Skip Navigation
Skip to contents

Ann Coloproctol : Annals of Coloproctology

OPEN ACCESS
SEARCH
Search
Advanced Search
mobile menu button

Articles

Page Path
HOME > Ann Coloproctol > Volume 31(6); 2015 > Article
Case Report
 Pilonidal Abscess Associated With Primary Actinomycosis
Han Boon Oh1,2, Mohamad Hashir Abdul Malik1, Chris Hang Liang Keh1
Annals of Coloproctology 2015;31(6):243-245.
DOI: https://doi.org/10.3393/ac.2015.31.6.243
Published online: December 31, 2015

1Department of General Surgery, Alexandra Hospital, Jurong Health Services, Singapore City, Singapore.

2University Surgical Cluster, National University Health System, Singapore City, Singapore.

Correspondence to: Han Boon Oh, M.D. University Surgical Cluster, National University Health System, 1E Kent Ridge Road, NUHS Tower Block, Level 8, Singapore 119228. Tel: +65-6779-5555, Fax: +65-6777-8427, han_boon_oh@nuhs.edu.sg
• Received: April 3, 2015   • Accepted: September 1, 2015

© 2015 The Korean Society of Coloproctology

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

prev next
  • 10,062 Views
  • 37 Download
  • 7 Web of Science
  • 7 Crossref
  • 8 Scopus
Full Article

Download PDF Download PDF

  • Pilonidal disease in the sacrococcygeal region usually presents as abscesses, recurrent inflammation, cellulitis or fistula tracks. However, few reports on actinomycosis affecting pilonidal sinuses have been published. We report a case of a 25-year-old woman who presented with a pilonidal abscess who underwent surgical drainage and debridement. Pus from the pilonidal abscess was sent for microbiology, which grew actinomyces turicensis associated with prevotella bivia and peptostreptococci. She was treated with oral amoxicillin-clavulanate after surgical drainage for one week and recovered well. Actinomycosis associated with pilonidal abscesses, though uncommon, should be recognized and can be satisfactorily treated with a combination of surgical drainage and antibiotics.
  • Keywords: Actinomycosis; Pilonidal abscess; Pilonidal disease; Pilonidal sinus; Actinomyces
Pilonidal disease was first described in 1880 by Hodges [1] and is derived from the Latin words pilus, which means hair, and nidus, which means nest. Pilonidal disease is postulated to be an acquired pathology and forms a sinus or cyst [2]. The sinus develops as a result of accumulation of hair and debris within the skin or hair follicles, aided by a negative pressure drawing more hair into the sinus. As inflammation and oedema occur as a result of the trapped hair and keratin, a cyst and eventually an abscess are formed. Bacteriology in an infected pilonidal sinus is commonly polymicrobial with both aerobic and anaerobic bacteria growths [3]. However, actinomycosis of pilonidal abscesses is rare. We present an unusual case of a pilonidal abscess associated with actinomycosis in a female patient who was not immunocompromised.
A 25-year-old Indian woman with a past medical history of childhood asthma and migraine headaches was admitted to the General Surgical Service for a painful swelling over her sacral region of one week's duration. This was associated with fever, chills and rigors. Physical examination revealed a hirsute lady, with a 4-cm by 8-cm lump with erythematous skin changes overlying the sacrococcygeal region with a discharging sinus in the midline 6 cm from the anal verge. Investigations revealed leukocytosis of 14.9×109/L with a raised C-reactive protein of 104.0 mg/L. A clinical diagnosis of pilonidal abscess was made, and the patient was started on intravenous amoxicillin-clavulanate and underwent an incision and drainage of the pilonidal abscess under general anesthesia.
Intraoperative findings revealed a 5-cm by 6-cm pilonidal abscess with a communicating inferior pit of 3 cm from the main abscess cavity. The abscess did not breach the sacral fascia, and there was no communication with the rectal canal. Frank, yellow pus, 50 mL, was evacuated from the abscess cavity and sent for culture and sensitivity. No obvious 'sulphur granules' were noted. Postoperatively, the patient recovered well without any complications, and she was discharged with oral amoxicillin-clavulanate for 1 week. Pus from the abscess grew Actinomyces turicensis sensitive to penicillin, as well as Prevotella bivia and Peptostreptococcus species. She was followed up in the clinic two weeks after surgery with a clean, granulating wound.
Pilonidal disease, which was commonly seen amongst American soldiers who had sat on long bumpy rides during World War II, was known then as "Jeep seat disease" [4]. Identified risk factors of pilonidal disease include hirsutism, male gender, obesity, poor hygiene, family history, and sedentary activity such as prolonged periods of sitting [5]. Patients with pilonidal disease typically present with an acute abscess above the natal cleft or with asymptomatic midline sinus pits at the sacrococcygeal region. Hair within the abscess cavity can be found in about one-third of women and two-thirds of men with pilonidal abscesses [6]. Diagnosis is made by clinical examination, with midline pits at the natal cleft being a distinguishing feature.
Bacteriology of pilonidal abscesses includes both aerobic and anaerobic bacteria and is typically polymicrobial. Anaerobic bacteria growth is predominant, with gram-negative aerobic bacteria being more common as these are part of the normal gastrointestinal flora. Actinomycosis of pilonidal sinuses, however, is relatively rare. It was first described by Reichman [7] in 1947 and then by Anscombe and Hofmeyr [8] in 1954.
Actinomycosis is caused by actinomyces, a gram-positive, microaerophilic bacterium that is part of the normal gastrointestinal flora. This infection commonly occurs in the cervicofacial, thoracic and abdominopelvic regions [9]. It is almost always polymicrobial, as it requires bacterial infection to convert the aerobic microenvironment to an anaerobic one, in which actinomyces can then migrate and infect the inflamed tissue. Yellow 'sulphur granules', which are composed of internal tangles of mycelial fragments and a rosette of peripheral clubs stabilized by a protein-polysaccharide complex, are sometimes seen macroscopically [10]. Micro-scopic findings reveal filamentous gram-positive fungal-like organisms. Actinomyces israelli is by far the most common species affecting humans, but other species like A. meyeri and A. turicensis have been identified in recent years [9]. A. turicensis, first identified in 1995 [11], has been described as a potent pathogen in genital, urinary tract and skin-related infections, is typically sensitive to penicillin, and has high resistance to metronidazole and ciprofloxacin [12]. Only two cases of pilonidal cysts with actinomycosis by A. turicensis have been reported since the isolation of A. turicensis in 1995 [12]. Primary perianal actinomycosis, while rare, has also been described [1314]. However, not all cases presented with classic 'sulphur granules' from the drained pus [13].
Treatment for pilonidal abscesses should include a combination of surgery and antibiotics. However, the optimal duration of antibiotic treatment is not known, and the duration should be guided by clinical parameters and regular inspection of the wound. Patients with actinomycosis typically require prolonged antibiotic treatment with penicillin G or amoxicillin, but in patients with optimal surgical excision of infected tissues, it has been reported that the duration can be reduced to 3 months [9]. Previous cases of perianal actinomycosis have reported a 2-week duration with satisfactory outcomes [14]. In our patient, we opted to perform an incision through the abscess, including the midline pits with curettage, drainage, and lavage of the abscess, combined with one week of oral amoxicillin-clavulanate.
In conclusion, actinomycosis of pilonidal cysts is a rare infection, which is often diagnosed postoperatively. Bacterial cultures are important to obtain a diagnosis and to guide antibiotic therapy. However, it can be successfully managed with a combination of surgical excision and debridement with an appropriate duration of antibiotics therapy. Surgeons should be aware of a possible diagnosis of actinomycosis, especially when drainage of the abscess reveals the typical 'sulphur granules', and should institute appropriate treatment with antibiotics.

CONFLICT OF INTEREST: No potential conflict of interest relevant to this article was reported.

  • 1. Hodges RM. Pilonidal sinus. Boston Med Surg J 1880;103:485–486.Article
  • 2. Karydakis GE. Easy and successful treatment of pilonidal sinus after explanation of its causative process. Aust N Z J Surg 1992;62:385–389. ArticlePubMed
  • 3. Ardelt M, Dittmar Y, Kocijan R, Rodel J, Schulz B, Scheuerlein H, et al. Microbiology of the infected recurrent sacrococcygeal pilonidal sinus. Int Wound J 2014;4 24 [Epub]. Article
  • 4. Classic articles in colonic and rectal surgery. Louis A. Buie, M.D. 1890-1975: Jeep disease (pilonidal disease of mechanized warfare). Dis Colon Rectum 1982;25:384–390. ArticlePubMed
  • 5. Harlak A, Mentes O, Kilic S, Coskun K, Duman K, Yilmaz F. Sacrococcygeal pilonidal disease: analysis of previously proposed risk factors. Clinics (Sao Paulo) 2010;65:125–131. ArticlePubMedPMC
  • 6. Hull TL, Wu J. Pilonidal disease. Surg Clin North Am 2002;82:1169–1185. ArticlePubMed
  • 7. Reichman HR. Pilonidal fistula complicated by actinomycosis; complete healing following surgical treatment, sulfonamides, and penicillin. Rocky Mt Med J 1947;44:820.PubMed
  • 8. Anscombe AR, Hofmeyr J. Perianal actinomycosis complicating pilonidal sinus. Br J Surg 1954;41:666.ArticlePubMed
  • 9. Valour F, Senechal A, Dupieux C, Karsenty J, Lustig S, Breton P, et al. Actinomycosis: etiology, clinical features, diagnosis, treatment, and management. Infect Drug Resist 2014;7:183–197. PubMedPMC
  • 10. Brown JR. Human actinomycosis: a study of 181 subjects. Hum Pathol 1973;4:319–330. ArticlePubMed
  • 11. Wust J, Stubbs S, Weiss N, Funke G, Collins MD. Assignment of Actinomyces pyogenes-like (CDC coryneform group E) bacteria to the genus Actinomyces as Actinomyces radingae sp nov and Actinomyces turicensis sp. nov. Lett Appl Microbiol 1995;20:76–81. ArticlePubMed
  • 12. Chudackova E, Geigerova L, Hrabak J, Bergerova T, Liska V, Scharfen J Jr. Seven isolates of Actinomyces turicensis from patients with surgical infections of the anogenital area in a Czech hospital. J Clin Microbiol 2010;48:2660–2661. ArticlePubMedPMC
  • 13. Bauer P, Sultan S, Atienza P. Perianal actinomycosis: diagnostic and management considerations: a review of six cases. Gastroenterol Clin Biol 2006;30:29–32. ArticlePubMed
  • 14. Coremans G, Margaritis V, Van Poppel HP, Christiaens MR, Gruwez J, Geboes K, et al. Actinomycosis, a rare and unsuspected cause of anal fistulous abscess: report of three cases and review of the literature. Dis Colon Rectum 2005;48:575–581. ArticlePubMed

Figure & Data

References

    Citations

    Citations to this article as recorded by  
    • Pilonidal sinus disease prevalence and risk factors in Saudi Arabia: A cross-sectional study
      Hadi A. Alabbas, Mohammed A. Balhareth, Basmah F. Nawawi, Jood E. Alzohari, Maryam A. AlQarni, Abdullah Y. Asiri, Omar H. Alahmadi, Khames T. Alzahran
      Journal of Family Medicine and Primary Care.2026; 15(1): 252.     CrossRef
    • Brain abscess caused by Actinomyces turicensis in a non-immunocompromised adult patient: a case report and systematic review of the literature
      Alessandra Imeneo, Lorenzo Vittorio Rindi, Andrea Di Lorenzo, Rosario Alessandro Cavasio, Pietro Vitale, Ilaria Spalliera, Mario Dauri, Daniele Guerino Biasucci, Ilaria Giuliano, Cartesio D’Agostini, Silvia Minelli, Maria Cristina Bossa, Anna Altieri, Mas
      BMC Infectious Diseases.2024;[Epub]     CrossRef
    • Skin and Soft Tissue Actinomycosis in Children and Adolescents
      Salih Demirhan, Erika Orner, Wendy Szymczak, Philip J. Lee, Margaret Aldrich
      Pediatric Infectious Disease Journal.2024; 43(8): 743.     CrossRef
    • Cutaneous Actinomycosis of the Perineum in an Immunocompetent Man
      Jeffrey A. Sanford, Walter L. Rush, Mary K. Klassen-Fischer, Jill I. Allbritton
      The American Journal of Dermatopathology.2022; 44(4): 272.     CrossRef
    • Pleural empyema caused by Actinomyces turicensis
      Apostolos C. Agrafiotis, Ines Lardinois
      New Microbes and New Infections.2021; 41: 100892.     CrossRef
    • Actinomycosis of the Appendix Mimicking Cecal Tumor Treated by Single-Port Laparoscopic Approach
      In Soo Cho, Sung Uk Bae, Hye Ra Jung, Kyung Sik Park, Woon Kyung Jeong, Seong Kyu Baek
      Annals of Coloproctology.2021; 37(2): 125.     CrossRef
    • Actinomyces turicensis parapharyngeal space infection in an immunocompetent host: first case report and review of literature
      Ayla Tabaksert, Ravi Kumar, Veena Raviprakash, Rajeev Srinivasan
      Access Microbiology .2021;[Epub]     CrossRef

    • Cite this Article
      Cite this Article
      export Copy Download
      Close
      Download Citation
      Download a citation file in RIS format that can be imported by all major citation management software, including EndNote, ProCite, RefWorks, and Reference Manager.
      Format:
      • RIS — For EndNote, ProCite, RefWorks, and most other reference management software
      • BibTeX — For JabRef, BibDesk, and other BibTeX-specific software
      Include:
      • Citation for the content below
      Pilonidal Abscess Associated With Primary Actinomycosis
      Ann Coloproctol. 2015;31(6):243-245.   Published online December 31, 2015
      DOI: https://doi.org/10.3393/ac.2015.31.6.243
      Close
    • XML DownloadXML Download
    Pilonidal Abscess Associated With Primary Actinomycosis
    Pilonidal Abscess Associated With Primary Actinomycosis
    Ann Coloproctol : Annals of Coloproctology Twitter Facebook
    © Korean Society of Coloproctology.
    TOP