capsule, when fistulas were present and often multiple ones. Contrary to the actinomycotic fistulas which appeared to be bright thickened grdnulations, easily bled on probing, those of tuberculosis lesions had the form of pale-pink faded granulations. In 3 patients we obtained liquid caseous pus. O n investigation of the pathological material elements of the specific granuloma as well as areas of caseous, “cold” pus were found. The latter is not characteristic for actinomycosis, in which there was active pus without a n y signs of distinct degeneration and unwinding off of the nuclear chromatin. I n lymphogranuloniatosis, reticulosarcoma and some other malignant lymphomas as well as in actinomycosis, the cervical nodes were the first to be involved and were rather dense. The oval form of the lymphatic nodes in malignant lymphoma, their surface even when the nodes were joined to form a conglomerate and had distinct policyclic outlines, absence of periadenitis, facilitated clinical differentiation of the processes. Some laboratory examinations were also helpful: changes in blood, involvement of the whole lymphatic system in advanced cases. Along with histological a n d cytological investigation they helped to detect neoplasms originating from the lymphoid tissue and lymph node stroma. T o diagnose metastases of the tumour into the lymphatic nodes was possible on puncture with subsequent cytological investigation. The material obtained was not purulent as in actinomycosis, but bloody with numerous tissue fragments; cancerous cells being revealed microscopically. Sometimes it was possible to reveal tumour growth in the main focus. A t times cancer simulated some inflammatory process, but in the place of degeneration a n ulcer was formed instead of a fistula. Symptoms of general intoxication were rnykosen 21, Heft 7 (1978)

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present in case of extended cancerous lesion and absent in actinomycosis of the lymph nodes. Submaxillary rialoadenitis due to localization of the process in the region of the lymphatic nodes most frequently affected by accinomycosis, presented serious difficulties for differential diagnostics. Considerable density, a round form, tuberosity a n d irregular outlines reFernbled actinomycosis of the lymphatic nodes. However, acute tenderness, elevated temperature, purulent exudate, discharged on palpation from the efferent duct of the salivary gland, hyperemia of the mucosa around the mouth of the duct filling defect under sialography made i t possible to establish a correct diagnosis. In sialoadenitis it was often possible to notice pain in che area of the lesion focus and enlargement during taking food, which was never the case in lymph node actinomycosis. In dermoid cyst the consistency was elastic, however, when there was a lor of fluid widening the cyst walls, palpation revealed its conciderable density and limited mobility. O n puncture of the dermoid cyst the syringe suctioned about 10-15 ml of whitish, less frequently purulent-like fluid. This was followed by complete disappearance of the pathological mass whereas on removal of pus from actinomycotic lesion the size of the lesion focus did not essentialy change. Treatment of patients with lymph node actinomycosis depended on the stage of the pathological process and included conservative therapy and in some cases - surgery (MINSKER 1971, 1974). The basis of the treatment comprised specific immunotherapy with actinolysate (in 137 patients) or actinoinycetic polyvalent vaccine“ (in 20 patients); in 4 patients no specific immunotherapy had been applied. To suppress the nonspecific microflora in 26 patients in the abscess stage and in 11 in the fistula stage we supplcmented antibacterial antibiotics and sulfanilamides (depending on the secondary flora sensitivity) in 10-14 d a y courses. As a means of supplementing the specific immunotherapy in patients with lowered reactivity in the abscess and fistula stages we applied autohemotherapy (in 5 patients) and transfusion of donor blood (2 patients). Conservative treatment being n o t quite effective, 54 patients had undergone surgery. Palliative surgical intervention - therapeutic punctures in t h e abscess stage (in 40 patients) - had promoted conversion of the process from t h e abscess stage into t h e infiltration stage and led to recovery. Radical operations - excision of t h e lymphatic node affected by actinomycosis - had been performed in 14 patients in t h e chronic stage, - in 8 of them in the abscess stage, and in 6 - in the fistula stage. I t should be noted that early diagnosis due to diagnostic puncture had considerably decreased the number of patients who needed excision of the lymphatic node. During t h e operation we had to incise multiple profusely bleeding adhesions, n o t infrequently containing small abscesses. Density and thickness of the adhesions depended on t h e lengh of process. The node itself, freed from t h e adhesions, was enlarged, dense and hyperemic. Sometimes the lymphatic node, more frequently a part of the node, appeared to be immersed into t h e contents of t h e abscess. O n disturbing the integrality of t h e lymphatic node capsule about 1 ml of thick cream pus was discharging into the wound. In 2 patients we had discovered nonaffected lymphatic nodes, immured in the scar tissues. A solid “oedema” of the surrounding tissues made t h e operation rather difficult. T h e affected lymph node o r nodes and t h e scars were excised within ad oculus intact tissues. The wound was closed completely by sutures. After the operation to avoid relapses the patients received actinolysate or actinomycetic polyvalent vaccine as a prophylactic.

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a

Soviet spccific immunopreparation

rnykosen 21, Heft 7 (1978)

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T h e length of t h e t r e a t m e n t depended on t h e duration of t h e process, stage a n d the period of the disease. In the initial period of t h e infiltrative stage in 40 patients one course with immunopreparations was enough to achieve clinical i m p r o v e m e n t ; in 4 of these patients clinical signs of t h e disease h a d disappeared after 5-10 injections of actinolysate or actinomycetic polyvalent vaccine; in 20 patients 1 a n d a half course of t h e latter had to be given. In t h e chronic period the n u m b e r of courses increased: 30 patients h a d been given 2 courses of specific immunotherapy, 11 - 2.5 courses, 1 2 - 3 courses, 8 4 courses, 9 5 courses a n d more. Regression of the disease was characterized by a decreased infiltration, diminished density of its peripheral areas, “melting” a n d “floating” of t h e affected l y m p h a t i c node. If rational t r e a t m e n t h a d been begun a t t h e initial period, regression of the disease was usually uninterrupted. In 48 patients in w h o m t h e disease h a d been developing for a r a t h e r long period, regression had periods of stabilization, w h e n d u r i n g 15-30 days no clinical i m p r o v m e n t was noticed in spite of adequate treatment. Continuation of t h e t r e a t m e n t h a d led to transformation of t h e process into recovery period. W e ahad noticed a progressive course of rhe process in 3 alcoholic patients; in 1 sparcsman a skier, who continued to t a k e p a r t in competitions a n d therefore was o f t e n exposed to co1.d~;in 2 patients with retained roots of demaged teeth t h r o u g h which t h e infection h a d entered; a n d 1 patient w i t h a foreign b o d y inoculated into t h e lower gum. After eliminating the causes o r a l cavity hygiene, anti-alcoholic t r e a t m e n t which supported the actinomycotic process, clinical recovery ens ed. etc. Hence, as a result of the complex treatment, 137 patients have recovered a n d th2 remaining 24 patients continue treatment.

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References 1952: 1. ALTGAUSEN, A. Ja. I. I. BERKMAN, actinomycosis. Med. Parasitol. a. Parasit On the subject of laboratory diagnostics Dis. (Rus). 16, 75. of actinomycosis. Clin. Med. (Rus),5, 83. 10. EGOROVA, T. P., 1973: Pathomorphology of experimental actinomycosis. Candidate 2. ASNIN,D. I., 1956: Immunodiagnostics of actinomycosis. MOSCOW. dissertation, Moscow. I. I. & Sh. I. LIBERMAN, 3. BARDYSHEVA, S. P. & N. A. PACHKAEVA,11. GERMANOVSKY, 1938: Pulmonary actinomycosis. Probl. of 1972: The part of physical methods in complex treatment of maxillofacial and Tubercul. (Rus). 106. cervical actinomycosis. In: Collection of E. I., 1970: Materials on clinic, 12. GORBUNOV, papers “Actual problems of stomatology”, diagnostics and surgical treatment of foot Moscow, p, 93. mycetoma. Candidate dissertation. Astrak4. BERDYGAN,K. I., 1960: The ways of dishan (USSR). tribution of actinomycotic process in 13. GRACHEV, N. A., 1965: O n importance of maxillofacial region. In: Collection of pathohistological investigation of biopsied scientific papers of Minsk Med. Inst., for diagnostics of cervico- facial actinomyMinsk (USSR), 24, 402. cosis. In: Collection of papers of Perm Med. Inst., Perm (USSR). 11, 222. 5. BERESTNEV,N. M., 1897: A case of intestinal actinomycosis. Medical Reviews 14. HARRIS, A. & J. PRIESTLEY, 1944: Gene(Rus). 47, 46. ralized actinomycosis, case with miliary 6. BERTA, M. & F. KULKA,1970: Lungenchest lesions. J. Iab. Clin. Med. 29, 815. actinomycose. Zschr. Atmungsorg. 131, 15. HARVEY, J., J. CANTRILL & A. FISHER, 213. 1957: Actinomycosis its recognicon and 7. DAVYDOVSKY, I. V., 1969: General Human treatment. Ann. Intern. Med. 46, 868. Pathology. Moscow. 16. HASSAN, A. M. & M. ELSHAHH,1972: 8. DIMENTSHTEIN, L. B., 1973: On clinic of Lymph code involvement in mycetome. lymph node actinomycosis of maxillofacial Trans. Roy. Trop. Med. Hyg., 66, 165. and cervical regions. In: Collection of papers dedicated to 200 anniv. of MONIK17. MINSKER,0. B., 1971: Experience with Institute, Moscow. p. 90. clinical classification of actinomycosis. In : 9. DMITRIEV, S. F., 1947: Lysis of actinomyCollection of papers “Problems of decp ces and its significance in the problem of mycoses“, Moscow. issue 2, p. 11. mykosen 21, Heft 7 (1978)

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18. MINSKER,0. B., 1974: Actinomycosis. In.: Big Medical Encyclopaedia, Moscow. 1, 178. Ju. S. 8i 19. MINSKER,0. B., T. P. EGOROVA, T. A. D B R E V L E VLymph A: node actinomycosis. Vrachebnoje delc- (Rus). 4, 1 1 1 . 20. MINSKER, 0. B. & T. G . ROBUSTOVA, 1969: Clinical forms of tongue actinomycosis. I n : Collection of papers "Problems of deep mycoses", Moscow. issue 1 , p. 322. 21. MINSKER,0. B., N. I. FETISOVA,G. S. PINZUR,M. A. MOSKOVSKAJA, L. B. DIMENTSHTEIN & T. v. VORONTZOVA, 1973: Application of the pellicle forming complexes in aerosol package in combined treatment of deep mycoses. In : Collection of papers of the 6nd. All-Union Conference of dermatologists a n d venereologists, Kharkov (USSR). p. 304. 22. OSPOVAT. B. L., 1963: Pulmonary actinomycosis. Moscow. 23. POKRC,VSKAIA, M. P. & M. S. M A K A R O V , 1942: Cytology of wound exudatc as an indication of wound healing process. Moscow. 24. PRCSGROV. A. E. 8: I. L. TAGER, 1950: Roentgenological invcstigation, some infections. Moscow. 25. RAUBER, A,, 1925: Zur Kenntnisse der primaren Aktinomykose der H a u t . insbesondere der Genitalgegend. Acta Derm. Venerol. 6, 493. 26. ROBUSTOVA, T. G., 1466: Maxillo-facial and cervical actinomycosis. Moscow. 27. SCHWARZ,H., 1931 : Aktinomykose in Lymphknoten. Zbl. Bakt., Abt. 1 , 122,373. 28. SERRPNORIOS, M., V. NAVARRO. .I. FONTAN, H. OLIVA & J. RAMIRES,1969: isolatcd hcpato-pancreatic actinornycosis Report of a case simulating a n acute abdomen of fatal course. Digestion 2, 262. 29. SOBOLEV. V. I., 1955: O n roentqenological diagnostics of pulmonary actinomycosis. Herald of Roentgenol. a. Radio]. (Rus) 5, 47. 30. SUTEEV,G. 0.. 1951 : Actinomycosis. Moscow. 31. SHLAPOBERSKY, V. .Ja.. 1927: O n pathogcnesis and pathological anatomy of pulmonary actinomycosis. In: Collection of papers of First Soviet Tuberculosis-Jzstitute, 2, issue 1. 32. TOMM,K., 1. RALEIGH 8: G . GUINN,1972: Thoracic Actinomycosis. Am. J . Surg. 124,46.

Address of the authors: D r . med. Sci. OSCAR B. MINSKER,Clinical Section of Deep Mycoses. Department of the Martsicovsky-Institute of Medical Parasitology and Tropical Medicine, ul. Malaja Pirogovskaja, 20, 1 1 943.5 Moscow.