Korean J Gastroenterol.  2017 Mar;69(3):191-195. 10.4166/kjg.2017.69.3.191.

Actinomycosis Involving Chronic Pancreatitis: A Case Report with Literature Review

• Yeo SJ
• Cho CM
• Jung MK
• Kim KJ
• Kim MH
• Cho SH
• Kim GC
• Seo AN

• KMID: 2383414
• DOI: http://doi.org/10.4166/kjg.2017.69.3.191

Abstract

Actinomycosis is a slowly progressive, chronic infectious disease. It is caused by the genus Actinomyces, which are gram-positive anaerobic bacteria. It presents as a mass-like lesion, composed of bacterial nidus and characteristic granulomatous inflammatory fibrosis. As such, it has frequently been mistaken for a malignancy. Surgical resection is a common procedure in these patients prior to a definite diagnosis. Although actinomycosis can occur in a variety of regions, including oral-cervicofacial, thoracic, and abdominopelvic cavities, the involvement of the pancreas is very rare. We report a case of a 44-year-old male with a symptomatic actinomycosis caused by a mass in the tail of the pancreas. The diagnosis was made using an endoscopic ultrasound-guided fine needle aspiration biopsy without surgical resection. After the treatment with antibiotics, the pancreatic mass was confirmed to be resolved on the follow-up computed tomography.

Keyword

Actinomycosis; Endosonography; Fine needle biopsy; Pancreas

MeSH Terms

Actinomyces
Actinomycosis*
Adult
Anti-Bacterial Agents
Bacteria, Anaerobic
Biopsy
Biopsy, Fine-Needle
Communicable Diseases
Diagnosis
Endoscopic Ultrasound-Guided Fine Needle Aspiration
Endosonography
Fibrosis
Follow-Up Studies
Humans
Male
Pancreas
Pancreatitis, Chronic*
Tail
Anti-Bacterial Agents

Figure

• 

  Fig. 1. Computed tomography scan images. (A) Multiple calcifications and stones (black arrows) were also noted in the head of the pancreas. (B) Contrast-enhanced axial image (portal phase) revealed diffuse parenchymal swelling with multiple calcification (black arrows) at the body of the pancreas. (C) Contrast-enhanced coronal image (portal phase) showed heterogeneous enhancement of the pancreas parenchyma and peripancreatic strands (white arrows). (D) Multifocal uneven pancreatic duct dilation (white asterisk) was also observed.

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  Fig. 2. Endoscopic ultrasonography (EUS) images. (A) A 19-mm sized, ill-defined, hypoechoic and heterogenous mass with central calcification was identified at the pancreatic tail. (B) EUS-guided fine needle aspiration biopsy using a 20-gauge needle was performed.

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  Fig. 3. Microscopic findings for the specimen. The specimen revealed sulfur granules, consisting of a conglomeration of filamentous bacteria, which was shown at the surrounding tissue with dense inflammatory infiltration by lymphocytes, neutrophils, and foamy macrophages (A, hematoxylin and eosin stain, ×100; B, hematoxylin and eosin stain, ×400).

• 

  Fig. 4. Computed tomography image. Contrast-enhanced axial image (portal phase) revealed remarkable regression of pancreatic inflammatory swelling and peripancreatic inflammatory infiltration.

Reference

References

1. Wong VK, Turmezei TD, Weston VC. Actinomycosis. BMJ. 2011; 343:d6099.

2. Garner JP, Macdonald M, Kumar PK. Abdominal actinomycosis. Int J Surg. 2007; 5:441–448.

3. Kim MC, Lee H, Park J, et al. A solitary pancreatic actinomycosis mimicking pancreatic cancer. Korean J Pancreas Biliary Tract. 2015; 20:130–135.

4. Lee JH, Lee KG, Oh YH, Park HK, Lee KS. Actinomycosis of the pancreas: a case report and review of the literature. Hepatogastroenterology. 2010; 57:358–361.

5. Maestro S, Trujillo R, Geneux K, et al. Pancreatic actinomycosis presenting as pancreatic mass and diagnosed with endoscopic ultrasound fine needle aspiration (EUS-FNA). Endoscopy. 2013; 45(Suppl 2 UCTN):E276–E277.

6. Piper MH, Schaberg DR, Ross JM, Shartsis JM, Orzechowski RW. Endoscopic detection and therapy of colonic actinomycosis. Am J Gastroenterol. 1992; 87:1040–1042.

7. Harsch IA, Benninger J, Niedobitek G, et al. Abdominal actinomycosis: complication of endoscopic stenting in chronic pancreatitis? Endoscopy. 2001; 33:1065–1069.

8. Kuesters S, Timme S, Keck T. Uncommon cause of an inflammatory pancreatic head tumor. Diagnosis: purulent actinomycosis and incidental T1-carcinoid of the pancreatic head. Gastroenterology. 2011; 141:e9–e10.

9. Somsouk M, Shergill AK, Grenert JP, Harris H, Cello JP, Shah JN. Actinomycosis mimicking a pancreatic head neoplasm diagnosed by EUS-guided FNA. Gastrointest Endosc. 2008; 68:186–187.

10. Hsu JT, Lo HC, Jan YY, Chen HM. Actinomycosis mimicking recurrent carcinoma after whipple's operation. World J Gastroenterol. 2005; 11:1722–1724.

11. Harris LA, DeCosse JJ, Dannenberg A. Abdominal actinomycosis: evaluation by computed tomography. Am J Gastroenterol. 1989; 84:198–200.

12. Lee IJ, Ha HK, Park CM, et al. Abdominopelvic actinomycosis involving the gastrointestinal tract: CT features. Radiology. 2001; 220:76–80.

13. Cintron JR, Del Pino A, Duarte B, Wood D. Abdominal actinomycosis. Dis Colon Rectum. 1996; 39:105–108.

14. Ferrari TC, Couto CA, Murta-Oliveira C, Conceição SA, Silva RG. Actinomycosis of the colon: a rare form of presentation. Scand J Gastroenterol. 2000; 35:108–109.

15. Weese WC, Smith IM. A study of 57 cases of actinomycosis over a 36-year period. A diagnostic ‘failure’ with good prognosis after treatment. Arch Intern Med. 1975; 135:1562–1568.