PMC6430034_01
(A) CT scan of the head and neck showing defect at hard palate with left side oroantral fistula (white circle). B. Clumps of gram-positive filamentous bacteria seen on gram stain of the bone biopsy.
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Soft tissue thickening surrounded this area; however, no evidence of osteomyelitis, bony erosions, or lymphadenopathy was detected (Fig. 1A). No granulomas were identified, and AFB staining showed negative findings (Fig. 1B).
PMC6430034_02
(A)  hand photo showing soft tissue swelling of the middle finger and a sinus. (B) MRI of the  hand showing multilobulated enhancing soft tissue mass at the base of the middle finger. (C) & D excisional biopsy revealed dermal infiltration by Gram positive filamentous bacteria with multiple microabscesses formation. GMS special stain (C) and H&E stain (D) highlights the filamentous bacteria.
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Multiple sinuses were noted (Fig. 2A). No signs of tenosynovitis or osteomyelitis were observed (Fig. 2B).
(A) CT scan of the chest showing pulmonary metastatic nodules. (B) GMS special stain showing clumps of filamentous bacteria within fragments of keratin flakes necrotic mucosal soft tissue and bone of right mandible.
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Histopathology revealed necrotic tissue with positive PAS and GMS staining, suggesting actinomycosis (Fig. 3). Chest CT showed pulmonary nodules enlargement, which was also noted 2 years prior to this presentation [(Fig. 3B].
PMC6430034_03
(A) CT scan of the chest showing pulmonary metastatic nodules. (B) GMS special stain showing clumps of filamentous bacteria within fragments of keratin flakes necrotic mucosal soft tissue and bone of right mandible.
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Histopathology revealed necrotic tissue with positive PAS and GMS staining, suggesting actinomycosis (Fig. 3). Chest CT showed pulmonary nodules enlargement, which was also noted 2 years prior to this presentation [(Fig. 3B].
PMC6430034_04
(A) Chest radiograph showing gas under the diaphragm (B) Plain radiograph of the pelvis showing IUD in site. (C) CT scan of the abdomen and pelvis revealed loculated collections adjacent to rectosigmoid and urinary bladder (D) H&E stain of colonic segment showing sulphur granules as indicated by the black arrows.
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An intrauterine contraceptive device (IUD) that had been implanted for 8 years had been removed one week prior to presentation (Fig. 4B). Chest radiography revealed gas under the diaphragm (Fig. 4A) and an assessment at the time showed findings consistent with a perforated viscus. Abdomen CT showed evidence of pneumoperitoneum with multiple and large loculated collections at the pelvis, and surrounding the sigmoid colon (Fig. 4C). A histopathology report confirmed the diagnosis of actinomycosis with prominent muscular and serosal layer involvement in the sigmoid colon (Fig. 4D and E).