SESSION TYPE: Infectious Disease Cases I
PRESENTED ON: Monday, October 22, 2012 at 01:45 PM - 03:00 PM
INTRODUCTION: Pulmonary actinomycosis is challenging to identify. Delayed diagnosis and misdiagnosis are common.
CASE PRESENTATION: A 47 year-old Hispanic male presented with recurrent hemoptysis of 30-60 ml four to five times per day. Initially, he was admitted to an outside hospital for similar symptoms lasting five days. A CT scan of the chest showed a middle lobe infiltrate and no endobronchial mass. Bronchoscopy located the bleeding to the lateral middle lobe. Initial cytopathology and microbiology were unremarkable, although Mycobacterium fortuitum grew after three weeks. The patient was discharged with a 10-day course of doxycycline and a steroid taper. He remained asymptomatic for two months until hemoptysis recurred and became severe. On physical exam the patient was afebrile and respiratory exam was unremarkable. Repeat imaging reported interval worsening of the middle lobe consolidation and a 1 cm rounded fluid density structure adjacent to the right hilum (Figure 1). Further diagnostic tests were unrevealing. Eventually, due to persistent and recurrent symptoms of hemoptysis, a lobectomy of the middle lobe was performed to control bleeding and obtain a diagnosis. Pathology revealed lymphocytic infiltrates associated with features of organizing pneumonia and isolation of bacilli-like, Grocott’s methenamine silver positively staining branching organisms consistent with Actinomyces (Figure 2). The patient was discharged on clindamycin due to a penicillin allergy. He has been relapse-free for six months.
DISCUSSION: Actinomycosis is a chronic suppurative infection caused by gram-positive, microaerophilic branching bacteria. It can involve any organ and can mimic a variety of pulmonary diseases. It has become a rare infection in the developed world attributed to improved oral hygiene and the availability of antibiotics (1,2). Pulmonary actinomycosis is less common (15% prevalence) than the cervicofacial type (60% prevalence) and has been reported in patients with underlying pulmonary disorders like emphysema, chronic bronchitis, and bronchiectasis (2). Hemoptysis has been reported in approximately 30% of thoracic actinomycosis, though massive hemoptysis is uncommon making this case unique. Current treatment is a 2-to 6-week course of intravenous penicillin G followed by oral penicillin V (or amoxicillin) for another 6-12 months (1,2).
CONCLUSIONS: In this patient the clinical picture of massive and persistent hemoptysis raised concern for malignancy or mycobacterial infection. When the comprehensive evaluation was nondiagnostic, a lobectomy was pursued to contain the bleeding. This revealed an unexpected diagnosis of pulmonary actinomycosis.
1) Hsieh MJ, Liu HP. Thoracic actinomycosis. Chest 1993; 104: 366-370.
2) Mabeza GF, Macfarlane J. Pulmonary actinomycosis. Eur Respir J 2003; 21(3): 545-551.
DISCLOSURE: The following authors have nothing to disclose: Dagmar Lin, Timothy Scialla
No Product/Research Disclosure InformationJackson Memorial Hospital/University of Miami, Miami, FL