- Case report
- Open Access
- Open Peer Review
Actinomycosis of the parotid masquerading as malignant neoplasm.
- Bipin T Varghese1Email author,
- Paul Sebastian1,
- K Ramachandran2 and
- Manoj Pandey1
https://doi.org/10.1186/1471-2407-4-7
© Varghese et al; licensee BioMed Central Ltd. 2004
- Received: 09 October 2003
- Accepted: 04 March 2004
- Published: 04 March 2004
Abstract
Background
Primary actinomycosis of the parotid gland is of rare occurrence and can mimic a malignant neoplasm both clinically as well as radiologically.
Case presentation
We present here a case of primary actinomycosis of the parotid gland presenting with a parotid mass lesion with erosion of skull bones.
Conclusions
Clinical presentation of cervico-facial actinomycosis is characterized by the presence of a suppurative or indurative mass with discharging sinuses. The lesion demonstrates characteristic features on fine needle aspiration cytology and histology, however at times the findings are equivocal.
Keywords
- Actinomycosis
- salivary gland
- parotid
- infection
- tumour
- pseudotumour
Background
Although cervico-facial actinomycosis is well described, primary actinomycosis of the parotid gland is rare. Actinomycosis was considered to be the commonest of all deep mycotic infections or mycetomas in the past [1]. However now it is well established that it is a granulomatous lesion characterized by chronic suppuration usually caused by Actinomyces israelii which is a gram positive, non-acid fast, anaerobic, commensal bacteria within the oral cavity (tonsillar crypts and tartar of teeth). Unlike most of the mycotic infections, actinomycosis is not an opportunistic infection and the portal of entry is not through inhalation. Actinomycosis usually occurs in healthy individuals when the local condition favours its growth and very often, it is a mixed bacterial growth [2]. It commonly affects the facial soft tissue although it can spread to adjacent, salivary gland, bone, and skin of face and neck. Primary actinomycosis of the parotid gland is very rare and can mimic malignancy [3].
The diagnosis of this rare condition can be reasonably made empirically even when conclusive histological or microbiological evidence is not available. A case of primary actinomycosis of the parotid gland, which was diagnosed by its clinical features, radiological findings and its response to empirical medical management, is presented.
Case presentation
Clinical photograph of the patient at initial presentation showing the parotid swelling.
Clinical photograph of the patient (left profile) at presentation showing parotid swelling and the draining sinuses.
CT scan showing mass in the parotid region with erosion of the base of skull, suggestive of a malignant parotid neoplasm.
CT scan showing the mass lesion in the parotid region with extension into left parapharyngeal space and thinning of lateral wall of maxilla.
Fine needle aspiration cytology (FNAC) of the parotid swelling and the neck node showed dense collections of neutrophils and macrophages with phagocytic activity, suggesting a chronic inflammatory process. Incision biopsy of the nodule with underlying parotid tissue showed salivary gland tissue with periductal lymphocytic infiltration in some of the ducts and adipose tissue, muscle bundles, sheets of lymphocytes, histiocytes, plasma cells, neutrophils and necrosis, suggestive of chronic sialadenitis. No fungal hyphae or bacteria or spores could be demonstrated in either the FNAC or in biopsy. AFB staining was negative.
Clinical photograph showing the full face of the patient after completion of the treatment, Regression of the parotid swelling can be appreciated
Clinical photograph (left profile) of the patient after completion of the treatment showing the healed sinuses.
Discussion
Differential Diagnosis of Painless parotid mass
Parotid Neoplasms |
Benign |
Malignant |
Chronic Suppurative diseases |
Mixed Infections / Actinomycosis |
Granulomatous diseases |
Tuberculosis |
Leprosy |
Cat scratch disease |
Syphilis |
Mycotic Infections |
Histoplasmosis |
Coccidiomycosis |
Cryptococcosis |
Mucormycosis |
Osteomyelitis |
Branchial cleft cyst |
Parapharyngeal Tumours |
Recognized routes of entry for cervico-facial actinomycosis include caries tooth, tooth extraction site and tonsils. It can also occur as a complication of trauma to respiratory and digestive tracts including operative procedures. Infection usually starts in the subcutaneous and submucous tissues and spreads by direct continuity [1, 2].
Clinical presentation of cervico-facial actinomycosis is characterized by the presence of a suppurative or indurative mass with discharging sinuses. Pus from the discharging sinuses contains tiny yellow sulphur granules, which are diagnostic [1]. Common initial symptoms of infection including pain, fever, erythema, oedema, and suppuration may be absent [5]. Histopathological feature are similar to that of chronic inflammatory disease. FNAC and exfoliative cytology may demonstrate Curshmann's spirals and actinomycetes filaments in fortuitous cases [7].
Ultrasound and radiological investigations fail to differentiate them from malignancy, although conventional sialography or computerised tomography (CT) with sialography has been suggested to present a consistent pattern in infections [8]. A CT scan finding of soft tissue and bony invasion, simulating malignant neoplasm, helps in distinguishing actinomycosis from other suppurative or granulomatous masses.
Drug of choice is penicillin or tetracycline. Anaerobic cultures may be helpful in selecting the appropriate antibiotic in refractory cases. Treatment is essentially medical with adjuvant surgical procedures like incision and drainage, and wound toilet [9–11]. A high index of clinical suspicion and negative tissue diagnosis of malignancy is the key to a presumptive diagnosis of this rare condition.
Declarations
Acknowledgement
Written consent was obtained from the patient for publication of the patient's details.
Authors’ Affiliations
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- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2407/4/7/prepub
Pre-publication history
Copyright
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