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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 8  |  Issue : 1  |  Page : 23-25

Pulmonary actinomycosis presenting as a pleural tumour


1 DM, Critical Care and Emergency Medicine, B & C Medical College Teaching Hospital and Research Centre, Birtamod, Jhapa, Nepal
2 Anaesthesia & Critical Care, B & C Medical College Teaching Hospital and Research Centre, Birtamod, Jhapa, Nepal
3 MBBS, Medical Officer, Critical Care and Emergency Medicine, B & C Medical College Teaching Hospital and Research Centre, Birtamod, Jhapa, Nepal

Date of Submission20-Dec-2018
Date of Decision03-May-2019
Date of Acceptance01-Oct-2019
Date of Web Publication11-Feb-2020

Correspondence Address:
Dr. Neeraj Kumar Keyal
Critical Care and Emergency Medicine, B & C Medical College Teaching Hospital and Research Centre, Birtamod, Jhapa
Nepal
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacp.jacp_27_18

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  Abstract 


Pulmonary actinomycosis is a rare gram positive higher prokaryotic bacterial infection. We hereby present a case of 78-year old male presented with non-specific symptoms like cough, shortness of breath (SOB) and chest pain mimicking as pulmonary tuberculosis, fungal infection and lung cancer but was diagnosed to have pulmonary actinomycosis. From this, we want to emphasize that pulmonary actinomycosis should be evaluated in all patients that are not responding to anti-tubercular and lung cancer treatment.

Keywords: Actinomycosis, malignancy, tuberculosis


How to cite this article:
Keyal NK, Shrestha R, Nepal N, Nakarmi M. Pulmonary actinomycosis presenting as a pleural tumour. J Assoc Chest Physicians 2020;8:23-5

How to cite this URL:
Keyal NK, Shrestha R, Nepal N, Nakarmi M. Pulmonary actinomycosis presenting as a pleural tumour. J Assoc Chest Physicians [serial online] 2020 [cited 2020 Feb 22];8:23-5. Available from: http://www.jacpjournal.org/text.asp?2020/8/1/23/278119




  Introduction Top


Actinomycosis is a chronic granulomatous disease caused by gram positive non-spore-forming anaerobic or micro aerophilic bacteria belonging to Actinomyceataceae.[1] Lung involvement is seen in only 15% patients. It is more common in male and in patients with respiratory disorders. It results from aspiration of gastrointestinal or oropharangeal secretions and from hematogeneous, lymphatic spread or spread from the neck through mediastinum but is rare.[2] There is no case report of actinomycosis presenting as a pleura tumour.


  Case history Top


A 78-year old hypertensive, diabetic chronic obstructive pulmonary disease (COPD) male with past history of pulmonary tuberculosis presented with cough, shortness of breath, chest pain and fever and weight loss of 10 kg in one month.

At presentation, Glasgow coma scale was 14/15. His pulse rate was 120 beats/per min regular, blood pressure 90/60 mm Hg, respiratory rate 26 breaths/min, oxygen saturation 88% on room air and temperature of 101°F. Respiratory system examination showed decreased breath sound on right side and crepitation on left side of chest. Cardiovascular system examination showed pansystolic murmur on tricuspid area. Abdominal examination was normal. In laboratory parameter, total leucocyte count was 22,500/mm3 with predominance of neutrophil, platelet count was normal, serum urea was 100mg/dl, creatinine was 2.7mg/dl. In liver function test bilirubin was normal, serum alanine aminitransferase (ALT) 3603U/L and serum aspartate aminotransferase (AST) was 2632 U/L and INR was 2.99. Pleural fluid examination showed exudative effusion. His sputum was negative for acid-fast bacilli, fungus and malignant cells.

Chest X-ray showed right-sided homogeneous opacity with tracheal shift suggesting of malignancy or collapse of right hemithorax ([Figure 1]). Contrast-enhanced chest tomography showed huge well-defined thin-walled hypodense cystic lesion occupying the right entire hemithorax causing mass effect and complete collapse of right lung with internal septation and calcific speaks suggesting of chronic empyema or pleural-based tumour ([Figure 2]). Lung biopsy was done and histopathological examination and staining with hematoxylin and eosin stain ([Figure 3]) confirmed it as pulmonary actinomycosis.
Figure 1 Chest X ray showing collapse of right side of lung

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Figure 2 CT Chest showing collapse of right lung with mass

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Figure 3 Hematoxylin and eosin staining showing sulfur granules

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He was diagnosed with pulmonary actinomycosis and penicillin G 16 Megaunit/day was started but patient expired on fifth day of starting treatment.


  Discussion Top


This case illustrates that pulmonary actinomycosis has similar presentation as other pulmonary disorders like pulmonary tuberculosis, fungal infection and lung malignancy which makes a lot of diagnostic dilemma among clinicians.[3]

Our patient’s age was 78 years which is different from other studies that have stated that pulmonary actinomycosis has bimodal age distribution at 11–20 years and other at 40–50 years.[4] This difference may be due to lack of study in this country and different geographical pattern. It is more common in male and COPD patients which is similar to our patient..[5] The average duration is six months for diagnosis of pulmonary actinomycosis but our patient was diagnosed in one month.[6] This may be due to early referral to our centre.

Pulmonary actinomycosis has a non-specific presentation like cough, sputum production, chest pain, dyspnoea, weight loss which was also seen in this patient and investigation for other disorders like chronic infection and malignancy of lung was negative. [7]

Pulmonary actinomycosis usually have non-specific finding on chest X-ray ranging from non-segmental pneumonia in lower zones to infiltrates and cavitating mass lesion involving pleura and chest wall.[8] In this patient, there was entire right-sided lung collapse which is usually a rare presentation of pulmonary actinomycosis.

There is a wide presentation of pulmonary actinomycosis on CT scan as a mass or pneumonia predominately affecting lower lobes. It is usually present with chronic segmental airspace consolidation containing necrotic low attenuation areas with peripheral enhancement, often accompanied by adjacent pleural thickening. Parenchymal involvement is seen as pleural thickening, empyema, effusion and small cavities which were also seen in our patient.[9] There was right-sided lung collapse which is unusual presentation of pulmonary actinomycosis.Pulmonary actinomycosis diagnosis is confirmed by histopathological examination by demonstration of sulphur granules which was also seen in this patient.

Penicillin at high dose is drug of choice but other drugs like ampicillin, tetracycline, clindamycin and levofloxacin can also be used. Surgery is also mode of treatment in patient presenting with complication like empyema, obstruction to mediastinal structure and failure of medical therapy. The prognosis is excellent with cure rate of 90% with early treatment and effective antibiotic therapy.


  Conclusion Top


Patient not responding for common chest disorder should be screened for actinomycosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wong VK, Turmezei TD, Weston VC. Actinomycosis. BMJ 2011; 343:d6099.  Back to cited text no. 1
    
2.
Mabeza GF, Macfarlane J. Pulmonary actinomycosis. Eur Respir J 2003;21:545-51.  Back to cited text no. 2
    
3.
Katsenos S, Galinos I, Styliara P, Galanopoulou N, Psathakis K. Primary bronchopulmonary actinomycosis masquerading as lung cancer. Case Rep Infect Dis 2015. doi: 10.1155/2015/609637  Back to cited text no. 3
    
4.
Heffner JE. Pleuropulmonary manifestations of actinomycosis and nocardiosis. Semin Respir Infect 1988;3:352-61.  Back to cited text no. 4
    
5.
Schaal KP, Lee HJ. Actinomycete infections in humans—a review. Gene 1992;115:201-11.  Back to cited text no. 5
    
6.
Weese WC, Smith IM. A study of 57 cases of actinomycosis over a 36-year period. A diagnostic ‘failure’ with good prognosis after treatment. Arch Intern Med 1975;135:1562-8.  Back to cited text no. 6
    
7.
Webb WR, Sagel SS. Actinomycosis involving the chest wall: CT findings. AJR Am J Roentgenol 1982;139:1007-9.  Back to cited text no. 7
    
8.
Heo SH, Shin SS, Kim JW, Lim HS, Seon HJ, Jung SI et al. Imaging of actinomycosis in various organs: a comprehensive review. Radiographics 2014; 34:19-33.  Back to cited text no. 8
    
9.
Brown JR. Human actinomycosis. A study of 181 subjects. Hum Pathol 1973;4:319-30.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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Abstract
Introduction
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Discussion
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