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Section Editor: Albert C. Yan, MD
Assistant Section Editor: Samir S. Shah, MD

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Arch Pediatr Adolesc Med. 2006;160(12):1298. doi:10.1001/archpedi.160.12.1298.
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DENOUEMENT AND DISCUSSION: TONSILLAR ACTINOMYCOSIS

Tonsillar actinomycosis was diagnosed in an otherwise healthy adolescent girl. Tissue histopathologic examination revealed amorphous fragments composed of slender filaments. Gram stain and Gomori methamine silver fungal stain confirmed the presence of gram-positive bacilli and granules compatible with actinomycosis. Staining for acid-fast bacilli was negative. Diagnostic evaluation was performed to locate the source of the granules. Neck and chest radiographs were normal and sputum cytologic results were negative. Direct laryngobronchoscopy revealed enlarged tonsils with copious amounts of thick particulate material in the crypts of the right tonsil.

She remained symptomatic despite 6 weeks of oral amoxicillin therapy. Subsequently, tonsillectomy was performed, and postoperatively, she stopped coughing up debris and had no further choking spells. She completed 6 months of amoxicillin therapy. She has remained well and has not expectorated any further masses.

Actinomyces species are strictly anaerobic, gram-positive, nonsporulating bacteria that are considered part of the normal flora of the mouth and gastrointestinal tract. Actinomycosis can involve virtually any anatomical site.1,2 Infections are typically indolent and spread contiguously, crossing soft-tissue planes and organs with ultimate formation of draining sinus tracts. Cervicofacial infections, otherwise known as “lumpy jaw,” are the most common and frequently follow tooth extraction, oral surgery, or facial trauma.2,3

Actinomycosis of the tonsils is a rare and poorly defined clinical entity. The presence of Actinomyces species in both inflamed and uninflamed tonsils has been recognized.4 Pransky et al5 reviewed histologic preparations from 460 patients undergoing tonsillectomy or adenotonsillectomy for recurrent tonsillitis or obstructive tonsillar hypertrophy. Actinomycetes were more prevalent in the tissues of patients with obstructive tonsillar hypertrophy. Actinomycosis was diagnosed in a 12-year-old girl who presented with difficulty swallowing for 3 months and had a tonsillar mass suggestive of a tumor.6 Cervicofacial actinomycosis may rarely present as acute upper respiratory tract obstruction requiring urgent airway management.7 To our knowledge, only 1 previous case of tonsillar actinomycosis presenting with a history of expectorating debris has been reported.8 That was of an adult who complained of chronic productive cough for 3 months. He had 1 episode of expectorating a small whitish mass. Histologic examination revealed Actinomyces species. The patient was treated with a course of oral phenoxymethylpenicillin with no further episodes. The symptoms in our patient were more pronounced since she was producing larger masses and more often and some of her coughing episodes were associated with significant choking. The coughing episodes and foreign body sensation were probably induced by aspirating or swallowing the masses that were formed in the right tonsil.

The optimal treatment of tonsillar actinomycosis is not clear. Although a patient may respond to antibiotic treatment,8 it is not clear if antibiotic treatment alone without surgical intervention is adequate. Our patient did not respond to antibiotic therapy alone and required tonsillectomy to clear the infection. Other forms of actinomycosis are usually treated with high-dose intravenous penicillin G or ampicillin for 4 to 6 weeks followed by high doses of oral penicillin, amoxicillin, erythromycin, clindamycin, minocycline, or tetracycline for a total of 6 to 12 months. However, surgical resection of the lesions and debridement of surrounding tissues and draining sinuses is necessary in most cases.2,3,9,10

Tonsillar actinomycosis should be considered in patients presenting with coughing associated with expectoration of particulate material. Tonsillectomy may be required in those patients who fail to respond to antibiotic treatment.

Correspondence: Hossam Al-Tatari, MD, Division of Pediatric Infectious Diseases, Children's Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI 48201 (haltatari@dmc.org).

Accepted for Publication: February 7, 2006.

Author Contributions:Study concept and design: Al-Tatari. Acquisition of data: Al-Tatari, Abdel-Haq, Asmar, Haupert, and Rabah. Analysis and interpretation of data: Al-Tatari, Abdel-Haq, and Asmar. Drafting of the manuscript: Al-Tatari, Abdel-Haq, and Asmar. Critical revision of the manuscript for important intellectual content: Al-Tatari, Abdel-Haq, Asmar, Haupert, and Rabah. Study supervision: Al-Tatari, Abdel-Haq, Asmar, Haupert, and Rabah.

Financial Disclosure: None reported.

Bhargava  DBhusnurmath  BSundaram  KR  et al.  Tonsillar actinomycosis: a clinicopathological study Acta Trop 2001;80163- 168
PubMed Link to Article
Richtsmeier  WJJohns  ME Actinomycosis of the head and neck CRC Crit Rev Clin Lab Sci 1979;11175- 202
PubMed Link to Article
Miller  MHaddad  AJ Cervicofacial actinomycosis Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85496- 508
PubMed Link to Article
Gaffney  RHarrison  MWalsh  MSweeney  ECafferkey  M The incidence and role of actinomyces in recurrent acute tonsillitis Clin Otolaryngol 1993;18268- 271
PubMed Link to Article
Pransky  SMFeldman  JIKearns  DBSeid  ABBillman  GF Actinomycosis in obstructive tonsillar hypertrophy and recurrent tonsillitis Arch Otolaryngol Head Neck Surg 1991;117883- 885
PubMed Link to Article
Yadav  SPChanda  RGathwala  GYadav  RK Actinomycosis of tonsil masquerading as tumour in a 12-year old child Int J Pediatr Otorhinolaryngol 2002;6373- 75
PubMed Link to Article
Balatsouras  DGKaberos  AKEliopoulos  PNKandiloros  DEconomou  CN Cervicofacial actinomycosis presenting as acute upper respiratory tract obstruction J Laryngol Otol 1994;108801- 803
PubMed Link to Article
Blackburn  LMGreen  ST Tonsillar actinomycosis presenting as expectorated debris J Infect 1997;34283- 284
PubMed Link to Article
Lockhart  GRWilliams  GPGilbert-Barness  E Pathological case of the month: thoracic and abdominal actinomycosis AJDC 1993;147317- 318
PubMed
Lippes  J Pelvic actinomycosis: a review and preliminary look at prevalence Am J Obstet Gynecol 1999;180265- 269
PubMed Link to Article

Figures

Tables

References

Bhargava  DBhusnurmath  BSundaram  KR  et al.  Tonsillar actinomycosis: a clinicopathological study Acta Trop 2001;80163- 168
PubMed Link to Article
Richtsmeier  WJJohns  ME Actinomycosis of the head and neck CRC Crit Rev Clin Lab Sci 1979;11175- 202
PubMed Link to Article
Miller  MHaddad  AJ Cervicofacial actinomycosis Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85496- 508
PubMed Link to Article
Gaffney  RHarrison  MWalsh  MSweeney  ECafferkey  M The incidence and role of actinomyces in recurrent acute tonsillitis Clin Otolaryngol 1993;18268- 271
PubMed Link to Article
Pransky  SMFeldman  JIKearns  DBSeid  ABBillman  GF Actinomycosis in obstructive tonsillar hypertrophy and recurrent tonsillitis Arch Otolaryngol Head Neck Surg 1991;117883- 885
PubMed Link to Article
Yadav  SPChanda  RGathwala  GYadav  RK Actinomycosis of tonsil masquerading as tumour in a 12-year old child Int J Pediatr Otorhinolaryngol 2002;6373- 75
PubMed Link to Article
Balatsouras  DGKaberos  AKEliopoulos  PNKandiloros  DEconomou  CN Cervicofacial actinomycosis presenting as acute upper respiratory tract obstruction J Laryngol Otol 1994;108801- 803
PubMed Link to Article
Blackburn  LMGreen  ST Tonsillar actinomycosis presenting as expectorated debris J Infect 1997;34283- 284
PubMed Link to Article
Lockhart  GRWilliams  GPGilbert-Barness  E Pathological case of the month: thoracic and abdominal actinomycosis AJDC 1993;147317- 318
PubMed
Lippes  J Pelvic actinomycosis: a review and preliminary look at prevalence Am J Obstet Gynecol 1999;180265- 269
PubMed Link to Article

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