A 78-Year-Old Man With a Lingual Ulcerative Lesion

Talib A. Najjar, DMD, MDS, PhD; Prabhjot Singh, DDS

Disclosures

July 21, 2016

Clinical findings that are commonly seen in actinomycosis infection include suppuration, draining sinuses, fistulas, and the presence of "sulfur granules" (small, white-yellow granular aggregates of bacterial filaments) in exudates or tissues. In patients with cervicofacial actinomycosis, there is a high tendency for poor dental hygiene, caries, oral trauma, dental extraction, or dental abscess. The oral condition in this patient was conducive to the development of actinomycosis.

A typical clinical presentation is a hard, "woody" swelling in the mandible and neck; an associated abscess may be present in contiguous soft tissue. Ulceration and induration in the tongue were noted in this patient, but no evidence suggested abscess formation, fistula tract, or sulfur-granule exudate. Pain and mild pyrexia are usually present in these cases, and sinus tracts may occur in long-standing disease.

Classically, the infection presents as a slowly enlarging and slightly tender swelling that may become indurated as a result of fibrosis and scar formation. The fibrosis may play an important role in the pathogenicity of the infection, because the microorganisms are virtually protected from the host defense; therefore, they are more resistant to antibiotics.

The pathogenicity ranges from an acute form, with rapid onset and purulent drainage from multiple sinus tracts, to a slowly progressing chronic form characterized by indurated fibrosis with little suppuration. The lesion in this patient fell into the latter category, with induration, fibrosis, and ulceration of the lingual mucosa. The infection usually occurs from a few weeks to a few months after the organism penetrates through the oral portal of entry (such as a facial bone fracture, periodontal socket, extraction site, pericoronitis, periapical inflammation, root canal treatment, or periodontal surgery).[1,2,3,4]

Histologically, actinomycotic lesions are characterized by mixed suppurative and granulomatous inflammatory changes. Proliferation of the connective tissues and the presence of sulfur granules are noted. Under the microscope, sulfur granules may appear cauliflower-like at low magnification, whereas at higher magnification the inflammatory reaction can be seen. These granules may be visualized in preparation of the biopsy specimen while the test tubes are being rotated manually. They can also be identified by washing sampled material and crushing it between a slide and coverglass after it has been Gram-stained. With Gram staining, these microcolonies contain gram-positive, filamentous or branching bacteria.

Occasionally, companion bacteria may be observed. Stressing that similar granules can be found in other bacterial infections, such as Nocardia infection and botryomycosis, is important. Botryomycosis is an S aureus infection that mimics actinomycosis. Infection with Nocardia may be differentiated from that with Actinomyces because it is acid-fast when stained. Gel diffusion methods and fluorescent antibody tests (immunofluorescence with fluorescein isothiocyanate antiserum) are also helpful because they can differentiate A israelii from other filamentous anaerobes that produce granules in tissue. They can be used retrospectively with formalin- and paraffin-embedded biopsy specimens.

Biopsies of the granulomatous lesion or of the fistula are especially useful when no purulent material is present and when the diagnosis remains unclear despite laboratory evaluation. In the absence of absolute bacterial identification from culture, the diagnosis must rely on the clinical presentation and histopathologic findings.[4]

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