Although actinomycosis has generally indolent clinical courses, it has high mortality risk if not treated properly, especially in cranial and spinal cases. However, orbitocranial actinomycosis is hard to be differentiated clinically and radiographically from other pathological conditions. A healthy 62-year-old man complained of a progressive headache and orbital pain, presenting a soft, tender subcutaneous mass over the right forehead. Imaging showed multiple enhanced lesions in the right orbit and the pterion with invasion to temporalis muscle and epidural space. In the operative view, white-yellowish lesion extended into the bone, muscle, and even the dura. Necrotic pus was drained from the extradural space. He was pathologically diagnosed with actinomycosis with sulfur granules. The lesion was completely regressed after antibiotic therapy for 20 weeks. The authors tried to determine the appropriate impression on this problematic lesion and optimal management of actinomycosis in neurosurgery.
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