Fawad Muzaffar, Majid Suhail, Zaheer Iqbal Awan, Simeen Ber Rehman.
Primary cutaneous Actinomycosis.
Pak Armed Forces Med J Jan ;55(2):172-3.

A 45-year-old male presented with the complaints of multiple sinus formation with scarring and purulent discharge over both shoulders for the last eight years. According to the patient eight years earlier, he developed a febrile illness. He underwent treatment for this at a clinic in his village run by a dispenser. He received intra-muscular injections into both deltoid muscles on multiple occasions. On dermatological examination, the right shoulder revealed a large atrophic plaque, 19 x 12 cm in size with puckered scars while the left shoulder revealed a 26 x 14 cm atrophic plaque with two discharging sinuses. The sinuses were composed of exuberant granulation tissue and discharged yellowish pus.The regional lymph nodes were not enlarged. On investigation, blood counts, chemistry andradiological examination of the chest, jaw and underlying bones were normal. Examination of the pus by direct microscopy revealed sulphur granules. A KOH mount was prepared which was negative for fungal hyphae. A skin biopsy specimen for histopathology revealed epidermal hyperplasia with multiple abscesses in the dermis with sheets of neutrophils. Granular colonies of gram positive staining microorganisms surrounded by chronic inflammatory infiltrate and fibrosis in the mid dermis as well as the classic `ray fungus` were seen. Tissue specimen and pus were incubated on Sabouraud`s medium and blood agar but no bacterial or fungal growth was seen. On the basis of clinical picture, presence of sulphur granules and a consistent histopathological picture, a diagnosis of primary cutaneous actinomycosis was made. It was most likely due to intramuscular injections using contaminated needles.

PakMediNet -Pakistan's largest Database of Pakistani Medical Journals - http://www.pakmedinet.com