Title: Colonies of Actinomyces in bilateral tonsils operated for halitosis, sore throat
and bilateral tonsillar hypertrophy - A causal or casual finding?
Abstract:
Actinomycosis of the tonsillar crypts, though not uncommon, is relatively infrequent
nowadays. It is caused by the branching filamentous gram positive bacteria belonging to
the Actinomycosis family. Known inhabitants of the oral cavity, hence poor dental
hygiene and oro-facial injury may predispose to symptomatic disease. Their importance
lies in the fact that they may have varied presentations ranging from suppurative lesions
to those mimicking oropharyngeal malignancies. Hence identification of this organism is
important for specific treatment strategies. The question whether their presence in
colonies in tonsil is incidental or causative for tonsillar lesions is still not definitely
solved. Here we describe a young patient presenting with halitosis, sore throat, recurrent
tonsillitis and bilateral tonsillar hypertrophy. The histopathology of the tonsillectomy
specimen revealed colonies of Actinomyces in bilateral tonsillar crypts, along with
cryptitis and reactive lymphoid hyperplasia.
Key words: Actinomycosis; tonsil; bilateral; halitosis; hypertrophy; tonsillectomy
Sir,
Actinomycosis infections of head and neck region are caused by various species of
tangled, filamentous, gram-positive bacteria belonging to the Actinomycosis family, of
which the most common human pathogen is Actinomyces israelii 1. In 55% they involve
the cervicofacial region, in 20% thoracic, and in 15% abdomino-pelvic. Actinomyces
colonizing tonsillar crypts has been described in 6.7-35% of tonsillectomy specimens1,2,
while some other studies proposed an even wider range3,4,5. Nevertheless, their
importance lies in the fact that they may have varied spectrum of presentations ranging
from mere commensals to suppurative, necrotic or fibrotic lesions to even those
simulating oropharyngeal malignancies6, 7. ‘Ray fungus’ as previously called (‘mycosis’
derived from the Greek word ‘mykes’), the first case of human actinomycosis was
reported by Von Langenbeck in 1845. In 1960’s Waksman showed that actinomyces is
actually a gram-positive bacteria, forming colonies that mimic branched networks of
fungal hyphae3. Here, we report a case of 28-year old male patient presenting with
malodor, sore throat and recurrent bouts of tonsillitis for the last four years. On
examination bilateral tonsils were hypertrophied and covered with thick grey white
slough. Investigations including those for immune status were all within normal limits,
except for mild neutrophilic leucocytosis (13,500/cu.mm) and mild anemia (hemoglobin:
10.5 gm/dl). The patient was put on oral antibiotics comprising of amoxycillin and
clavulenic acid, and an interval tonsillectomy by intraoral approach was done to alleviate
the recurrent symptoms. Bilateral tonsils were removed from the tonsillar bed; the patient
had an uneventful recovery with no intraoperative or postoperative hemorrhage.
Amoxycillin clavulenic acid, initially intravenous and replaced later by oral therapy,
along with chorhexidine mouthwash and oral hygiene reinforcement were continued, and
complete healing took place in two weeks duration.
Microscopic examination of the excised bilateral tonsillar tissue showed squamous
hyperplasia of the surface epithelium, with focal ulceration. Underlying lymphoid tissue
had evidence of reactive hyperplasia with prominent germinal centers; scattered
neutrophils and cryptitis were also seen. Radiating, amorphous, faintly hematoxyphilic,
large colonies morphologically in accordance with Actinomyces were seen, adherent to
the surface epithelium and invading the crypts. The periphery of these colonies showed
branched fungi-like configuration (Figure 1). The colonies were Gram positive, as well as
Periodic Acid Schiff (PAS) positive (Figure 2).
Actinomyces show fermentative type of carbohydrate metabolism; special requirements
for successful culture of the organism include avoidance of contamination, strict
anaerobic conditions or under increased carbon dioxide (5% CO2) tension and prolonged
culturing (7-14 days) at 36⁰C±1⁰C. Enriched media for aerobic incubation include sheep
blood agar, peptone yeast extract glucose (PYG) or brain heart infusion (BHI) broth. For
anaerobic incubation, Schaefer agar, Tarozzi broth, or kanamycin-vancomycin blood agar
(KV agar) may be used. Filamentous organisms are identified to species or group level by
use of appropriate bacteriological methods, like Gram staining and gas liquid
chromatography (GLC) analysis of the acid fermentation end products8.
While some authors9 believe that Actinomycosis may have a damaging role to the tonsils,
most of the others
3,4
opine that they are common saprophytes in this tonsillar area.
However, the organism becomes pathogenic in devitalised tissue with reduced oxygen
tension10. Precipitating factors like dental caries, dental manipulations, maxillofacial
trauma, foreign bodies, radiotherapy, diabetes mellitus and last but not the least, poor
dental hygiene, as seen in this patient, are known to cause disease in cervico-facial
region. Disruption of the mucosal barrier of the tonsil is required for the bacteria to
become infective and cause disease. Hyperplastic squamous lining with surface
ulceration, cryptitis, organisms deep into the tonsillar lymphoid tissue, and bilateral
hypertrophy in this patient favor of a causal (etiological) rather than a casual (incidental)
finding. Treatment may be carried out by intravenous penicillin G; amoxicillin with or
without clavulenic acid, imipenem, clindamycin, ceftriaxone, vancomycin, rifampicin,
erythromycin, or doxycycline may be used as alternative drugs, some of which in case of
penicillin allergy10. Treatment should be individualized, with surgery as an adjuvant to
long term antibiotics for abscess, fistula, cavity formation, or deep seated infections1.
Initial intravenous formulation is replaced by oral therapy till complete healing of the
lesion. Tonsillectomy may be considered in cases of hypertrophy to the point of
pharyngeal obstruction, frequent recurrent tonsil infections, with or without peritonsillar
abscesses7. In this patient tonsillectomy was done for recurrent tonsillitis, sore throat and
bilateral hypertrophy, refractory to antibiotic treatment; diagnosis was established by
histological examination of the excised tonsils.
To conclude, though a known commensal, Actinomycosis may have an etiological role in
long standing symptomatic tonsillar lesions refractory to antibiotic treatment. A high
level of clinical inspection and identification is of utmost importance because of the
capacity of the resultant lesions to masquerade as malignancy. Prolonged antibiotics
combined with surgery may be required. Hence, a surgical, pathological and
microbiological team effort is necessary for a satisfactory outcome.
References:
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Legends:
Figure 1: Microphotograph showing follicular tonsillitis with colonies of Actinomyces
(arrow) (Hematoxylin and Eosin stain, 100x magnification); Inset: higher magnification
of the periphery of the colonies showing filamentous branched, hyphae-like structures
(Hematoxylin and Eosin stain, 400x magnification).
Figure 2: Microphotograph showing PAS positive colonies of Actinomycosis invading
into the tonsillar lymphoid tissue (Periodic Acid Schiff stain, 400x magnification).