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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 8  |  Issue : 2  |  Page : 129-132

Actinomycotic infection of the tonsils: A case report and review of the literature


Department of ENT and Head and Neck Surgery, Mahatma Gandhi Medical College and Research Institute, Puducherry, India

Date of Web Publication18-Dec-2018

Correspondence Address:
Stavanger Singh Bakshi
House No: B2, Shree Pushpa Complex, 15th Bharathi Street, Ananda Nagar, Puducherry - 605 009
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohs.ijohs_43_17

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  Abstract 


Actinomycotic infections of the head and neck, although fairly uncommon, represent an important entity because of its varied presentation, difficult diagnosis, and long course of treatment. A 20-year-old female presented with throat pain and difficulty in swallowing for 1 year. Examination revealed a Grade IV enlargement of the left tonsil. The patient underwent tonsillectomy, and the postoperative histopathology revealed actinomycosis. Actinomyces is anaerobic filamentous bacteria which are known to colonize as commensals in tonsillar crypts which on histology show an outer zone of granulation tissue and a central zone of necrosis containing many sulfur granules that represent microcolonies of Actinomyces. Actinomycosis of the head-and-neck region is a significant entity because it can mimic other common lesions, especially in the oropharynx. In cases of recurrent tonsillitis and tonsillar hypertrophy, tonsillectomy is the treatment of choice, and histopathological examination of resected tissue is strongly advocated. This report supports the view that Actinomyces may have a causal association with recurrent acute tonsillitis and tonsillar hypertrophy.

Keywords: Actinomycosis, chronic tonsillitis, tonsillectomy


How to cite this article:
Bakshi SS, Kaipuzha RR, Gopalakrishnan S, Govindarajan A. Actinomycotic infection of the tonsils: A case report and review of the literature. Int J Oral Health Sci 2018;8:129-32

How to cite this URL:
Bakshi SS, Kaipuzha RR, Gopalakrishnan S, Govindarajan A. Actinomycotic infection of the tonsils: A case report and review of the literature. Int J Oral Health Sci [serial online] 2018 [cited 2019 Sep 15];8:129-32. Available from: http://www.ijohsjournal.org/text.asp?2018/8/2/129/247808




  Introduction Top


Actinomyces are anaerobic, Gram-positive, nonacid fast, branched, filamentous bacteria which are known to colonize as commensals in gingival crypts, dental calculi, and tonsillar crypts in oral cavity.[1],[2] The percentage of tonsillectomy specimens with colonization of tonsillar crypts by Actinomyces varies from 6.7% to 35% as seen in various studies.[3],[4],[5] Actinomycosis is not an opportunistic infection and usually occurs in healthy individuals. The characteristic finding on histological examination of the tissue is an outer zone of granulation tissue and a central zone of necrosis containing many sulfur granules that represent microcolonies of Actinomyces.[6] Actinomycosis infections of the head and neck, although fairly uncommon, represent an important entity because of its varied presentation that may mimic other common diseases, the difficulties involved in its diagnosis, and the long course of treatment mandatory to eradicate the disease.


  Case Report Top


A 20-year-old female, a known case of fibrous dysplasia involving the frontal bone, maxilla, and mandible on the left side, presented to the outpatient department with complaints of chronically progressive pain and difficulty on swallowing since a year. The patient gave no history of change in voice, difficulty in breathing, snoring, mouth breathing, or painful neck swelling. She had been prescribed several courses of antibiotics and analgesics by various local general practitioners over the course of this 1-year period.

On general examination, the patient had dysmorphic facies, but the rest of the examination was essentially unremarkable. Examination of the throat revealed a Grade IV enlargement of the left tonsil which had an irregular surface with multiple whitish excrescences on the surface. There was Grade II enlargement of the right tonsil. Videolaryngoscopy confirmed the clinical findings. Given the unusual clinical appearance of the mass, the patient underwent contrast-enhanced computed tomography of the neck which showed a well-defined heterogeneous mass lesion with irregular borders is noted in oropharynx arising from left tonsillar fossa measuring 3 cm × 3.1 cm × 3.5 cm [Figure 1]. Fine-needle aspiration was reported as nonspecific.
Figure 1: Contrast-enhanced computed tomography of neck axial section showing a well-defined heterogeneous mass lesion with irregular borders is noted in oropharynx arising from left tonsillar fossa measuring 3 cm × 3.1 cm × 3.5 cm

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Subsequently, the patient was taken up for tonsillectomy under general anesthesia, and the specimen [Figure 2] was sent for histopathological examination which revealed tonsillar crypts lined by squamous epithelium with underlying subepithelium composed of lymphoid follicles with prominent germinal centers. Focal areas in the crypts showed actinomycosis with areas of central necrosis [Figure 3]. Postoperatively, the patient was managed with a course of IV penicillin for 2 weeks followed by 6 months of oral penicillin. The patient was asymptomatic at 1-year follow-up, and examination did not reveal any recurrences in the tonsillar fossa.
Figure 2: Postoperative specimen showing right enlarged tonsil

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Figure 3: Hematoxylin and eosin stained slide showing tonsillar crypts lined by squamous epithelium with underlying subepithelium composed of lymphoid follicles with prominent germinal centers (a). Focal areas in the crypts showed actinomycosis with areas of central necrosis (b)

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  Discussion Top


Von Langenbeck was the first to report actinomycotic infection of humans in 1845, and he attributed the cause to be a fungus, a view that was reflected by Harz in 1877 when he named the infecting organism as Actinomyces, which means ray fungus. Israel and Ponfick delineated the anaerobic nature of Actinomyces and isolated it from humans in 1891.[7] Five species have been identified as follows: Actinomyces israelii, Actinomyces bovis, Actinomyces naeslundii, Actinomyces viscosus, and Actinomyces odontolyticus. Except for A. bovis, all the species are normal inhabitants of the human oral cavity.[6]

Actinomyces is a Gram-positive, anaerobic, or microaerophilic bacterium that grows as hyphae or filamentous organism. Precipitating factors for the infection include dental caries, dental manipulations, and maxillofacial trauma.[8] The pathogenesis of the organism is ascribed to its ability to act as an intracellular parasite and thus resist phagocytosis, as well as its tendency to spread without respect for established tissue plains or anatomic barriers. Cope, in 1938, classified actinomycosis infection into three distinct forms: cervicofacial (50%), pulmonothoracic (30%), and abdominopelvic (20%).[9]

Actinomycosis has been identified in numerous locations in the oral cavity and pharynx such as dental plaques, tonsillar crypts, carious dentin, gingival surface, and periodontal pockets. Actinomycosis acts as a commensal organism and is unable to penetrate healthy tissues to cause infection, indicating that there should be a portal of entry into unhealthy or disturbed tissue for infection to develop.[10] Actinomycotic infection has been reported in a small percentage of people presenting with chronic tonsillitis,[1] but this has been a point of contention between various authors, as some consider Actinomyces of the tonsil to be a simple saprophytism, whereas others consider it to be infective for the tonsillar tissue.[11],[12]

Definitive diagnosis may be established only by positive culture; however, actinomycosis growth is very difficult even on appropriate anaerobic media, and so, microbiological identification of this organism is often impossible. Incisional biopsy can assist to a large extent the diagnosis of actinomycosis. The typical findings include the presence of sulfur granules seen as basophilic masses with a granular center and a radiating fringe of club-shaped protrusions as well as the distinctive filamentous and beaded Actinomyces.[11] Computed tomography and magnetic resonance imaging usually yield nonspecific findings, contributing only to define radiological features of the mass and its involvement in adjacent soft tissues. On account of this, the clinical differential diagnosis of actinomycosis is usually quite difficult.[13]

The current recommended medical therapy includes 4 weeks of high-dose IV penicillin followed by a 3–6-month course of oral penicillin, continuing treatment even after total resolution of symptoms. Other antimicrobials that have been found to be effective include tetracycline, erythromycin, and clindamycin. These can be used in penicillin-allergic patients with good success rates. Ciprofloxacin has been used for the treatment of recalcitrant cases.[14] Hyperbaric oxygen has also been used in one report as adjuvant treatment because of its direct bactericidal effect.[10] Classical surgical excision is thought as a definitive treatment for the head-and-neck actinomycosis, and tonsillectomy is usually curative for tonsillar actinomycosis.[1]

There are no specific measures for preventing actinomycosis, however, maintenance of good personal orodental hygiene, and in particular, removal of dental plaque may reduce the density if not the incidence of colonization and low-grade periodontal infection with Actinomyces species.[15]


  Conclusion Top


Actinomycosis of the head-and-neck region is an important entity because it can masquerade any oropharyngeal malignancies or can mimic any other common lesions in the oropharynx. Lesions in the head-and-neck region that does not respond for common antibiotic therapy may arouse suspicion of actinomycosis. In tonsillar actinomycosis, tonsillectomy is the treatment of choice, and histopathological examination of resected tissue is the diagnostic modality of choice. This case highlights the need to consider actinomycosis in the differential diagnosis of unilateral tonsillar hypertrophy.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bhargava D, Bhusnurmath B, Sundaram KR, Raman R, Al Okbi HM, Al Abri R, et al. Tonsillar actinomycosis: A clinicopathological study. Acta Trop 2001;80:163-8.  Back to cited text no. 1
    
2.
Soler Sendra A, Subirana Pozo FX, Consola Maroto B, Serra Carreras J, Cuquet Pedragosa J. Tonsillar actinomycosis manifested as expectorated debris. Acta Otorrinolaringol Esp 2009;60:372-4.  Back to cited text no. 2
    
3.
Assimakopoulos D, Vafiadis M, Askitis P, Sivridis E, Skevas A. The incidence of actinomyces Israeli colonization in tonsillar tissue. A histopathological study. Rev Stomatol Chir Maxillofac 1992;93:122-6.  Back to cited text no. 3
    
4.
Mohamad I. Actinomyces in the tonsils: Hospital university Saints Malaysia experience. Internet J Otorhinolaryngol 2009;8:1-4.  Back to cited text no. 4
    
5.
Gaffney R, Harrison M, Walsh M, Sweeney E, Cafferkey M. The incidence and role of actinomyces in recurrent acute tonsillitis. Clin Otolaryngol Allied Sci 1993;18:268-71.  Back to cited text no. 5
    
6.
Mohanty S. Actinomycosis of faucial tonsil masquerading as oropharyngeal malignancy. Indian J Otolaryngol Head Neck Surg 2006;58:82-4.  Back to cited text no. 6
    
7.
Rippon JW. Medical Mycology. Philadelphia: W.B. Saunders; 1974. p. 13-28.  Back to cited text no. 7
    
8.
Schwartz HC, Wilson MC. Cervicofacial actinomycosis following orthognathic surgery: report of 2 cases. J Oral Maxillofac Surg 2001;59:447-9.  Back to cited text no. 8
    
9.
Belmont MJ, Behar PM, Wax MK. Atypical presentations of actinomycosis. Head Neck 1999;21:264-8.  Back to cited text no. 9
    
10.
Nagler R, Peled M, Laufer D. Cervicofacial actinomycosis: A diagnostic challenge. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:652-6.  Back to cited text no. 10
    
11.
Yadav SP, Chanda R, Gathwala G, Yadav RK. Actinomycosis of tonsil masquerading as tumour in a 12-year old child. Int J Pediatr Otorhinolaryngol 2002;63:73-5.  Back to cited text no. 11
    
12.
Aydin A, Erkiliç S, Bayazit YA, Koçer NE, Ozer E, Kanlikama M, et al. Relation between actinomycosis and histopathological and clinical features of the palatine tonsils: A comparative study between adult and pediatric patients. Rev Laryngol Otol Rhinol (Bord) 2005;126:95-8.  Back to cited text no. 12
    
13.
Morikawa I, Shin T, Watanabe H, Matsuo K, Yukizane K. Actinomycosis originating from palatine tonsil and its diagnosis. (in Japanese) Otologia Fukuoka 1985;31:382-86.  Back to cited text no. 13
    
14.
Bennhoff DF. Actinomycosis: Diagnostic and therapeutic considerations and a review of 32 cases. Laryngoscope 1984;94:1198-217.  Back to cited text no. 14
    
15.
Smego Jr., RA, Foglia G. Actinomycosis. Clin Infect Dis 1998;26:1255-63.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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