Multiple fungating masses on the abdomen due to Actinomyces

A 61-year-old immunocompetent Hispanic man with a history of a gunshot wound to the abdomen and exploratory laparotomy 24 years before presentation, as well as multiple left-sided inguinal incarcerated hernia repairs, presented with numerous abdominal wounds that had slowly progressed over 6 months (figure A). Despite increased purulent discharge from the patient's wounds, he denied abdominal pain or fevers. A CT of his abdomen and pelvis demonstrated multiple enterocutaneous fistulae and subcutaneous soft tissue and skin thickening extending from the midabdominal wall, involving the left flank, and extending inferiorly along the pelvis with multiple foci of air.