| Abstract|| |
Actinomycosis is a chronic infection caused by Actinomyces israelii, usually seen in immunocompromised patients or in the background of tissue injury. Cervicofacial actinomycosis presenting as a fixed jaw swelling in an elderly individual can mimic malignancy and pose a diagnostic dilemma. We report here a case of cervicofacial actinomycosis diagnosed by fine needle aspiration, along with a review of the relevant literature. A 60 year-old man presented with a gradually increasing 6 × 5 cm swelling in the left side of his jaw. The swelling was fixed, without any apparent sinus or abscess. Fine needle aspiration was diagnostic as it revealed colonies of actinomyces surrounded by polymorphs and chronic inflammatory cells. The histopathological study of the excised specimen confirmed the cytological findings. Fine needle aspiration is an effective tool in the diagnosis of actinomycosis although its documentation is rare. Difficulties in the management can be avoided by early diagnosis using the fine needle aspiration technique.
Keywords: Actinomycosis; cervicofacial; fine needle aspiration.
|How to cite this article:|
Venkatesh K, Saini ML, Niveditha S R. Fine needle aspiration cytology of cervicofacial actinomycosis. J Cytol 2008;25:113-4
| Introduction|| |
Actinomycosis is an uncommon bacterial infection nowadays. It is usually found in the tropical and subtropical areas of the world, primarily in immunocompromised patients. Actinomycosis is a chronic suppurative disease caused by Actinomycosis israelii in human beings. The infection is also seen in cattle, dogs and cats.  Fine needle aspiration diagnosis of actinomycoses is rare although the infection is well documented in exfoliative cytology in relation to intrauterine device users.  We report here a case of cervicofacial actinomycosis masquerading clinically as malignancy and diagnosed by fine needle aspiration cytology.
| Case Report|| |
A 60 year-old male presented with a gradual enlargement of a left-sided neck mass. The mass was of 6 × 5 cm size, firm-to-hard, and was fixed to the underlying soft tissue. The age of the patient and history of smoking coupled with the presence of a hard, fixed mass raised the suspicion of a malignancy. On local examination, the skin was found to be smooth and there was no apparent abscess or discharging sinus; general examination revealed a well preserved male. Fine needle aspiration yielded a moderate amount of a yellowish, blood-tinged aspirate. The slides were stained with Papanicolaou and Giemsa stains; Ziehl Neelsen stain was also done to rule out tuberculosis. The smears showed colonies of actinomyces with radiating filaments showing an intense basophilic staining on Papanicolaou staining. The colonies showed occasional branching and were surrounded by radiating, hyaline, eosinophilic material representing the Splendore Hoeppli phenomenon [Figure 1]. A neutrophilic exudate was also present along with lymphocytes and other chronic inflammatory cells. The Ziehl Neelsen stain was negative for acid-fast bacilli. A diagnosis of actinomycosis was made and excision was advised. The excised specimen also revealed abscesses with actinomycotic colonies surrounded by chronic granulation tissue. The patient responded well to a course of penicillin.
| Discussion|| |
Actinomyces organisms are commensals in the oral cavity and alimentary canal. The common clinical presentations are cervicofacial, thoracic, and abdominal.  Actinomycosis is also seen as a genital infection in females, particularly those with history of intrauterine contraceptive device usage. Apart from these sites, the infection has also been reported in the testis  and liver.  Cranial and intracranial actinomycosis have also been reported by Sundaram et al . 
Actinomyces are gram-positive anaerobes belonging to the order of higher bacteria which include mycobacteriaceae and streptomyceae . Cytologically, actinomyces colonies appear as amorphous basophilic clumps on Papanicolaou staining, referred to as "Gupta bodies".  These clumps show numerous, uniformly thick filaments which extend to the margin of the clumps.
Hematoxylin and eosin-stained sections show colonies of filamentous actinomyces bacteria with peripherally situated, radiating, hyaline eosinophilic material representing the 'Splendore Hoeppli' phenomenon. There is dense polymorphonuclear infiltration around each colony, surrounded by chronic granulation tissue. Other stains which can be used to identify the organisms are Gram and silver stains. Polymerase chain reaction using the 16S ribosomal RNA gene amplification has been developed for the diagnosis of actinomycosis. 
Actinomyces is an endogenous infection found predominantly in the tonsils and carious teeth. The organisms can invade gingival tissue and produce an inflammatory reaction, giving rise to a lumpy jaw.  The disease starts as a suppurative, inflammatory process and then proceeds on to become a chronic inflammatory lesion. It spreads through direct contact, causing formation of multiple abscesses, which either fuse together or remain discrete due to the formation of fibrous septa between them. These abscesses discharge multiple pinhead-sized, yellowish sulphur granules in the pus, which is a characteristic feature of this disease. Bones can be involved in cases of chronic infections which receive inadequate treatment or are misdiagnosed. Radiographs show spheroidal, radiolucent lesions associated with periosteal reaction, indicating new bone formation.  The infection can be treated effectively with beta-lactam agents combined with beta-lactamase inhibitors.  The abscesses need to be drained and the affected bone should be curetted to debride any necrotic tissue.
Actinomycosis is a disease of low pathogenicity, occurring predominantly in immunocompromised individuals. The infection has myriad presentations, sometimes mimicking malignancy. Therefore, an early diagnosis by fine needle aspiration cytology is warranted for effective antibiotic therapy and surgical resection.
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Monika Lamba Saini
Department of Pathology, Kempegowda Institute of Medical Sciences and Research Centre, Bangalore - 560 004
Source of Support: None, Conflict of Interest: None