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Postgraduate Education Corner: Chest Imaging and Pathology for Clinicians |

A 50-Year-Old Man With a Cough and Painful Chest Wall MassCough and Painful Chest Wall Mass FREE TO VIEW

Quentin Jones, MBBS; Rachel Benamore, MBBChir; Eve Fryer, BMBCh; Anny Sykes, PhD
Author and Funding Information

From the Oxford Centre for Respiratory Medicine (Drs Jones and Sykes) and the Department of Radiology (Dr Benamore), Churchill Hospital; and the Department of Histopathology (Dr Fryer), John Radcliffe Hospital, Oxford, England.

Correspondence to: Quentin Jones, MBBS, Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, OXE 7L3, England; e-mail: quentinjones7@hotmail.com


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(5):1158-1161. doi:10.1378/chest.13-2039
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A 50-year-old man presented with a 1-week history of a painful hard lump above his right nipple. He attended the Accident and Emergency Department when the lump suddenly grew bigger and more painful. He had been unwell for 4 weeks, with a productive cough, loss of appetite, and weight loss. He was normally well, and there was no relevant medical history. He smoked 50 cigarettes a day and drank excessive quantities of alcohol each week. He worked in a warehouse and had not traveled outside the United Kingdom. On examination, he was comfortable at rest and did not look unwell. He was apyrexial, and oxygen saturations were 98% on room air. His BP was 110/70 mm Hg, and pulse rate was 90 beats/min. There was a large, hard, tender mass above his right nipple associated with some bruising of the skin. On auscultation of his chest, a few crackles were audible. His dentition was poor. The remainder of his physical examination was normal.

Laboratory workup showed a hemoglobin concentration of 9.7 g/dL, WBC count of 21,000 cells/μL, neutrophils count of 19,000 cells/μL, platelet count of 438,000 cells/μL, sodium concentration of 127 mmol/L, potassium concentration of 3.6 mmol/L, creatinine concentration of 56 μmol/L, and C-reactive protein level of > 150 mg/L. An HIV test result was negative.

The patient underwent a chest radiograph (Fig 1) and a contrast-enhanced CT chest scan (Figs 2-4). The chest radiograph showed multifocal, bilateral consolidation and diffuse, poorly marginated, increased opacity in the right midzone and enlargement and increased density of the adjacent soft tissues, suggestive of a chest wall mass. The CT scan showed multifocal bilateral nodular and mass-like consolidation, which contained areas of low attenuation in keeping with necrosis (Figs 2, 3). The mass-like consolidation in the middle lobe was causing rib erosion and extended directly into the anterior chest wall, deep to the pectoralis major muscle, where there was a multiseptated low-density collection (Figs 3, 4).

Figure Jump LinkFigure 1. Chest radiograph showing multifocal bilateral consolidation. There is a diffuse, poorly marginated, increased opacity in the right midzone and enlargement and increased density of the soft tissues, suggestive of a chest wall mass.Grahic Jump Location
Figure Jump LinkFigure 2. The CT scan shows multifocal, bilateral, nodular, and mass-like consolidation.Grahic Jump Location
Figure Jump LinkFigure 3. CT scan showing the mass-like consolidation in the middle lobe contains areas of low attenuation in keeping with necrosis and is causing rib and costal cartilage erosion; it extends directly into the anterior chest wall, deep to the pectoralis major muscle, where there is a multiseptated low-density collection.Grahic Jump Location
Figure Jump LinkFigure 4. CT scan sagittal view showing rib erosion.Grahic Jump Location

An ultrasound of the right anterior chest wall was performed, which confirmed that the swelling was caused by a localized fluid collection. Image-guided aspiration yielded frank pus. Gram stain showed gram-positive filamentous rods.

What is the diagnosis?
Diagnosis: Actinomycosis with empyema necessitans
Clinical Discussion

Actinomycoses are commensals in the human oropharynx, GI tract, and female genitalia. Rarely, they cause chronic suppurative granulomatous inflammation with abscess and sinus tract formation. The most common sites of infection are the face, jaw, abdomen, pelvis, and lungs.1 Pulmonary actinomycosis accounts for 15% to 20% of cases1,2 and is associated with chronic respiratory disorders, alcoholism, and poor oral hygiene.3,4 Aspiration of secretions containing actinomycosis is thought to be the mechanism of infection.5 The disease is more common in men2; it has been suggested that this may be because of poorer oral hygiene in men and higher rates of trauma from fist fights.5 A clue to the diagnosis in this patient was the history of poor dentition and increased alcohol intake. On taking a more detailed history, it transpired that he had recently removed a rotten tooth himself with a pair of pliers.

Like pneumonia, pulmonary actinomycosis frequently presents with a low-grade fever, cough, and shortness of breath. However, unlike in pneumonia, the history is often longer, and weight loss and chest pain may be prominent features (as in this patient).6 There are usually pulmonary infiltrates, which may invade surrounding structures including the ribs, mediastinum, and soft tissue of the chest wall, causing pain. This patient developed empyema necessitans caused by invasion of the pleural space followed by invasion of the chest wall. It is likely that the history of sudden chest pain and the increasing size of the chest wall mass were caused by rupture of the abscess though the chest wall.

The mainstay of treatment of actinomycosis is prolonged antibiotics. In vitro studies indicate that the organism is sensitive to a wide range of antibiotics, including penicillin.7 Historically, treatment consisted of high-dose IV penicillin for a long duration (generally 6 weeks) followed by oral antibiotics for up to 6 to 12 months.8 The risk of developing penicillin resistance is thought to be low. More recently, successful outcomes with a shorter duration of antibiotics have been reported.9 In a series of 16 patients, cure was achieved after a median duration of 2 weeks of IV antibiotics and 3 months of oral penicillin.10 Erythromycin, clindamycin, and doxycycline are alternative antibiotics for patients allergic to penicillin.11,12

Surgery may be needed in the treatment of large abscesses and empyema, especially if sinus tracts, fistulas, or extensive necrotic tissue are present.13 Surgery should also be considered in patients who respond poorly to antibiotics. A retrospective review identified five patients who had responded poorly to initial antibiotics and went on to have successful surgical treatment.14 Prolonged antibiotic treatment is also necessary after surgery, because surgery alone is not curative. Prognosis in actinomycosis is generally excellent.9

Radiologic Discussion

Pulmonary actinomycosis may mimic other chronic suppurative lung diseases such as TB, nocardiosis, fungal disease, lung abscess, and thoracic malignancies. Radiographic findings in actinomycosis are often nonspecific, particularly in the early stages of infection. Various CT scan findings have been described, including multifocal or mass-like consolidation, which may involve the chest wall and pleura and may cavitate and form abscesses and sinus tracts. There is often a peripheral and lower-lobe predominance of disease.15 Unlike in most infections, regional lymphadenopathy is rare.

The differential diagnoses of the radiologic findings in actinomycosis include infection (TB, fungal disease, invasive pulmonary aspergillosis, botryomycosis, nocardiosis, and other subacute bacterial necrotizing pneumonias), malignancy (multifocal adenocarcinoma, necrotic bronchogenic carcinoma, and lymphoma), and vasculitis (granulomatosis with polyangiitis [Wegener] and atypical granulomatosis with polyangiitis). In this patient, infection was most likely caused by the presumed abscess formation in the chest wall.

The diagnosis of pulmonary actinomycosis can be difficult. Up to one-quarter of cases may be misdiagnosed initially as malignancy, leading to delay in treatment and unnecessary surgical procedures.16 An added diagnostic difficulty is that actinomycosis may colonize necrotic tissues and coexist with malignancy.2 The presence of air bronchograms within mass-like, pleural-based densities may help distinguish actinomycosis from malignancy; however, imaging alone is insufficient to make the diagnosis. Pathologic confirmation by culturing actinomycosis is vital.

Pathologic Discussion

Actinomycosis is a slow-growing, gram-positive rod that frequently branches. The organism was first isolated in the nineteenth century from jaw abscesses in cattle. The name “actinomycosis” derives from the Greek term “akino,” which refers to the radiating appearance of sulfur granules and “mykos,” meaning fungus (a misnomer because the organism is actually a bacterium). Sulfur granules are colonies of organisms arranged in round basophilic masses with eosinophilic terminal clubs on staining with hematoxylin-eosin. However, they are often best seen when stained with periodic acid shift diastase, which highlights their structure (Fig 5). Sulfur granules can be distinguished from the Bollinger granules found in Botryomycosis (a rare granulomatous bacterial infection, usually caused by Staphylococcus aureus, which mimics actinomycosis). Bollinger granules are rings of bacteria surrounded by eosinophilic matrix but, unlike sulfur granules, they lack filamentous structures.

Figure Jump LinkFigure 5. Actinomycosis forming sulfur granules (periodic acid shift diastase, original magnification × 100).Grahic Jump Location

Actinomycosis is a fastidious organism that may be difficult to isolate. Failure to culture the organism can be caused by antibiotic therapy, overgrowth by a contaminant, or inadequate culture technique. Less than 30 min of exposure to air may result in inhibition of actinomycosis. Protected specimen brushing with expedient transport of specimens and taking a sample prior to administering antibiotics may improve the yield. Bronchoscopy is usually not useful in making the diagnosis.

Demonstration of a gram-positive filamentous branching organism and sulfur granules on histologic examination supports the diagnosis of actinomycosis. However, sulfur granules are not always present and can occur in other conditions, such as nocardiosis. If actinomycosis is suspected, the microbiology laboratory should be asked specifically for actinomycosis cultures. In general, the organism is identified by colony morphology and biochemical profiling. Molecular genetic techniques using polymerase chain reaction, 16s ribosomal RNA sequencing, and comparison with a database, or fluorescence in situ hybridization can rapidly confirm the diagnosis. Direct staining with fluorescent-conjugated monoclonal antibody may also allow rapid identification.

In this patient, cultures of pus aspirated from the chest wall grew Actinomyces meyeri. The chest wall abscess was incised and drained. A 32F chest drain was inserted into the pleural cavity, with a corregated drain into the subpectoral abscess cavity. The patient received 6 weeks of IV benzyl penicillin followed by 6 months of oral penicillin and made a good recovery.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions:CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

Mabeza GF, Macfarlane J. Pulmonary actinomycosis. Eur Respir J. 2003;21(3):545-551. [CrossRef] [PubMed]
 
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(12):1562-1568. [CrossRef] [PubMed]
 
Russo TA. Agents of actinomycosis.. In:Mandell GL., ed. Principles and Practice of Infection Disease.5th ed. New York, NY: Churchill Livingstone; 1995:2645-2654.
 
Brown JR. Human actinomycosis. A study of 181 subjects. Hum Pathol. 1973;4(3):319-330. [CrossRef] [PubMed]
 
Bennhoff DF. Actinomycosis: diagnostic and therapeutic considerations and a review of 32 cases. Laryngoscope. 1984;94(9):1198-1217. [CrossRef] [PubMed]
 
Kinnear WJ, MacFarlane JT. A survey of thoracic actinomycosis. Respir Med. 1990;84(1):57-59. [CrossRef] [PubMed]
 
Smith AJ, Hall V, Thakker B, Gemmell CG. Antimicrobial susceptibility testing ofActinomycesspecies with 12 antimicrobial agents. J Antimicrob Chemother. 2005;56(2):407-409. [CrossRef] [PubMed]
 
Brook I. Actinomycosis: diagnosis and management. South Med J. 2008;101(10):1019-1023. [CrossRef] [PubMed]
 
Wong VK, Turmezei TD, Weston VC. Actinomycosis. BMJ. 2011;343:d6099. [CrossRef] [PubMed]
 
Sudhakar SS, Ross JJ. Short-term treatment of actinomycosis: two cases and a review. Clin Infect Dis. 2004;38(3):444-447. [CrossRef] [PubMed]
 
Fass RJ, Scholand JF, Hodges GR, Saslaw S. Clindamycin in the treatment of serious anaerobic infections. Ann Intern Med. 1973;78(6):853-859. [CrossRef] [PubMed]
 
Kolditz M, Bickhardt J, Matthiessen W, Holotiuk O, Höffken G, Koschel D. Medical management of pulmonary actinomycosis: data from 49 consecutive cases. J Antimicrob Chemother. 2009;63(4):839-841. [CrossRef] [PubMed]
 
Conant EF, Wechsler RJ. Actinomycosis and nocardiosis of the lung. J Thorac Imaging. 1992;7(4):75-84. [CrossRef] [PubMed]
 
Song JU, Park HY, Jeon K, Um SW, Kwon OJ, Koh WJ. Treatment of thoracic actinomycosis: a retrospective analysis of 40 patients. Ann Thorac Med. 2010;5(2):80-85. [CrossRef] [PubMed]
 
Kwong JS, Müller NL, Godwin JD, Aberle D, Grymaloski MR. Thoracic actinomycosis: CT findings in eight patients. Radiology. 1992;183(1):189-192. [PubMed]
 
Slade PR, Slesser BV, Southgate J. Thoracic actinomycosis. Thorax. 1973;28(1):73-85. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1. Chest radiograph showing multifocal bilateral consolidation. There is a diffuse, poorly marginated, increased opacity in the right midzone and enlargement and increased density of the soft tissues, suggestive of a chest wall mass.Grahic Jump Location
Figure Jump LinkFigure 2. The CT scan shows multifocal, bilateral, nodular, and mass-like consolidation.Grahic Jump Location
Figure Jump LinkFigure 3. CT scan showing the mass-like consolidation in the middle lobe contains areas of low attenuation in keeping with necrosis and is causing rib and costal cartilage erosion; it extends directly into the anterior chest wall, deep to the pectoralis major muscle, where there is a multiseptated low-density collection.Grahic Jump Location
Figure Jump LinkFigure 4. CT scan sagittal view showing rib erosion.Grahic Jump Location
Figure Jump LinkFigure 5. Actinomycosis forming sulfur granules (periodic acid shift diastase, original magnification × 100).Grahic Jump Location

Tables

References

Mabeza GF, Macfarlane J. Pulmonary actinomycosis. Eur Respir J. 2003;21(3):545-551. [CrossRef] [PubMed]
 
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(12):1562-1568. [CrossRef] [PubMed]
 
Russo TA. Agents of actinomycosis.. In:Mandell GL., ed. Principles and Practice of Infection Disease.5th ed. New York, NY: Churchill Livingstone; 1995:2645-2654.
 
Brown JR. Human actinomycosis. A study of 181 subjects. Hum Pathol. 1973;4(3):319-330. [CrossRef] [PubMed]
 
Bennhoff DF. Actinomycosis: diagnostic and therapeutic considerations and a review of 32 cases. Laryngoscope. 1984;94(9):1198-1217. [CrossRef] [PubMed]
 
Kinnear WJ, MacFarlane JT. A survey of thoracic actinomycosis. Respir Med. 1990;84(1):57-59. [CrossRef] [PubMed]
 
Smith AJ, Hall V, Thakker B, Gemmell CG. Antimicrobial susceptibility testing ofActinomycesspecies with 12 antimicrobial agents. J Antimicrob Chemother. 2005;56(2):407-409. [CrossRef] [PubMed]
 
Brook I. Actinomycosis: diagnosis and management. South Med J. 2008;101(10):1019-1023. [CrossRef] [PubMed]
 
Wong VK, Turmezei TD, Weston VC. Actinomycosis. BMJ. 2011;343:d6099. [CrossRef] [PubMed]
 
Sudhakar SS, Ross JJ. Short-term treatment of actinomycosis: two cases and a review. Clin Infect Dis. 2004;38(3):444-447. [CrossRef] [PubMed]
 
Fass RJ, Scholand JF, Hodges GR, Saslaw S. Clindamycin in the treatment of serious anaerobic infections. Ann Intern Med. 1973;78(6):853-859. [CrossRef] [PubMed]
 
Kolditz M, Bickhardt J, Matthiessen W, Holotiuk O, Höffken G, Koschel D. Medical management of pulmonary actinomycosis: data from 49 consecutive cases. J Antimicrob Chemother. 2009;63(4):839-841. [CrossRef] [PubMed]
 
Conant EF, Wechsler RJ. Actinomycosis and nocardiosis of the lung. J Thorac Imaging. 1992;7(4):75-84. [CrossRef] [PubMed]
 
Song JU, Park HY, Jeon K, Um SW, Kwon OJ, Koh WJ. Treatment of thoracic actinomycosis: a retrospective analysis of 40 patients. Ann Thorac Med. 2010;5(2):80-85. [CrossRef] [PubMed]
 
Kwong JS, Müller NL, Godwin JD, Aberle D, Grymaloski MR. Thoracic actinomycosis: CT findings in eight patients. Radiology. 1992;183(1):189-192. [PubMed]
 
Slade PR, Slesser BV, Southgate J. Thoracic actinomycosis. Thorax. 1973;28(1):73-85. [CrossRef] [PubMed]
 
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