Sir,
We present a case of a 31-year-old school teacher who presented with nonhealing recurrent exophytic lesions on ventral aspect of wrist over the past two years; associated with an occasional granular discharge which would stop by itself. There was no history of any systemic diseases, trauma, or intrauterine device use.[1,2]
Examination showed an open wound with heaped margins and an inflamed base on the ventral aspect of wrist [Figure 1]. Clinical differentials included fungal infection, tuberculosis, and malignancy. Malignancy was least possible because of slow course and absence of systemic symptoms. Since the last 1½ years, she had been prescribed erythromycin, gentamycin, and fluconazole for varying durations but was relieved by none. Six months back, an HRUSG of the wrist was done which revealed a heterogeneous, heteroechoic SOL measuring 48 mm × 22 mm with internal components, mild vascularity, and involving the tendons of flexor compartment of wrist. Biopsy performed at the same time showed “sinus tract lined by granulation tissue.”
Figure 1.
Clinical picture flexor aspect wrist
Starting afresh investigations, we found culture of discharge was negative for fungal elements, Ziehl–Neelsen and Auramine stains negative and erythrocyte sedimentation rate 45 mm in 1st h. X-ray wrist showed uninvolved radius and ulna [Figure 2].
Figure 2.
X-ray wrist showing normal bones
Repeat biopsy in our department showed fibrocollagenous tissue partially lined by unremarkable stratified squamous epithelium, diffusely infiltrated by polymorphs, plasma cells, lymphocytes, and multinucleated histiocytes forming ill-defined granulomas [Figure 3] around eosinophilic globular fibrillary structures (granules) and numerous proliferating capillaries, without necrosis or atypia. Diagnosis of “Actinomycosis of skin and subcutis” was rendered and the patient is responding well to intravenous penicillin injection prescribed for 6 months.
Figure 3.
View of basophilic granules with radiating eosinophilic structures and surrounding granulomatous inflammation (H and E, ×100)
Actinomycosis is a rare bacterial infection caused by Actinomyces israelii, Actinomyces viscosus, and other species like Propionibacterium propionicus, which normally inhabit certain body regions but are dormant unless they break the lining. Common sites of involvement are cavities such as mouth, nose, throat, lungs, stomach, and intestine.[1,3] The discharging sinus with oozing of yellow granular material is almost a hallmark of clinical presentation of actinomycosis.[2] The wrist is an uncommon site for this infection.[1] Since it is not contagious and is slowly evolving, diagnosis is usually delayed, and by the time targeted treatment begins, the patient has already had several antibiotics, however without any benefit.[4]
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References
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