Laryngeal actinomycosis mimicking relapse of laryngeal carcinoma in a 67-year-old man

Description

A 67-year-old man, a heavy smoker with a history of myocardial infarction, was followed up for a T3N2M0 laryngeal carcinoma. After primary chemotherapy, lateral pharyngo-laryngectomy was performed, followed by radiotherapy. Two-years later, mild dyspnoea at rest appeared and a relapse was suspected, as an ulcerated lesion with oedema was detected during endoscopy (figure 1A). Pathological examination of biopsies revealed cartilage suppurative necrosis with sulphur granules (figure 1C) and filamentous Gram-positive fungal-like pathogen (figure 1D). Actinomyces odontolyticus grew in bacterial cultures. Oral amoxicilline (6 g/day) was prescribed. One month later, the laryngeal lesion disappeared (figure 1B). The antimicrobial therapy was prolonged to 3 months. No relapse occurred during the follow-up.

Figure 1.

Endoscopy aspect of the larynx before (A; showing a limited ulceration with mucosal oedema) and after one month of amoxicillin therapy (B). Pathological examination of the biopsies revealing cartilage suppurative necrosis with sulfure granules (C, arrow; Hematoxylin Erythrosine Saffron staining, X40) and filamentous Gram-positive fungal-like pathogen (D, arrow; ×100).

Actinomyces spp. are fastidious organisms that belong to the commensal oral flora.¹ Cervicofacial actinomycosis is a chronic infectious disease usually associated with neglected dental infections or oro-maxillo-facial trauma, resulting in direct and progressive mucosal invasion of Actinomyces spp. Typically, actinomycosis is associated with large slow-progressive multiple abscess formations with draining sinus tracts.¹ Laryngeal actinomycosis is poorly described, as ∼20 cases are reported in the literature only.^{2 3} It is noteworthy that most of patients, as in our case: (1) had a history of laryngeal carcinoma and radiotherapy and (2) presented with an ulceration mimicking laryngeal cancer relapse, neither with abscess nor sinus tract.^{2 3} Pathological analysis is of crucial importance for the diagnosis, as the bacterial cultures could be negative.¹ Surgery is not required for such limited lesion, as oral prolonged penicillin or amoxicillin therapy is usually associated with a successful clinical response.

Learning points.

Laryngeal actinomycosis:

• could be observed in patients with past history of laryngeal cancer and radiotherapy,

• may mimic cancer relapse, as the clinical presentation might be limited to a an ulcerated lesion, neither with abscess nor with sinus tract,

• usually respond well to prolonged penicillin or amoxicillin therapy.