A 49-year-old man presented to us after undergoing right hemimandibulectomy and right neck dissection in July 2011, followed by chemoradiation for submandibular cystic adenocarcinoma (T4N2M0). Following the surgery, he developed trismus and difficulty in brushing his teeth. Five years later, he developed chronic right sided facial pain associated with recurrent purulent skin discharge and fever. Multiple trials of antibiotics including ciprofloxacin failed to achieve complete recovery. A dental assessment showed multiple decayed teeth. Dental treatment could not be administered due to his markedly reduced ability to open his mouth (8 mm). His temperature, heart rate, and blood pressure were 37.1 C, 95 beats/minutes, and 131/82 mmHg. A small right sided sub-mandibular fistula draining a minimal amount of pus was observed on examination. His CBC, ESR, and CRP laboratory results were all normal. Enhanced head and neck CT did not reveal any underlying fluid collection, and no apparent fistula was observed on radiological evaluation. The right mandible bone biopsy was negative for AFB, TB-PCR, and bacterial cultures. Another biopsy taken from the right upper alveolar edge consisted of yellowish tan colored soft tissue. The bacterial culture was negative; however, heavy growth of mixed candida species was noted on tissue culture. 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].
The patient received a high dose of intravenous penicillin (6 million units/day) for 6 weeks followed by ceftriaxone for 1 month through a peripherally inserted central catheter. He also received 6 weeks of oral voriconazole for a non-albicans candida tissue infection. Oral amoxicillin was then continued for one year. Furthermore, hyperbaric oxygen (HBO) therapy was also administered, leading to dramatic improvement.
(A) CT scan of the chest showing pulmonary metastatic nodules.