SESSION TYPE: Bronchology Student/Resident Case Report Posters
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Pulmonary Actinomycosis (PA) is uncommon, constituting only 15% of all forms of Actinomycosis.1 The presence of lung tissue abnormalities such as emphysema, chronic bronchitis and bronchiectasis play an important role in the development of this infection. 1Nearly a quarter of PA cases are initially misdiagnosed as lung malignancy.2 Moreover, this infection may rarely even coexist with lung cancer, as Actinomyces tends to invade devitalized necrotic tissues. There has been only 1 case reported in the English literature. We present the first case of concomitant PA and Lung Adenocarcinoma diagnosed by Electromagnetic Navigational Bronchoscopy Fine Needle Aspiration (ENB FNA).
CASE PRESENTATION: The patient is a 65-year-old man with past medical history of chronic obstructive pulmonary disease, 40 pack/year smoker, and hypertension who presents with periodic scant cough for 2 years. The patient had no chest pain, weight loss or fever. One year before the admission, an incidental finding on CT of ill-defined subcentimeter opacity in the right upper lung was attributed to subpleural scarring. A year later, repeat CT scan showed adjacent development of a semisolid nodule of 1.4 x 1.3 cm. PET/CT performed 3 weeks later showed that the lesion doubled in size along with very modest FDP uptake. Given the rapid increase in size, ENB FNA was performed to exclude infectious etiology. Fiducial markers were also deployed to facilitate eventual robotic resection for possible malignancy. ENB FNA showed atypical cells suggestive of adenocarcinoma as well as granuloma and fungal filaments characteristic of Actinomycosis. Robotic resection of the lesion confirmed the diagnosis of adenocarcinoma.
DISCUSSION: PA is difficult to recognize and diagnose. Conventional bronchoscopy with bronchoalveolar lavage has not shown to be consistently effective to diagnose PA. Moreover, bronchial samples should be obtained under strict anaerobic conditions that do not routinely occur with ordinary bronchoalveolar lavage.1 In our case, ENB FNA proved to be a safe, effective procedure in obtaining adequate samples. ENB FNA is a useful tool to demonstrate both preserved fungal elements and adenocarcinoma. Our patient’s hospital course involved a severe right lower lobe pneumonia following right upper lobectomy for Stage IA Adenocarcinoma.
CONCLUSIONS: ENB FNA may be well suited to detecting concomitant infectious etiologies along with neoplasia, and possibly improving patient outcomes.
1) G.F. Mabeza, J. Macfarlane. Pulmonary Actinomycosis. Eur Respir J 2003; 21: 545-51.
2) Hussam Elkambergy, et al. Pulmonary actinomycosis: the great masquerader. BMJ Case Rep. 2009:2009:brc07.2008.0374.
DISCLOSURE: The following authors have nothing to disclose: Maria del Castillo, Ravindra Rajmane, Jun-Chieh Tsay
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