Actinomycosis

An 85-year-old man had a 4-year history of recurrent pneumonia with a persistent pleural effusion. He underwent repeated bronchoscopy that revealed a right bronchus intermedius mass, but bronchial washes and biopsies remained nondiagnostic. A repeat bronchoscopy was performed, and a Wang needle aspiration of the mass was obtained that showed sulfur granules, diagnosing actinomycosis. The patient was started on appropriate antibiotic therapy. Actinomycosis must be considered in a patient with recurrent pneumonia and an endobronchial mass. Wang needle aspiration via bronchoscopy may be an important diagnostic tool. (CHEST 2001; 119:1966-1968)

Key words: actinomycosis; bronchoscopy; endobronchial; pneumonia; Wang needle aspiration.

Abbreviation: RBI = right bronchus intermedius

Actinomycosis is a chronic suppurative bacterial infection. The causative agents are Gram-positive, nonspore-forming anaerobic or microaerophilic rods. They are endogenous oral saprophytes that dwell in carious teeth, dental plaque, and gingival and tonsillar crypts.[1] Pulmonary actinomycosis is mainly acquired through aspiration of organisms from the oropharynx.[1] The thoracic disease accounts for approximately 15 to 20% of actinomycosis cases. The thoracic disease classically presents as either a mass lesion or pneumonitis with or without pleural involvement. Primary endobronchial actinomycosis is an exceptionally uncommon cause of a mass lesion obstructing the trachea or bronchi. We present a case of endobronchial actinomycosis diagnosed using Wang needle aspiration.

CASE RETORT

An 85-year-old black man was admitted in August 1999 with a 1-day history of nausea, vomiting, and left flank pain. On review of symptoms, he reported having mild shortness of breath at rest off and on for the past 4 years. Since February 1996, he has had recurrent episodes of pneumonias and persistent bilateral pleural effusions. An extensive workup had been done over time, which included a CT scan of the chest showing right middle and lower lobe atelectasis with bilateral pleural effusion, and calcified lymph nodes in the precarinal and right hilar areas. Repeated bronchoscopy revealed a right bronchus intermedius (RBI) mass occluding 90% of its orifice. However, sputum obtained, mucosal biopsies of the mass and wash collected from the RBI, multiple thoracentesis, and a pleural biopsy remained nondiagnostic.

His medical history was also significant for a tooth abscess in February 1996 preceding his initial pneumonia, diabetes mellitus type II, hypertension, atrial fibrillation, chronic renal insufficiency, a 30-pack/year history of smoking ending in 1976, and a moderate history of alcohol use. On physical examination, the significant findings were mild respiratory distress and pallor. The lungs had percussion dullness in the right base with decreased air entry on auscultation and decreased tactile fremitus. The pulse was irregular. There was mild palpation tenderness over the left costovertebral angle and left lower quadrant. There was two-plus edema on the lower extremities.

Laboratory analysis revealed a urinary tract infection and low hemoglobin. Chest radiography showed increased right pleural effusion compared to June 1999. A CT scan of the chest done 3 weeks prior to hospital admission showed interval increase in right-sided pleural effusion and nonvisualization of a short segment of the bronchus intermedius. Bronchoscopy was repeated, and the mass obstructing the RBI was seen again (Fig 1). Wash was collected from the RBI, and Wang needle aspiration was done of the mass. The Wang needle aspirate showed colonies of Actinomyces with sulfur granules (Fig 2). Thoracentesis was not repeated. He was started on penicillin G, 2 million U q6h, and then switched to ceftriaxone, 2 g once daily for 4 weeks, and then switched to amoxicillin for an additional 5 months.

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DISCUSSION

A diagnosis of actinomycosis cannot be made from sputum cytology and/or culture unless obtained directly from the bronchus, as it can be found in 30 to 50% of normal saliva specimens.[2] Thoracic Actinomyces were diagnosed by thoracotomy in the past.[3,4] Fiberoptic bronchoscopy allows a minimally invasive approach to make the diagnosis. However, the reported diagnostic yields on BAL, bronchial wash, and bronchial biopsies reported have been low.[3,5] It has been reported that physiologic saline solution, which is commonly used for BAL, inhibits the growth of pathogenic Actinomyces. Some authors[6] have suggested that in a small crushed bronchial biopsy, the morphologic appearance of the sulfur granule may get distorted, making diagnosis difficult. The Wang needle aspirate obtained a submucosal tissue sample unlike the mucosal biopsies and was diagnostic of Actinomycosis. A literature review of the past 25 years uncovered no reported case of endobronchial actinomycosis diagnosed using Wang needle aspiration. Dissemination by biopsy is a theoretical possibility, but no reference could be found in the literature regarding it. In our case, the history of a tooth abscess preceding the patient's initial pneumonia may be relevant. A diagnosis delayed up to 44 months from the beginning of symptoms is reported by all authors,[3] as was the case in our patient. The hallmark of actinomycosis is the formation of yellow sulfur granules. Although they may be abundant, only a single granule was identified in 26% of specimens in one series.[7]

CONCLUSION

Endobronchial actinomycosis is rare and should be considered in a patient with recurrent pneumonia and an endobronchial mass. Fiberoptic bronchoscopy could help avoid a surgical procedure and aid in making a diagnosis. Wang needle aspirate by bronchoscopy may be used to obtain clinical material for diagnosis.

REFERENCES

[1] Russo TA. Agents of actinomycosis: part III; Infectious diseases and their etiologic agents. In: Mandell GL, ed. Mandell, Douglas and Bennett's principles and practice of infectious diseases. 4th ed. New York, NY: Churchill Livingstone, 1995; 2280-2281

[2] Weese WC, Smith M. A study of 57 cases of actinomycosis over a 36-year period. Arch Intern Med 1975; 135:1562-1568

[3] Jensen BM, Kruse-Anderson S, Anderson K. Thoracic actinomycosis. Scand Thorac Cardiovasc Surg 1989; 23:181-184

[4] Kinnear WJM, MacFarlane JT. A survey of thoracic actinomycosis. Respir Med 1990; 84:57-59

[5] Dalhoff K, Wallner S, Finck C, et al. Endobronchial actinomycosis. Eur Respir J 1994; 7:1189-1191

[6] Ariel I, Breuer R, Kamal NS, et al. Endobronchial actinomycosis simulating bronchogenic carcinoma. Chest 1991; 99: 493-495

[7] Hsieh MJ, Liu HP, Chang JP. Thoracic actinomycosis. Chest 1993; 104:366-370

(*) From the Division of Pulmonary and Critical Care Medicine (Drs. Bakhtawar and Salian), Department of Medicine; and Department of Pathology (Dr. Schaefer), University of Arkansas for Medical Sciences, Little Rock, AR.

Manuscript received August 8, 2000; revision accepted December 12, 2000.

Correspondence to: Iram Bakhtawar, MBBS, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham, Slot 555, Little Rock, AR 72205; e-mail: Bakhtawariram@ UAMS.edu

COPYRIGHT 2001 American College of Chest Physicians
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