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Primary Cutaneous Actinomycosis: a Rare Soft Tissue Infection

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Primary Cutaneous Actinomycosis: a Rare Soft Tissue Infection 184 Indian Journal of Medical Microbiology vol. 26, No. 2 leading to misdiagnosis.[8] A similar situation might have 2. Lalitha MK, Anandi V, Srivastava A, Thomas K, Cherian AM, been present in the present case had the second CSF sample Chandi SM. Isolation of Acanthamoeba culbertsoni from a not been sent to the laboratory and those abnormal cells patient with meningitis. J Clin Microbiol 1985;21:666-7. were not noticed in the wet preparation. In another case 3. Gogate AA, Singh BN, Deodhar LP, Jhala HI. Primary amoebic meningo-encephalitis caused by Acanthamoeba report, amoebic trophozoites were detected in a routine (report of two cases). J Postgrad Med 1984;30:125-8. cytological examination of CSF sample leading to early 4. Hamide A, Sarkar E, Kumar N, Das AK, Narayan SK, Parija [5] diagnosis of GAE and subsequent survival of the patient. SC. Acanthamoeba meningoencephalitis: A case report. Neurol So it is necessary to have a high index of suspicion to India 2002;50:484-6. recognize this infection, especially when CSF examination 5. Petry F, Torzeeski M, Bohl J, Schwenkmezger TW, Scheid P, is negative for routine organisms and treatment with Walohnik J, et al. Early diagnosis of Acanthamoeba infection conventional antibiotics fails.[3] Some investigators have during routine cytological examination of cerebrospinal ß uid. used serological and molecular diagnostic methods[9] that are J Clin Microbiolol 2006;44:1903-4. non-invasive but are time-consuming, expensive and need 6. Schwarzwald H, Shah P, Hicks J, Levy M, Wagner ML, Kline MW. Disseminated Acanthamoeba infection in a human further evaluation. CT and MRI imaging Þ ndings have also [10] immunodeÞ ciency virus-infected infant. Pediatr Infect Dis J been found useful in diagnosis of GAE but no signiÞ cant 2003;22:197-9. Þ nding in CT scan head was observed in this patient. 7. Tan B, Weldon-Linne M, Rhone D, Penning C, Visvesvara G. Acanthamoeba infection presenting as skin lesions in patients There is no known effective therapy for this disease. with the acquired immunodeÞ ciency syndrome. Arch Pathol Various treatment regimens have been tried for GAE but Lab Med 1993;117:1043-6. therapeutic success has been elusive in most of the cases. The 8. Steinberg JP, Galindo RL, Kraus ES, Ghanem KG. drugs that have been tried in varied combinations include Disseminated acanthamoebiasis in a renal transplant recipient amphotericin-B, rifampicin, trimethroprim-sulfamethoxazole, with osteomyelitis and cutaneous lesions: Case report and ketokonazole, ß uconazole, sulfadiazine, albendazole etc. literature review. Clin Infect Dis 2002;35:e43-9. Timely diagnosis, early initiation of antimicrobial therapy, 9. Qvarnstorm Y, Visvesvara GS, Sriram R, de Silva AJ. virulence of the agent and host immune factors all play a role Multiplex real-time PCR assas for simultaneous detection of Acanthmoeba spp., Balamuthia mandrillaris and Naegleria in determining the outcome of GAE. fowleri. J Clin Microbiol 2006;44:3589-95. The current report highlights the importance of including 10. Singh P, Kochhar R, Vashishta RK, Khandelwal N, Prabhakar S, Mohindra S, et al. Amebic meningoencephalitis: Spectrum GAE in differential diagnosis of any patient with subacute of imaging Þ ndings. Am J Neuroradiol 2006;27:1217-21. central nervous system syndrome with no known cause. It is more common especially in patients with compromised immunity. Increasing familiarity of the clinicians, clinical *V Kaushal, DK Chhina, R Kumar, HS Pannu, microbiologists and pathologists with infections due to HPS Dhooria, RS Chhina free living amoebae will certainly help in more aggressive diagnosis and reporting, understanding of the risk factors, Departments of Microbiology (VK, DKC, RK), improvement in therapeutic interventions and prevention of Medicine (HSP, HPSD), Gastroenterology (RSC), fatal outcomes in such cases. Dayanand Medical College and Hospital, Ludhiana - 141 001, Punjab, India References *Corresponding author (email: <[email protected]>) 1. Martinez AJ, Visvesvara GS. Free living, amphizoic and Received: 02-08-07 opportunistic amebas. J Brain Pathol 1997;7:583-98. Accepted: 03-09-07 PRIMARY CUTANEOUS ACTINOMYCOSIS: A RARE SOFT TISSUE INFECTION Actinomycosis caused by Actinomyces spp. is a chronic and associated with external trauma and local ischemia. We report suppurative infection caused by an endogenous gram positive a case of a primary cutaneous actinomycosis of the thigh in a bacterium. The unusual sites of infection are the head and neck, 30-year-old man. The patient acquired the infection through an thorax and abdomen and are almost always endogenous in origin. injection wound which progressed to multiple discharging sinuses. Primary cutaneous actinomycosis is very rare and is usually Clinical material from the wound demonstrated the presence of www.ijmm.org April-June 2008 Case Reports 185 Actinomyces in smears and cultures. The patient was diagnosed and after 72 hours. The Gram stain of the same showed similar successfully treated with surgical resection and combined antibiotic gram positive bacilli as seen in the clinical sample (Fig. 1). therapy. The cold acid fast stain using 1% H2SO4 was negative. The isolate was identiÞ ed up to genus level as Actinomyces spp. Key words: Injection wound, primary cutaneous actinomycosis using standard methods.[1] All other test results including Actinomycosis is an anaerobic, gram positive blood biochemistry, haematology, urine analysis and stool bacterial infection, seen in different parts of the body. examination were within normal limits. Actinomycosis is caused in humans by Actinomyces israelii The histopathology of the biopsy tissue showed ray fungus and in animals by A. bovis, A. naeslundii and A. viscosus surrounded by polymorphonuclear leucocytes associated with have been documented. The infection is commonly seen hyperkeratosis of epidermis and dermal inÞ ltration, which in tropical countries and characterised by chronic and corroborated the microbiological Þ ndings (Fig. 2). progressive suppurative inß ammation, typically presenting as cervicofacial, thorax and abdomen lesions. Primary Antibiotic sensitivity by disc diffusion method showed cutaneous actinomycosis is a rare entity and the diagnosis resistance to ampicillin and sensitivity to cefuroxime and requires a high index of suspicion. Primary disease of co-trimoxazole. The wound debridement was done and the extremities is uncommon and mostly has an association with patient was treated with intravenous Penicillin G 6 million trauma and bites. units qid for 4 weeks and oral cotrimoxazole 960 mg BD 4 weeks along with supportive treatment comprising of daily Case Report dressing, multivitamins, iron supplement and NSAIDs. A 30-year-old healthy man with swelling in back of the left thigh since 10 months was referred by the local surgeon to a private hospital in Belgaum for further treatment as his swelling started increasing with granular pus for which he had consulted the doctor. Prior to this, the patient had visited a village doctor, who had prescribed an oil-based ointment for local application and advised him hot fomentation with some plant leaves soaked in oil. He gave history of taking an injection followed by which he developed the swelling measuring around 1 cm in size, which started increasing in size and occupied almost whole of the back of the thigh- approximately 15 cm in size and later on he developed multiple discharging sinuses. The lesion was dusky red, Þ rm ß uctuating nodules with white to yellowish thick granular pus. The pus sample was sent to our department for culture and sensitivity. Figure 1: Gram stain of the granules from pus showing gram positive The sample was scanty, thick in consistency and bacilli (×400) yellowish in colour though no offensive smell was noticed. Gram stain of the sample was performed, which showed plenty of pus cells with non-sporing, long, gram positive bacilli. As the sample was not sufÞ cient we requested for a fresh sample. Few yellowish granules were obtained which were washed in saline and centrifuged. Small drop of the deposit was collected on a clean grease free slide and crushed between the slides and direct wet mount as well as Gram stain of the same was performed which revealed gram positive bacilli with polymorphonuclear cells (Fig. 1). The fresh sample was inoculated on two sets of blood, chocolate and MacConkey’s agar. One set was incubated aerobically and the other set in a candle jar at 37°C. Anaerobic incubation was not done due to lack of facilities. While no growth was seen on plates incubated Figure 2: Histopathology of the biopsy tissue showing hyperkeratosis aerobically minute translucent colonies were observed on of the epidermis, dense InÞ ltration of the dermis and colonies of blood and chocolate agar plates incubated in a candle jar Actinomycetes (H&E, ×100) www.ijmm.org 186 Indian Journal of Medical Microbiology vol. 26, No. 2 The patient showed a drastic improvement. The sites. Punctured wounds, dental extractions or compound lesion started regressing with no discharge. The patient fractures are some routes of infection. In these types of was discharged and advised to come for follow-up after infections, there is usually a history of a surgical procedure, one month. After one month the swelling had subsided to which the source and mode of spread can be traced completely with no discharge. as the organism becomes pathogenic in the presence of devitalized tissues with reduced oxygen tension. Cutaneous Discussion localisations
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