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From question on page 127

This man was suffering from oesophageal actinomycosis. Actinomyces, whose typical “sulphur granules” are shown as blue/purple clumps on the Haematoxilin and Eosin stain in fig 1 (arrow), are anaerobic rods that cause a subacute to chronic infection characterised by a granulomatous inflammatory reaction. Local spread, with formation of abscesses and sinus tracts, is common. This should be searched for with thoracic computed tomography scanning or barium studies in the oesophageal form of the disease. Overall incidence has previously been reported as 1 per 300 000 (most commonly craniofacial) but oesophageal involvement is rare. It is more common in immunocompromised patients, with six of the nine cases in the English literature being associated with acquired immunodeficiency syndrome (AIDS). Gamma scintography has previously shown 43% of inhaled drugs are delivered to the oesophagus and this patient may have had local immunocompromise of the oesophagus due to inhaled steroids. The patient made a full recovery after a course of intravenous, followed by oral, penicillin which is the suggested treatment.

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