An aspirate from a fluctuant interscapular mass found on a 45-year-old man showed "sulfur granules" (Figure, top). He had noted the mass for about one month and had leg ulcers, nonproductive cough, and weight loss for four months. A granule was crushed, Gram stained, and examined under the microscope. Gram-positive branching filaments and a radiating fringe of eosinophilic clubs characteristic of an actinomycotic granule were seen (Figure, bottom). Anaerobic culture of aspirate yielded Actinomyces israelii.
Sulfur granules are aggregates of microorganisms admixed with inflammatory debris characteristically but not exclusively found in actinomycosis. Granules vary in color (white to yellow) and size (0.25 to 2 mm in diameter). Sulfur granules may be absent or poorly organized in an occasional case of actinomycosis. Caution should be exercised in interpretation of granules from sputum, since they may be produced by saphrophytic organisms in the tonsillar crypts. Sulfur granules may also be produced by
Varkey B. Sulfur Granules. JAMA. 1982;248(22):3025. doi:10.1001/jama.1982.03330220067044
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