A 27-year-old male patient presented as multiple fistulas along with pain and swelling of the left hand since 2 years. He was a daily laborer and remembered a history of trauma to his hand around 2 years ago. He received different antibiotics but was left without cure. There was no history of any immunodeficiency or underlying disease. Physical examination was normal except a swelling in the left hand that extended from wrist to metacarpophalangeal joint of all the fingers, along with multiple discharging sinuses at the dorsal and palmar aspects of the hand [Figures 1 and 2]. The discharge was scanty and purulent with an offensive odor. The swelling was immobile in all directions and was fixed to the underlying structures. The movement at the metacarpophalangeal joint was restricted.
An initial clinical diagnosis of tuberculosis was made due to endemicity of the disease in Odisha, India. The routine biochemical and hematological tests including erythrocyte sedimentation rate were within the normal range. The X-ray of the upper extremity revealed no significant abnormalities. Swabs collected from the discharging sinuses were subjected to microbiological studies. Few pus cells and no bacteria were detected in the microscopy. Microbiological cultures for aerobic and anaerobic organisms showed growth of only Staphylococcus aureus which was sensitive to linezolid. Based on acid fast staining and culture, tuberculosis was ruled out. Hence, patient was advised with oral 600 mg of linezolid twice daily for 10 days, which yielded only a partial, but not complete relief. Finally, curettage and biopsy of the draining sinuses was made, which revealed many neutrophils with some colonies consisting of radiating filaments, surrounded by eosinophilic hyaline material creating a sun-ray pattern, similar to that of actinomycosis [Figure 3]. There was no evidence of lung disease, tooth problems or gingivitis in patient. Hence, a diagnosis of primary actinomycosis of hand was made for which he was treated with surgical debridement [Figure 4] and intravenous and oral penicillin therapy for 6 months to which patient showed excellent response.