Rapid Diagnosis of Actinomycosis by Thin-needle Aspiration Biopsy PHILIP G. POLLOCK, M.D., DAVID S. MEYERS, M.D., WILLIAM J. FRABLE, M.D., JOSEPH F. VALICENTI, JR., M.D., FRANK P. KOONTZ, PH.D., AND CAROLYN S. BEAVERT, M.A., M.S.P.H.

Pollock, Philip G., Meyers, David S., Frable, William J., Valicenti, Joseph F., Jr., Koontz, Frank P. and Beavert, Carolyn S.: Rapid diagnosis of actinomycosis by thin-needle aspiration biopsy. Am J Clin Pathol 70: 27-30, 1978. Actinomycosis was diagnosed in three cases by the use of thin-needle aspiration biopsy technic. Aspiration was utilized for morphologic studies and collection of material for microbiologic isolation. The critical histologic features of sulfur granules remain intact with aspiration technic. Thinneedle aspiration biopsy is a safe, simple, and rapid technic employed in the diagnosis of neoplastic disease. The use of this technic in the diagnosis of actinomycosis is demonstrated in this report. (Key words: Actinomycosis; Cytology.)

Departments of Pathology, University of Iowa School of Medicine, Iowa City, Iowa, and University of Missouri, School of Medicine, Columbia Missouri; Division of Surgical Pathology and Cytopathology, Medical College of Virginia, Richmond, Virginia; and Pathology Department, University of South Carolina, Charleston, South Carolina

Materials and Methods

ACTINOMYCOSIS is a non-contagious disease produced by anaerobic or microaerophilic organisms of the genus Actinomyces, normally present in the oral cavity. Actinomycosis is typically characterized as a chronic suppurative fibrosing inflammatory disease, predominantly of the cervicofacial area, with a tendency toward formation of sinus tracts and distant spread via aspiration or direct extension. Pathogenesis is related to conditions favoring a reduced tissue oxidation-reduction potential combined with a break in the mucous membrane barrier. Clinical and laboratory diagnosis is often delayed due to the infrequency of the lesion, the variety of clinical presentations, prior partial antibiotic therapy, and difficulty in isolating the organisms. This delay may contribute to difficulty in eradicating the organism, thereby increasing the likelihood of widespread involvement. The presumptive diagnosis is based on finding the typical granules and gram-positive, nonacid-fast, branching bacilli in the exudate or tissue sections. Definitive diagnosis is made by culture. Aspiration biopsy is a well-known technic utilized in the diagnosis of neoplastic disease. Herein we report three cases of actinomycosis, illustrating the spectrum of the disease. The diagnosis in these cases was either first suggested or confirmed by the method of thin-needle aspiration. The technic is safe, simple, and accurate, and allows early diagnosis of suspected cases of actinomycosis.

Case I. A 40-year-old diabetic Caucasian man sought treatment at the University of Iowa Medical Clinics for a painful submandibular mass of two months' duration. The mass had appeared a week after a

Received May 23, 1977; received revised manuscript July 6, 1977; accepted for publication July 6, 1977. Address reprint requests to Dr. Pollock: Department of Pathology, Erlanger Hospital, Chattanooga, Tennessee 37403.

* Equipment:- Aspir-Gun. Available from Everest Company Incorporated, 5 Sherman St., Lindon. New Jersey 07036.

0002-9173/78/0700/0027 $00.60 © American Society of Clinical Pathologists


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The thin-needle technic as described by Franzen and Zajicek and more recently by Frable was used for morphologic identification.41"' Where the volume was sufficient, a single aspirate provided diagnostic material for both morphologic and cultural studies. Otherwise, the material in the first aspirate was utilized for cultural identification and a second aspirate was obtained for morphologic studies. Aspiration for microbiologic identification is done by similar technic. Following removal of the needle* from the aspirate site, excess air in the syringe is expelled. If the microbiology laboratory is readily available, it is recommended that the intact syringe with needle be stoppered and immediately transported for plating in aerobic and anaerobic culture. Otherwise, the aspirate material can be injected into a prereduced anaerobic transport vial at the bedside. Direct smears are made and stained by a Gram stain and a modified Ziehl-Neelson technic. 10 The cultures are processed by standard mycologic, aerobic, and anaerobic technics. 7 1 3 Following the expression from the syringe of material to be used for morphologic studies, cell block preparations can be made. The needle is again detached and 50% ethanol is aspirated in the syringe. The needle is then reattached to the syringe. The ethanol is flushed through the needle into a centrifuge tube. Paraffin-embedded cell blocks are made by standard technics.



A.J.C.P. . J u l y 1978

' M**• t

FIG. 2 (right). Portion of aspirated sulfur granule, demonstrating peripheral palisading of branching filaments with central zone granulation of pleomorphic forms. Methenamine silver. x400. dental extraction and had partially resolved in response to erythromycin administration, recurring following a second dental extraction and remaining refractory to erythromycin. Examination on an outpatient basis revealed a firm 5 x 4-cm right submandibular mass with a 2 x 1-cm centrally placed fluctuant area overlying the mass. A fine-needle aspiration with culture was performed. Cell blocks and direct smears were made from the aspirate. Cave 2. A 32-year-old Negro man complained of a mass in the left side of the neck that had been present for four months with intermittent drainage. Two years previously he had had dental extractions without noticeable problems. The patient came to the University of Missouri Hospital with a slightly tender mass, 5 x 4 cm, in the left digastric triangle. A drainage site was present in the submandibular area, but material could not be expressed. Direct laryngoscopy during general anesthesia disclosed no abnormality, and fine-needle aspiration with culture was performed in the operating room, followed by excision of the mass. Case 3. A 45-year-old Caucasian man complained of the sudden onset of low thoracic back pain radiating anteriorly around the rib cage from the spine. He was seen by his physician and a diagnosis of pneumonia was rendered, with subsequent antibiotic therapy. Six months later he was admitted to the Medical College of Virginia Hospitals in acute distress, with fever, chills and severe back pain. There was point tenderness localized to the T8 area with drainage. Laboratory abnormalities included: leukocyte count 10,800 cu mm with 62% neutrophils and 10% eosinophils and alkaline phosphatase 118 IU/1. Tomographic x-ray studies re-

vealed destruction of a portion of the body of the T8 vertebra and an adjacent small mass. Aspiration was performed using general anesthesia. A 16-gauge needle was inserted under fluoroscopic control to localize the lesion and a fine needle, 0.6 mm in external diameter by 7 inches long, was threaded through the larger needle. Material from the aspirate was submitted for culture and cytologic examination, including smears and cell block preparations.

Results Examination of the paraffin-embedded clot section from Case 1 (Fig. 1) revealed five sulfur granules surrounded by inflammatory cells and fibrinous debris. The granules, as stained with hemotoxylin and eosin, appeared as round to oval amphophilic structures, ranging in size from 75 to 160 /xm. The central portions of the structures were granular, while the periphery consisted of a radiating fringe of eosinophilic rods. Methenamine silver stain further delineated the structures, revealing the borders of the granules to consist of pleomorphic rods radiating in a parallel fashion. Occasional filaments branched in acute angles and had enlarged club-like tips (Fig. 2). The Brown

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FIG. 1 (/

Rapid diagnosis of actinomycosis by thin-needle aspiration biopsy.

Rapid Diagnosis of Actinomycosis by Thin-needle Aspiration Biopsy PHILIP G. POLLOCK, M.D., DAVID S. MEYERS, M.D., WILLIAM J. FRABLE, M.D., JOSEPH F. V...
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