|LETTER TO THE EDITOR
|Year : 2013 | Volume
| Issue : 2 | Page : 157-158
A rare case of cutaneous actinomycosis
Pragya A Nair1, Nishit A Bodiwala1, Shivang A Patel1, Keyuri B Patel2
1 Department of Skin and V. D., Pramukhswami Medical College, Karamsad, Gujarat, India
2 Department of Pathology, Pramukhswami Medical College, Karamsad, Gujarat, India
|Date of Web Publication||17-Apr-2013|
Pragya A Nair
Department of Skin and V. D., Pramukhswami Medical College, Karamsad, Gujarat - 388 120
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Nair PA, Bodiwala NA, Patel SA, Patel KB. A rare case of cutaneous actinomycosis. Indian Dermatol Online J 2013;4:157-8
|How to cite this URL:|
Nair PA, Bodiwala NA, Patel SA, Patel KB. A rare case of cutaneous actinomycosis. Indian Dermatol Online J [serial online] 2013 [cited 2020 Mar 29];4:157-8. Available from: http://www.idoj.in/text.asp?2013/4/2/157/110645
Primary cutaneous actinomycosis is a rare entity and the diagnosis requires a high index of suspicion. Despite clues suggestive of the disease, delayed diagnosis or misdiagnosis as tuberculosis is common in our country. It is a subacute to chronic bacterial infection caused by a filamentous gram-positive anerobic to microaerophilic bacterium that is not acid fast.
In man, it is caused by Actinomycosis israelis and in animals by Actinomycosis bovis. Human infections due to A. bovis, A. israelii, A. naeslundi, and A. viscosus have been documented.  It is characterized by suppurative granulomatous inflammation and formation of multiple abscesses and sinus tracts that may discharge sulfur granules. It commonly occurs over the neck, thorax, and abdomen.  Puncture wounds, dental extractions, and compound fractures are some of the portals of infection. The reported male to female ratio is 3:1. Primary disease of the extremities is uncommon and mostly associated with trauma or insect bite.
A 54-year-old farmer presented to us with a non-healing wound below the right elbow joint since one year. The wound started as a solitary reddish nodule that progressively increased in size and number with pus and blood discharge. There was no history of any trauma or insect bite. There was no history of fever, cough, or chest pain and no past history of pulmonary tuberculosis.
The patient was treated in between by many private doctors with oral antibiotics with partial improvement. Incision and drainage was done six months ago, with recurrence.
Local examination showed multiple erythematous nodules and plaques with discharge below the right elbow joint and sinus formation at one place [Figure 1]. No regional lymphadenopathy was present. Hematological and biochemical parameters were normal except ESR, which was raised, Mantoux's test was negative, and X-ray chest was normal. Gram stain from pus revealed gram-positive filamentous rods with polymorphonuclear cells. Culture from the discharge was not performed. Lupus vulgaris, scrofuloderma and actinomycosis were kept in mind and a one of the nodules was biopsied.
|Figure 1: Multiple erythematous nodules and plaque with discharge over the right elbow joint|
Click here to view
Histopathological examination showed hyperkeratosis and mild acanthosis of the epidermis. Acute inflammation was noted in the upper and mid dermis with bacterial colony of actinomycetes surrounded by acute inflammatory infiltrate comprising plasma cells, macrophages, and neutrophils [Figure 2]. Epitheloid cell granuloma was not seen in the section. Changes were suggestive of cutaneous actinomycosis. The patient was given oral cotrimoxazole along with amoxicillin 2 g daily. The skin lesions flattened and regressed within four months.
|Figure 2: Bacterial colony of actinomycosis in the upper dermis with infiltrate of neutrophils. (H and E stain, ×40)|
Click here to view
Primary cutaneous actinomycosis of extremities is uncommon. The reason behind this is the exclusively endogenous inhabitation of the etiological organism. , Cutaneous actinomycosis manifesting with nodular lesions that tend to form a fistula need to be differentiated clinically from other chronic inflammatory skin diseases such as cutaneous tuberculosis, sporotrichosis, and nocardiosis.  Histopathological examination is important to confirm the pathology by demonstrating the presence of organism and other inflammatory changes. 
Involvement of the extremities is rare in actinomycosis; there was no history of trauma, hence exact pathogenesis is unclear. Clinical picture appeared to be tuberculosis but histopathology established the diagnosis as primary cutaneous actinomycosis.
Our patient responded to cotrimoxazole and amoxicillin within four months. Early diagnosis facilitates effective antibiotic therapy.
| References|| |
|1.||Apothéloz C, Regamey C. Disseminated infection due to Actinomyces meyeri: Case report and review. Clin Infect Dis 1996;22:621-5. |
|2.||Fazeli MS, Bateni H. Actinomycosis: A rare soft tissue infection. Dermatol Online J 2005;11:18. |
|3.||Metgud SC. Primary cutaneous actinomycosis: A rare soft tissue infection. Indian J Med Microbiol 2008;26:184-6. |
|4.||Che Y, Tanioka M, Matsumura Y, Kore-Eda S, Miyachi Y. Primary cutaneous actinomycosis on the nose. Eur J Dermatol 2007;17:167-8. |
[Figure 1], [Figure 2]