Chest Infections: Fellow Case Report Slide: Chest Infections I |

A Great Masquerader: A Convoluted Path to an Uncommon Diagnosis FREE TO VIEW

Bhuvin Buddhdev, MD; Kajalben Buddhdev, MD; Brian Boer, MD
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University of Nebraska Medical Center, Omaha, NE

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):132A. doi:10.1016/j.chest.2016.08.141
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SESSION TITLE: Fellow Case Report Slide: Chest Infections I

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Monday, October 24, 2016 at 03:15 PM - 04:15 PM

INTRODUCTION: We present an interesting case that undermines the importance of high index of suspicion for non-malignant causes of lung masses

CASE PRESENTATION: A 55 year old female smoker (45 pack-year) with no significant past medical history presented to clinic with a 2 month history of productive cough, pleuritic chest pain, fever, night sweats, and weight loss of 30 pounds. General exam revealed unremarkable vital signs, poor dentition, tongue ulceration, a palpable right submandibular lymph node, and decreased breath sounds in the right upper lungs. Chest radiograph demonstrated rightward tracheal shift and dense consolidation of the right upper lobe. Subsequent CT scan of the chest and neck showed 9.5 x 6.5 x 5.6 cm right upper lobe mass with cavitary component with mediastinal and cervical lymphadenopathy. PET scan demonstrated increased F-18 FDG uptake in the lung mass, tongue lesion and submandibular lymph node. Bronchoscopy with lavage, endobronchial biopsy, and endbronchial ultrasound with transbronchial needle aspirate of lymph nodes were all non-diagnostic. The tongue mass was concurrently evaluated by biopsy which revealed squamous cell carcinoma. After multi-disciplinary discussion, she underwent glossectomy, radical neck dissection, and tracheostomy. Meanwhile, her right upper lobe progressively collapsed and appeared to be predominantly necrotic on CT. She subsequently underwent right upper lobectomy. Pathology of resected lung revealed sulfur granules consistent with actinomycosis. She was treated with amoxicillin for 6 weeks and had complete resolution of her pulmonary symptoms.

DISCUSSION: Actinomycosis is a rare disease caused by anaerobic gram-positive bacteria. It has clinical features that makes it difficult to distinguish from more common etiologies such as malignancy, tuberculosis, lung abscess, and invasive fungal infections. Due to its relative rarity coupled with its propensity to mimic many other diseases, clinicians need to be aware of this “great masquerader.” In one case series, the diagnosis was suspected on admission in <7% of patients who subsequently diagnosed with actinomycosis with average duration of 6 months to confirm diagnosis

CONCLUSIONS: Our case underscores the diagnostic dilemmas inherent to this disease and reinforces the need to have a high index of suspicion when actinomycosis may be in the differential

Reference #1: Qiu L, et al. Pulmonary Actinomycosis Imitating Lung Cancer on (18)F-FDG PET/CT: A Case Report and Literature Review. Korean J Radiol. 2015 Nov-Dec;16(6):1262-5

DISCLOSURE: The following authors have nothing to disclose: Bhuvin Buddhdev, Kajalben Buddhdev, Brian Boer

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