Endobronchial actinomycosis is a rare condition often associated with a foreign body aspiration. We report such a case in a 45-year-old man who presented with dyspnea and cough. Bronchoscopy revealed a mass obstructing the bronchus intermedius and biopsy of the lesion revealed actinomycosis. On repeat bronchoscopy after 4 weeks of antimicrobial treatment, a pistachio nut shell was seen and successfully removed.
A 45-year-old man, who never smoked, presented with dyspnea and cough that was attributed to worsening asthma. He had no other symptoms. There was no history of cerebrovascular event, swallowing difficulty, dental or periodontal problem. He had a clinical diagnosis of asthma for 9 years. He was treated with inhaled steroids and bronchodilators and oral corticosteroid without relief of his symptoms.On examination his vital signs were normal and oxygen saturation by pulse oximetry was 97%. No lymphadenopathy or clubbing was detected. Auscultation of the lung fields showed wheezing more prominent on the right side. The rest of his physical examination was unremarkable.Laboratory results revealed normal complete blood count and serum chemistries. Chest radiograph showed nonspecific right sided parenchymal infiltrate. Computed tomography (CT) of the chest revealed marked narrowing of the bronchus intermedius, bronchiectasis of the right lower lobe with an infiltrate. Fiberoptic bronchoscopy revealed an endobronchial mass causing near total occlusion of the bronchus intermedius with severe mucosal inflammation and edema, mimicking endobronchial carcinoma. The bronchial mucus membrane was very friable and bled easily. Endobronchial biopsy revealed large multiple colonies of Actinomyces sp. (“sulphur granules”) surrounded with inflammatory cells (Fig 1).He had allergy to penicillin. Intravenous ceftriaxone via an indwelling catheter was started. Bronchoscopy repeated 4 weeks after antibiotic treatment revealed a pistachio nutshell lodged in the bronchus intermedius (Fig 2) which was successfully removed using endobronchial biopsy forceps. Two weeks after bronchoscopic removal of the nutshell the patient was completely free of symptoms. He was continued on antibiotic for 3 months.
Actinomycosis is most frequently caused in humans by Actinomyces israelii and the usual route of lung infection is by aspiration of oropharyngeal or gastrointestinal secretions. Endobronchial actinomycosis is a rare form of pulmonary actinomycosis most often associated with foreign body aspiration. Chouabe et al reported the largest series of endobronchial actinomycosis cases in predominantly men with known risk factors - poor dental hygiene and debilitation- for actinomycosis (1). The presenting symptoms in these patients were cough, hemoptysis and recurrent pneumonia. The initial bronchoscopy findings in all the cases revealed endobronchial mass obstructing the bronchial lumen suggestive of malignancy. Foreign body was detected during initial bronchoscopy in 50% of cases; chicken bone being most common. Our case differs from previously reported cases. Our patient is young, without debilitation or predisposing conditions. Our literature review did not reveal any previous case of endobronchial actinomycosis associated with pistachio nutshell aspiration. However our patient is similar to the cases cited previously in having an endobronchial mass mimicking tumor.
In conclusion, endobronchial actinomycosis associated with foreign body aspiration is a rare cause of endobronchial mass and atelectasis. In our patient, prominent wheezing on the right side and CT finding of a nearly occluded bronchus intermedius raised the diagnostic consideration of bronchogenic carcinoma. Histopathologic examination confirmed the diagnosis of actinomycosis. The important learning point in this case is the importance of repeating fiberoptic bronchoscopy after few weeks of antibiotic therapy to specifically look for foreign body which may be missed on the initial bronchoscopy.
Manish Joshi, None.