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Year : 2019  |  Volume : 62  |  Issue : 4  |  Page : 629-630
Primary actinomycosis of anterior abdominal wall: A rare occurrence, diagnosed on fine needle aspiration cytology


Department of Pathology, Seth G.S. Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India

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Date of Web Publication14-Oct-2019
 

   Abstract 


Actinomycosis, a chronic suppurative and granulomatous infection, is caused by Actinomyces israeli. The common clinical presentations are cervicofacial, abdominal, and thoracic regions. Abdominal wall actinomycosis following pelvic or intraperitoneal involvement is known, but isolated abdominal wall involvement is extremely rare and can mimic malignancy. We report a case of primary actinomycosis of anterior abdominal wall, diagnosed on fine needle aspiration cytology (FNAC). Identifying fluffy colonies and branching swirling filaments positive for fungal and Gram stain on cytology smears aid correct diagnosis. FNAC is an effective and reliable tool for early diagnosis of actinomycosis. The treatment is centered around antibiotics, and thus it is essential to diagnose accurately and avoid unnecessary surgery.

Keywords: Abdominal wall, actinomycosis, fine needle aspiration cytology

How to cite this article:
Agnihotri M, Kothari K, Naik L. Primary actinomycosis of anterior abdominal wall: A rare occurrence, diagnosed on fine needle aspiration cytology. Indian J Pathol Microbiol 2019;62:629-30

How to cite this URL:
Agnihotri M, Kothari K, Naik L. Primary actinomycosis of anterior abdominal wall: A rare occurrence, diagnosed on fine needle aspiration cytology. Indian J Pathol Microbiol [serial online] 2019 [cited 2019 Nov 21];62:629-30. Available from: http://www.ijpmonline.org/text.asp?2019/62/4/629/269060





   Introduction Top


Actinomycosis is a chronic suppurative and granulomatous infectious disease caused by actinomyces species, usually Actinomyces israeli.[1] It occurs most frequently in the cervicofacial, abdominal, and thoracic regions.[2] Abdominal wall actinomycosis without pelvic and intraperitoneal involvement is extremely rare and can mimic multiple disease processes including malignancy.[3] It requires early and accurate diagnosis for successful therapy. We report a case of primary actinomycosis of anterior abdominal wall, diagnosed on fine needle aspiration cytology (FNAC).


   Case Report Top


A 54-year-old female presented with a painful swelling over the left iliac region since 2 years. The swelling was firm, mobile, and measured 1.5 × 1.5 cm in size. On examination, a sinus was noticed at the left inguinal region which was associated with intermittent seropurulent discharge. No lymph nodes were palpable. There was no history of fever, tuberculosis, or any significant past illness. Routine laboratory tests were normal. Ultrasonography showed two fistulous tracts in the left inguinal subcutaneous plane, communicating with each other and the left iliac swelling along with multiple necrotic and non-necrotic inguinal lymph nodes on the left side, the largest measuring 1.1 × 0.5 cm. However, there was no communication seen with any internal organs. The patient was advised FNAC. Aspiration yielded scanty purulent fluid material and the smears were stained with Giemsa and Papanicolaou stain. Smears showed dense neutrophilic infiltrate, numerous histiocytes, and multinucleated giant cells [Figure 1]a. Various-sized fragments of fluffy material were seen [Figure 1]b. These fragments were composed of colonies of thin swirling branching filamentous structures [Figure 1]c. No granuloma or atypical cells were present. The colonies were positive for Gram stain and Grocott's methenamine silver (GMS) stain [Figure 1]d. They were not acid-fast, thereby ruling out Nocardia. On the basis of morphology and staining characteristics, a diagnosis of actinomycosis was made. Culture was negative on both bacterial and fungal (Sabouraud) media, thus confirming the diagnosis; however, culture for definite species of actinomyces could not be performed. Subsequently, the patient received high-dose penicillin treatment and recovered completely.
Figure 1: (a) Smear shows dense neutrophilic infiltrate, histiocytes, and multinucleate giant cells. (Papanicolaou stain, 400×). (b) Fluffy colonies (Giemsa stain, 400×). (c) Colonies were composed of thin filamentous structure showing branching (Giemsa stain, 1000×). (d) Positive for Grocott's methenamine silver (GMS) stain (400×)

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   Discussion Top


Actinomyces is an anaerobic Gram-positive filamentous bacteria that is normally present in the oral cavity, gastrointestinal tract, and bronchus.[4] It has low virulence and the disease occurs when the mucosal barrier has been compromised by trauma or in immune-susceptible individuals.[5]

The common clinical presentations of actinomycosis are cervicofacial, abdominal, and thoracic regions.[6] Abdominal actinomycosis accounts for 20% of actinomycosis infections and can occur due to destruction of mucosal barriers, including perforated bowel, endoscopic procedures, trauma, and appendicectomy.[6],[7] Increased usage of intrauterine device has also resulted in rise in frequency of abdominal infection.[7] Involvement of abdominal wall following pelvic or intraperitoneal is known, but isolated abdominal wall involvement as seen in this case is extremely rare.[8] Clinically, it may present as an abdominal mass mimicking malignancy or as sinuses which may be suspicious of tuberculosis.[8] Consequently, a majority of cases are diagnosed after histopathological examination of the specimen obtained by surgical exploration and resection.[8]

FNAC is a minimally invasive and reliable tool for early diagnosis of actinomycosis and can avoid unnecessary surgery. The diagnostic cytological feature is the presence of fluffy colonies composed of branching swirling filamentous bacteria.[9] These are characteristically positive for fungal (GMS) and Gram stain and are not acid-fast as seen in the present case.[9] This triad of special stains will differentiate it from Nocardia which is partially acid-fast. The background can show suppurative and/or granulomatous inflammatory response. In suspected cases, adequate material should be aspirated for performing special stains and culture. The gold standard remains culture, but the organisms are difficult to grow as they are anaerobic.[8],[9]

The treatment is high-dose antibiotics, including the standard treatment of parenteral penicillin G for 2–6 weeks, followed by 6–12 months of oral penicillin.[10] Thus, early and accurate diagnosis is required for successful therapy.


   Conclusion Top


A high index of suspicion and procuring adequate material for special stains can aid in correct diagnosis on FNAC and institution of effective treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Karaca B, Tarakci H, Tumer E, Calik S, Sen N, Sivrikoz ON. Primary abdominal wall actinomycosis. Hernia 2015;19:1015-8.  Back to cited text no. 1
    
2.
Deodhar SD, Shirahatti RG, Vora IM. Primary actinomycosis of the anterior abdominal wall (a case report). J Postgrad Med 1984;30:133.  Back to cited text no. 2
    
3.
Carkman S, Ozben V, Durak H, Karabulut K, Ipek T. Isolated abdominal wall actinomycosis associated with an intrauterine contraceptive device: A case report and review of the relevant literature. Case Rep Med 2010;2010:340109.  Back to cited text no. 3
    
4.
Acquaro P, Tagliabue F, Confalonieri G, Faccioli P, Costa M. Abdominal wall actinomycosis simulating a malignant neoplasm: Case report and review of the literature. World J Gastrointest Surg 2010;2:247-50.  Back to cited text no. 4
    
5.
Sumer Y, Yilmaz B, Emre B, Ugur C. Abdominal mass secondary to actinomyces infection: An unusual presentation and its treatment. J Postgrad Med 2004;50:115-7.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Ridha A, Oguejiofor N, Al-Abayechi S, Njoku E. Intra-abdominal actinomycosis mimicking malignant abdominal disease. Case Rep Infect Dis 2017;2017. doi: 10.1155/2017/1972023.  Back to cited text no. 6
    
7.
Sheth PB, Neela V. Bhuptani NV, Jalu J. Actinomycosis involving abdominal wall – An unusual site: A case report. Int J Res Med 2013;3161-3.  Back to cited text no. 7
    
8.
Garner JP, Macdonald M, Kumar PK. Abdominal actinomycosis. Int J Surg 2007;5:441-8.  Back to cited text no. 8
    
9.
Singh DK, Saran RK, Gondal R. Primary actinomycosis of the anterior abdominal wall: Rare diagnosis of a case by fine needle aspiration cytology. Acta Cytol 2010;54:746-7.  Back to cited text no. 9
    
10.
Hefny AF, Joshi S, Saadeldin YA, Fadlalla H, Abu-Zidan FM. Primary anterior abdominal wall actinomycosis. Singapore Med J 2006;47:419-21.  Back to cited text no. 10
    

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Correspondence Address:
Mona Agnihotri
Department of Pathology, Seth G.S. Medical College and K.E.M. Hospital, Parel, Mumbai - 400 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_193_18

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