IMAGE OF THE MONTH Dysphagia Caused by Esophageal Actinomycosis Prashanthi N. Thota,* Xiuli Liu,‡ and Madhusudhan R. Sanaka* *Department of Gastroenterology and Hepatology, ‡Department of Anatomic Pathology, Center of Excellence for Barrett’s Esophagus, Cleveland Clinic, Cleveland, Ohio
71-year-old woman presented with worsening odynophagia and weight loss requiring hospitalization while on treatment with decitabine for newly diagnosed acute myeloid leukemia. Empiric treatment with a proton pump inhibitor and an antifungal agent did not alleviate the symptoms. Physical examination was unremarkable except for pallor and mild tachycardia, with a heart rate of 108 beats per minute. Laboratory findings included pancytopenia, with a white blood cell count of 280/uL, a hemoglobin level of 6.9 g/dL, a platelet count of 13,000/uL, and a normal electrolyte level. She received 2 U of packed red blood cells and 3 U of a platelet transfusion, after which she underwent an upper endoscopy. It showed extensive and deep ulceration involving 80% circumference at 32 to 35 cm from the incisors (Figure A). A pathology examination showed inflamed granulation tissue with abundant bacterial colonization. The bacteria were gram-positive rods, less than 1 mm in width, with focally branching filaments (Figures B and C). The differential diagnosis for these bacteria included Actinomycetes, nocardia, and dermatophilus. Culture confirmed that the bacteria were Actinomycetes. The patient was started on amoxicillin 500 mg 3 times a day. She was switched to erythromycin because she developed a rash. She continued the erythromycin for 2 months and then stopped after a remarkable improvement of her symptoms. A follow-up endoscopy showed complete healing of the ulcer with a mild fibrotic stricture treated by balloon dilation. Actinomycetes are facultatively anaerobic, grampositive bacilli occurring as part of the normal flora in
A
the gastrointestinal tract, bronchial tree, and female genital tract. These organisms have a low degree of pathogenicity but can lead to severe infections, most commonly chronic cervicofacial suppurative infections. However, infection with these organisms can occur in nearly any part of the body.1 Although Actinomycetes israelii remains the most common pathogen, 4 other species (Actinomycetes naeslundii, Actinomycetes viscosus, Actinomycetes odontolyticus, and Actinomycetes bovis) are known to exist. Generally, Actinomycetes infections are preceded by some known insult to the native mucosa, for example, prior dental or surgical procedures, trauma, infection, or intrauterine device placement.1 Actinomycetes esophagitis is an uncommon infection reported mostly in patients immunocompromised owing to underlying malignancy or human immunodeficiency virus infection.2 To date, 24 cases have been reported in the literature. Patients present with odynophagia or dysphagia. Common endoscopic findings include white plaques, ulcerations, strictures, and, rarely, fistulas. Biopsies show acute inflammation surrounded by fibrosing granulation tissue. Such material contains sulfur granules, which are colonies of organisms forming an amorphous center surrounded by a rosette of clubbed filaments. Patients respond well to 4 to 6 weeks of intravenous penicillin, 3 to 4 million units intravenously every 4 hours, followed by oral penicillin or amoxicillin for 6 to 12 months.3 In patients with a penicillin allergy, tetracycline, minocycline, erythromycin, clindamycin, ceftriaxone, and imipenem are viable alternative treatments.4
Clinical Gastroenterology and Hepatology 2015;13:xxi–xxii
IMAGE OF THE MONTH, continued In conclusion, actinomycosis is a rare cause of infectious esophagitis that should be considered in the differential diagnosis of odynophagia in immunocompromised patients.
4.
Arora AK, Nord J, Olofinlade O, et al. Esophageal actinomycosis: a case report and review of the literature. Dysphagia 2003;18:27–31.
References 1. 2.
Burden P. Actinomycosis. J Infect 1989;19:95–99. Abdalla J, Myers J, Moorman J. Actinomycotic infection of the oesophagus. J Infect 2005;51:39–43.
3.
Chou FT, Cheng KS, Chiang I-P. Esophageal actinomycosis. Adv Ther 2006;23:623–626.
xxii
Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2015.01.012
71-year-old woman presented with worsening odynophagia and weight loss requiring hospitalization while on treatment with decitabine for newly diagnosed acute myeloid leukemia. Empiric treatment with a proton pump inhibitor and an antifungal agent did not alleviate the symptoms. Physical examination was unremarkable except for pallor and mild tachycardia, with a heart rate of 108 beats per minute. Laboratory findings included pancytopenia, with a white blood cell count of 280/uL, a hemoglobin level of 6.9 g/dL, a platelet count of 13,000/uL, and a normal electrolyte level. She received 2 U of packed red blood cells and 3 U of a platelet transfusion, after which she underwent an upper endoscopy. It showed extensive and deep ulceration involving 80% circumference at 32 to 35 cm from the incisors (Figure A). A pathology examination showed inflamed granulation tissue with abundant bacterial colonization. The bacteria were gram-positive rods, less than 1 mm in width, with focally branching filaments (Figures B and C). The differential diagnosis for these bacteria included Actinomycetes, nocardia, and dermatophilus. Culture confirmed that the bacteria were Actinomycetes. The patient was started on amoxicillin 500 mg 3 times a day. She was switched to erythromycin because she developed a rash. She continued the erythromycin for 2 months and then stopped after a remarkable improvement of her symptoms. A follow-up endoscopy showed complete healing of the ulcer with a mild fibrotic stricture treated by balloon dilation. Actinomycetes are facultatively anaerobic, grampositive bacilli occurring as part of the normal flora in
A
the gastrointestinal tract, bronchial tree, and female genital tract. These organisms have a low degree of pathogenicity but can lead to severe infections, most commonly chronic cervicofacial suppurative infections. However, infection with these organisms can occur in nearly any part of the body.1 Although Actinomycetes israelii remains the most common pathogen, 4 other species (Actinomycetes naeslundii, Actinomycetes viscosus, Actinomycetes odontolyticus, and Actinomycetes bovis) are known to exist. Generally, Actinomycetes infections are preceded by some known insult to the native mucosa, for example, prior dental or surgical procedures, trauma, infection, or intrauterine device placement.1 Actinomycetes esophagitis is an uncommon infection reported mostly in patients immunocompromised owing to underlying malignancy or human immunodeficiency virus infection.2 To date, 24 cases have been reported in the literature. Patients present with odynophagia or dysphagia. Common endoscopic findings include white plaques, ulcerations, strictures, and, rarely, fistulas. Biopsies show acute inflammation surrounded by fibrosing granulation tissue. Such material contains sulfur granules, which are colonies of organisms forming an amorphous center surrounded by a rosette of clubbed filaments. Patients respond well to 4 to 6 weeks of intravenous penicillin, 3 to 4 million units intravenously every 4 hours, followed by oral penicillin or amoxicillin for 6 to 12 months.3 In patients with a penicillin allergy, tetracycline, minocycline, erythromycin, clindamycin, ceftriaxone, and imipenem are viable alternative treatments.4
Clinical Gastroenterology and Hepatology 2015;13:xxi–xxii
IMAGE OF THE MONTH, continued In conclusion, actinomycosis is a rare cause of infectious esophagitis that should be considered in the differential diagnosis of odynophagia in immunocompromised patients.
4.
Arora AK, Nord J, Olofinlade O, et al. Esophageal actinomycosis: a case report and review of the literature. Dysphagia 2003;18:27–31.
References 1. 2.
Burden P. Actinomycosis. J Infect 1989;19:95–99. Abdalla J, Myers J, Moorman J. Actinomycotic infection of the oesophagus. J Infect 2005;51:39–43.
3.
Chou FT, Cheng KS, Chiang I-P. Esophageal actinomycosis. Adv Ther 2006;23:623–626.
xxii
Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2015.01.012
