Actinomyces naeslundii: A rare cause of chronic purulent canaliculitis

Case ReportBrunei Int Med J. 2013; 9 (2): 118-121Actinomyces naeslundii:A rare cause of chronic purulentcanaliculitisIrimpan Lazar FRANCIS 1 , Mohan RAMALINGAM 1 , Nadir Ali Mohamed ALI 1 ,Nayan JOSHI 1 , Terrence Rohan CHINNIAH 2 , Kavitha PRABHU 2 ,Pemasari Upali TELISINGHE 31Department of Ophthalmology, 2 Department of Microbiology, 3 Department ofPathology, RIPAS Hospital, Brunei DarussalamABSTRACTChronic canaliculitis is an uncommon disease with a protracted course. Its management is prolongedand difficult. An elderly lady was diagnosed to have left lower chronic purulent canaliculitis. Conservativetreatment alone did not effect a complete cure. Canaliculotomy with removal of sulphur granulesand canalicular curettage also had to be performed to achieve a permanent cure. Unlike many cases ofcanaliculitis, this patient presented numerous complications confined to the canaliculus. To the best ofour knowledge, this is the first report of Actinomyces naeslundii (A. naeslundii) causing chronic purulentcanaliculitis and associated complications. A. naeslundii canaliculitis should be considered in thedifferential diagnosis of chronic conjunctivitis with epiphora.Keywords: Actinomyces naeslundii, canaliculotomy, canaliculitis, dacryocystitisINTRODUCTIONChronic canaliculitis is a rare uni-ocular infectionof the lacrimal canaliculus, which drainstears from the eye. 1-3 It may be caused bybacteria, fungi, or viruses. Actinomyces israeli(A. isreali) is the commonest bacteria reportedto cause chronic canaliculitis. 2, 4 It is oftenmisdiagnosed as chronic conjunctivitis andmay be inadequately treated. 2, 5 This conditionpredominantly affects the elderly population.Actinomyces naeslundii (A. naeslundii) isa commensal of the oral cavity, and has beenCorrespondence author: Irimpan Lazar FRANCISDepartment of Ophthalmology,RIPAS Hospital, Bandar Seri Begawan, BA1710,Brunei Darussalam.Tel: +673 8772253E mail: fril50@hotmail.comimplicated in periodontal disease and dentalroot caries. We believe this is the first reportof A. naeslundii causing chronic purulent canaliculitiswith the associated complications.CASE REPORTA 74-year-old Malay lady was referred to theeye clinic with chronic watering, discharge,pain and intermittent conjunctivitis, involvingher left eye which had failed to respond tomedical treatment involving systemic andtopical antibiotics. She gave a history of sporadicpain and redness with persistent wateringand discharge. She was known to havehypertension with renal impairment, atrial

FRANCIS et al. Brunei Int Med J. 2013; 9 (2): 119Fig. 1: Chronic canaliculitis with pouting punctum.fibrillation, mitral regurgitation and sick sinussyndrome with an implanted permanent cardiacpacemaker. Examination showed a wateryleft eye with purulent discharge and mattedlashes. There was associated erythema andswelling of the inner end of the lower eyelidand medial angular congestion. The lowerpunctum was stenosed (Figure 1), and appearedred, swollen and pouting. The lowerpunctum and canaliculus was tender to gentledigital manipulation which expressed a thickwhite tenacious discharge containing solidpale-yellow sulphur granules (Figure 1). Thelower canaliculus was strikingly thickened.Probing of the left upper canaliculus revealeda ‘hard stop’ whilst that of the lower canaliculuswas gritty in nature with a ‘soft stop’.Chronic dacryocystitis was also identified inthe same eye as evidenced by regurgitation ofmucoid substance when the upper punctumwas irrigated with saline. revealed immaturethe lower canaliculus sample revealed Grampositive cocci in small groups and pairs withlarge numbers of gram positive branching filaments(Figure 2), while that from the uppercanaliculus showed chain forms of gram positivecocci. Culture of the lower canaliculussample showed profuse growth of A. naeslundiialong with Staphylococcus aureus whilstthat of the upper canaliculus showed a moderategrowth of Streptococci Lancefield groupF.Based on the antibiotic sensitivity, shewas started on oral doxycycline, 100mg twicedaily with topical ciprofloxacin drops fourtimes a day. However doxycycline had to bediscontinued two days later following the developmentof dyspepsia and was replaced withcataracts in both eyes and evidence of drynessin the right eye.A working diagnosis of left chronicdacryocystitis with ipsilateral lower purulentcanaliculitis was made. The expressed purulentmaterials from upper and lower canaliculiwere separately sent for bacteriological analysisand sensitivity testing. Gram-staining ofFig. 2: Actinomyces naeslundii under gram stain,branching filaments are indicated by white arrow(H&E stain Magnification x40).

FRANCIS et al. Brunei Int Med J. 2013; 9 (2): 120The post-operative period was uneventfuland she was discharged on the secondday. She was started on oral Ciprofloxacin500mg twice daily. for one month. The woundhealed well and the sutures were removedafter seven days. She was followed-up in theclinic for six months after surgery and she hasnot shown any recurrence or complications.Fig. 3: Canaliculus slit open showingsulphur granules.oral amoxicillin-clavulanic acid 625mg twicedaily for 10 days. Although some improvementwas noted, the infection did not completelysubside as evidenced by continuingdischarge of pus and granules. She was alsoadditionally treated with bi-weekly intracanalicularlavage with 5% povidone iodine for herlower canaliculus for three weeks.DISCUSSIONActinomyces are cast-forming Gram-positive,non-acid fast, non-spore bearing anaerobicrods, characterised by filamentous branchingat acute angles, and are difficult to isolate,identify and culture. Although these organismsare normal commensals of the mouth,gastrointestinal tract and the female genitaltract, they may cause infectious disease(Actinomycosis) of which oral and cervicofacialActinomycosis are the commonest. ThoughA single-snip lower canaliculotomyunder local anaesthesia with sedation waswhereby daily lavage with povidone iodinewas performed for three days pre-operatively.Intra-operatively, the stenosed punctum wasdilated gently and the canaliculus was irrigatedwith iodine solution. The lower punctumand canaliculus were then probed and slit,then opened with a single snip along its posterioraspect. Exploration revealed a sausagelikegross dilatation of the lower canaliculuswith the distal end blocked by greyish fibroustissue. The canalicular mucosa was oedematousand thickened. Immediately beyond thepunctum, there was a diverticulum inferiorly,which was studded with large sulphur granules(Figure 3). The granules were removed,the mucosa was curetted, and sent for histopathologicalstudies. Considering the highrisks involved, surgery was completed with adacryocystectomy on the same side.rare, pelvic Actinomycosis, is a known complicationof intra-uterine contraceptive devices(IUCD). When it affects the abdominal cavity,Actinomycosis may present with a neoplasmlikemass. It is known to cause liver, splenic,colon and caecal abscesses.These organisms are also known tocause opportunistic infections within hollowspaces, like the canaliculus, producing indolentand slowly progressive infection with yellowsulphur granules. 2 The granules are coloniesof intertwined branching Actinomycesfilaments, solidified by tissue exudates andpus cells. Actinomyces canaliculitis accountsfor approximately 2% of all lacrimal drainagesystem diseases presenting with epiphora. 2, 5Majority of reported cases involvedfemales and the lower canaliculus.3, 6, 7Though complete cure has been reported with

FRANCIS et al. Brunei Int Med J. 2013; 9 (2): 121conservative management, our case neededadditional surgical intervention namely, punctoplastyand snip canaliculotomy with evacuationof the sulphur granules and curettage.The organisms, although usually sparse in thepus, are concentrated in the sulphur granulesalmost always form part of a mixed infection.Actinomyces naeslundii have similarmorphological features as other Actinomycesstrains. PubMed search of the literatureshowed no previously reported cases of A.naeslundii-related chronic canaliculitis. Hence,we believe this the first report of such an infection.Various treatment options have beenreported with some advocating that completecure can be achieved with conservative line oftreatment alone but others are of the opinionsthat surgical treatment namely punctoplasty,canaliculotomy and expression of granuleswith or without curettage is the line of treatment.1, 8 Hussain et al. reported that medicaltherapy alone could not eradicate the infection.9 Surgical procedures such as punctoplastyand canaliculotomy are safe procedure.1, 10, 11Our patient had chronic canaliculitiswith stenosed punctum as well as chronicdacryocystitis on the same side, requiringboth medical and surgical management.In conclusion, primary chronic purulentcanaliculitis is a rare form of unilaterallacrimal system pathology. However, it shouldbe considered in the differential diagnosis ofepiphora and chronic or recurrent conjunctivitis.Our case highlights a rare cause of chronicpurulent canaliculitis, which can also be difficultto isolate and identify. A complete eradi-cation of the canalicular Actinomyces infectioncannot be achieved unless and until all theconcretions are removed.REFERENCES1: McKellar MJ, Aburn NS. Cast-forming actinomycesisraeli canaliculitis. Aust N Z J Ophthalmol.1997; 25:301-3.2: Pande M, Mathew R, Ramprakash M, Kalyani M.Actinomycotic lacrimal canaliculitis. Indian J PatholMicrobiol. 2010; 53:864-5.3: Sathananthan N, Sullivan TJ, Rose GE, MoseleyIF. Intubation dacryocystography in patients with aclinical diagnosis of chronic canaliculitis(“Streptothrix”). Br J Radiol. 1993; 66:389-93.4: Bharathi MJ, Ramakrishnan R, Meenakshi R,Vasu S. Nocardia asteroides canaliculitis: a casereport of uncommon aetiology. Indian J Ophthalmol.2004; 22:123-5.5: Vagarali MA, Karadesai SG, Dandur MS. Lacrimalcanaliculitis due to actinomyces – a rare entity.Indian J Pathol. 2011; 54:661-3.6: Lee MJ, Choung HK, Kim NJ, Khwarg SI. OneSnip Punctoplasty and Canalicular curettagethrough the punctum. Ophthalmology. 2009;116:2027-307: Lin SC, Kao SC, Tsai CC, et al. Clinical characteristicsand Factors associated the outcome of lacrimalcanaliculitis. Acta Ophthalmologica. 2011;89:759–63.8: Al-Mujaini A, Wali U, Al-Senawi R. Canaliculitis:Are we missing the diagnosis? Oman J Ophthalmol.2009; 2:145-6.9: Hussain I, Bonshek RE, Loudon K, Armstrong M,Tullo AB. Canalicular infection by actinomyces. Eye(Lond). 1993; 7:542-4.10: Briscoe D, Edelstein E, Zacharopoulos I, KenessY, Kilman A, Assia EL. Actinomyces canaliculitis:diagnosis of a masquerading disease. Graefes ArchClin Exp ophthalmol. 2004; 242: 682-6.11: Anand S, Hollingworth K, Kumar V, SandramouliS. Canaliculitis: the incidence of long-termepiphora following canaliculotomy. Orbit. 2004; 23:19-26.