Primary actinomycosis is a rare soft tissue infection which requires a high degree of clinical suspicion to diagnose and it should be differentiated from other chronic conditions like tuberculosis.DECLARATIONSCompeting interestsNone declaredFundingNo funding obtainedEthical approvalWritten informed consent was obtained from the patient or next of kinGuarantorRohan KhandelwalContributiorshipRK, PCM: Operating surgeons and involved in manuscript preparation. IJ: Pathologist; reported the histopathology slides SP, AS, SY: Assisting surgeons and helped in manuscript preparation PS, SS: Helped in review of literature and management of the patientReviewerJody ParkerCase report Section:A 42-year-old lady presented to the surgical OPD with complaints of a swelling with multiple discharging sinuses over her right thigh for the past two years. The swelling was insidious in onset and was gradually increasing in size. There was no history of any trauma or insect bite at the site of the lesion. The patient had no past history suggestive of tuberculosis or diabetes mellitus. She was postmenopausal for the last four years and had no past history of intrauterine contraceptive device insertion. She had been treated by multiple doctors in various centres, over the last 6 months and had taken extended courses of oral antimicrobial therapy.On examination there was a 15 cm x 20 cm, irregularly shaped, indurated swelling in the medial aspect of the right thigh extending from the perineum to mid-thigh (Figure 1). There were multiple sinuses draining yellow coloured pus along with sulphur granules. There were no other lesions elsewhere on the body.DownloadOpen in new tabDownload in PowerPointFigure 1 Actinomycotic lesion over the thigh extending to the perineum. Multiple openings of sinuses can be seenThe pus from the discharging sinuses was sent for microscopy and a biopsy from the lesion was sent for histopathological examination. Gram staining revealed Gram positive bacilli, but no organisms could be cultured. Histopathological examination confirmed the diagnosis of actinomycosis (Figure 2).DownloadOpen in new tabDownload in PowerPointFigure 2 High power view (100X) showing an actinomycotic colony in a background of chronic inflammationA MRI scan was done and it revealed multiple sinuses in the medial aspect of the right thigh extending to the underlying muscles (Figure 3). There were no lesions in the underlying bone.DownloadOpen in new tabDownload in PowerPointFigure 3 MRI image showing multiple sinuses extending till the underlying muscles. The bone appears to be normalThe patient was started on co-trimaxozole and cindamycin for a period of 1 month, after which the patient was taken up for surgical excision of the lesion followed by split skin grafting to cover the created defect (Figure 4). During excision, the whole lesion along with the involved muscle was removed. Multiple sinus tracks were encountered during surgery.DownloadOpen in new tabDownload in PowerPointFigure 4 Postoperative picture after resection of the lesion and split skin thickness graft in placeThe patient had a wound infection in the postoperative period, which responded to parental antibiotics. The patient was discharged on oral co-trimaxazole and clindamycin for 15 days following which only co-trimaxozole was continued for 2 months.The patient has been in regular follow-up and there has been no recurrence till after 1 year of surgery (Figure 5).DownloadOpen in new tabDownload in PowerPointFigure 5 Picture after one year of surgery, showing no signs of recurrence and a well healed scarDiscussion Section:Actinomycosis is subacute to chronic, suppurative granulomatous disease that tends to produce draining sinus tracts. This usually manifests as cervico-facial, thoracic or abdominal actinomycosis. It is most commonly caused by Actinomyces israelii in humans and Actinomycosis viscosus, Actinomycosis bovis, Actinomycosis naeslundii in animals. Actinomycosis is an anaerobic, gra
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