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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 2  |  Issue : 3  |  Page : 298-301

Pulmonary actinomycosis masquerading as a malignant lung tumor


1 Department of Pulmonary Medicine, King George Medical University, Lucknow, Uttar Pradesh, India
2 Department of Pathology, RML Institute, Lucknow, Uttar Pradesh, India
3 Department of Medicine, Balrampur Hospital, Lucknow, Uttar Pradesh, India

Date of Web Publication12-Jun-2015

Correspondence Address:
Dr. Ajay Kumar Verma
Department of Pulmonary Medicine, King George's Medical University, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-3334.158722

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  Abstract 

Pulmonary actinomycosis being a rare disease is an important and challenging diagnosis to make. The disease is commonly confused with conditions such as chronic suppurative lung diseases and malignancy thus requiring a high index of suspicion. Considerable psychological and physical morbidity, including unwarranted surgery can be prevented with an early and accurate diagnosis. We hereby present a case of 60-year-old male who presented to a tertiary care hospital with the chief complaint of hemoptysis and chest pain. On evaluating for the cause of hemoptysis, the clinical and radiologic findings were suggestive of lung cancer. The diagnosis of actinomycosis was determined by computed tomography guided transthoracic lung biopsy. Respiratory physicians should be aware of this important differential when investigating patients for persistent pulmonary shadowing.

Keywords: Hemoptysis, malignancy, pulmonary actinomycosis


How to cite this article:
Prakash V, Kant S, Mishra AK, Verma AK, Shukla S, Yadav S. Pulmonary actinomycosis masquerading as a malignant lung tumor. CHRISMED J Health Res 2015;2:298-301

How to cite this URL:
Prakash V, Kant S, Mishra AK, Verma AK, Shukla S, Yadav S. Pulmonary actinomycosis masquerading as a malignant lung tumor. CHRISMED J Health Res [serial online] 2015 [cited 2020 Aug 6];2:298-301. Available from: http://www.cjhr.org/text.asp?2015/2/3/298/158722


  Introduction Top


Actinomyces organisms are anaerobic or microaerophilic, non-spore-forming, Gram-positive bacilli [1] deriving its name from the resemblance to fungi. [2] Among six pathogenic species of Actinomyces spp.,  Actinomyces israelii Scientific Name Search he most common human pathogen. It usually involves oral and cervicofacial areas. About 15% of the infections caused by Actinomyces involve the thorax. [3],[4] Pulmonary actinomycosis may presents as a pulmonary infiltrate or a mass. The most common symptoms are chest pain, productive cough, and dyspnea. These non-specific clinical and radiologic presentations make pulmonary actinomycosis difficult to be diagnosed and often lead to misinterpretation as malignancy rather than an infective process. We hereby present a case of 60-year-old male who presented with findings suggestive of lung cancer but eventually the diagnosis of actinomycosis was determined by computed tomography guided transthoracic lung biopsy. Respiratory physicians should be aware of this important differential when investigating patients for persistent pulmonary shadowing.


  Case Report Top


A 60-year-old male, nonhypertensive non diabetic presented to our department with chief complaints of hemoptysis and severe chest pain for 7 months. General examination was nonsignificant and on respiratory examination there were findings of a space occupying lesion on the left upper hemithorax that is decreased breath sound and dullness on percussion. Routine blood investigations were within normal limits. X-ray chest confirmed the suspicion of left upper zone Intrathoracic mass [Figure 1]. He was a chronic bidi smoker (smoking index 1000 and pack years 50).
Figure 1: X-ray chest PA view showing left upper zone Intrathoracic mass

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Considering the age, smoking habit, and clinical profile, there was a high suspicion of any lung malignancy particularly bronchogenic carcinoma (BACA). So a contrast-enhanced computed tomography (CT) thorax was ordered to further evaluate the etiology which revealed an ill-defined heterogeneously enhancing soft tissue attenuation lesion with irregular margin (measuring approx. 5.5 × 4.2 × 5.0 cm) in size in left upper lobe. The lesion was also infiltrating the overlying pleura and was seen abutting with left subclavian and common carotid artery [Figure 2]. Features suggestive of lymphangitis carcinomatosa were also present [Figure 3]. All these features were in favor of diagnosis of a neoplastic etiology-BACA. The other possible differentials that were in our mind were tubercular intrathoracic mass, Askin's tumor and neurogenic tumors.
Figure 2: Computed tomography thorax demonstrating left upper lobe Intrathoracic mass invading overlying pleura, subclavian and common carotid artery

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Figure 3: Computed tomography thorax revealing possible lymphangitis carcinomatosa

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To confirm lung malignancy and for further subtyping CT guided fine-needle aspiration cytology and biopsy was done. To our utmost surprise the histopathology revealed multiple periodic acid Schiff positive colonies on a background of dense neutrophillic infiltrate confirming actinomycosis [Figure 4]. Patient was started on i.m. Benzyl Penicillin 5 million IU/day and he is performing well. He has now got relief from hemoptysis and chest pain and is in our regular follow-up.
Figure 4: Periodic acid Schiff stain showing actinomyces colonies along with a background of neutrophilic infiltrate

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This case emphasizes that respiratory physicians should be aware of actinomycosis as an important differential diagnosis when investigating patients suspected for lung malignancy. Identification of Actinomycosis at an early stage will lead to a reduction in morbidity and mortality as the disease has an excellent prognosis on treatment and will also help in differentiating it from BACA that has a grave prognosis.


  Discussion Top


Actinomyces organisms are anaerobic or microaerophilic, non-spore-forming, Gram-positive bacilli [1] deriving its name from the resemblance to fungi. [2] About 15% of the infections caused by Actinomyces involve the thorax. [3],[4] Most probable mechanism for pulmonary actinomycosis is aspiration from the oral cavity or gastrointestinal tract in a person with poor oral hygiene. Actinomyces israelii which is supposed to be the main cause in majority of the cases of pulmonary actinomycosis can be commonly found in the oral cavity particularly in case of poor oral hygiene and sometimes by direct extension from the infected cervical fascia.

The typical presenting features are chest pain, productive cough associated with skin changes, fistulas, and underlying pleural and bony abnormalities visible on a chest radiograph. However, the differential diagnosis of these conditions is very broad and can even mimic lung cancer. Spread to the pleura and chest wall may result in chest wall pain. The disease has the potential to be the cause of a chronic debilitating illness. [4],[5],[6],[7],[8],[9],[10] Definitive diagnosis on clinical grounds can be difficult. Pulmonary actinomycosis frequently develops in middle to old aged males, especially having the habit of alcohol abuse, smoking and structural lung diseases. While the clinical presentations are now milder than those in the previous reports, hemoptysis is one of the cautious symptoms of pulmonary actinomycosis. [11]

On radiological evaluation, there may be a peripheral and/or lower lobe predominance which probably reflects the role of aspiration in its pathogenesis. [3] Most lesions may be unilateral. [12] Chest wall and bony invasion are a common finding. Periosteal reaction of ribs strongly favors pulmonary actinomycosis. [13] The radiological findings of pulmonary actinomycosis can vary a lot ranging from a benign infection to metastatic tumor. [14] The main concern for many physicians is to distinguish the disease from a neoplasm. [14] On simple chest radiographs, consolidation or mass-like lesion is common. [14] On chest CT scan, pulmonary actinomycosis can present as a patchy air-space consolidation, nodular appearance with central low attenuation, mass appearance, pleural thickening, empyema or lymphadenopathy. [14] Mass-like shadow is the most common radiographic finding (37%) and endobronchial mass with luminal occlusion is the most frequent bronchoscopic finding (56%). [15] The relatively noninvasive procedure such as transthoracic needle biopsy is very useful for its diagnosis. [14]

Antibiotic treatment with penicillin and alternatively doxycycline is associated with an excellent clinical cure rate despite high rates of penicillin intolerance, individual treatment duration can be shortened below the recommended 6-12 months; however, treatment below 3 months in exclusively medically treated patients might be associated with complications during follow-up. [16]

Respiratory physicians should be aware of this important differential diagnosis which will expedite the diagnosis of this well treatable condition with an excellent prognosis, if picked up early. [17] It deserves attention because of the potential difficulty in the differential diagnosis of it from lung cancer. [17] In conclusion, it could be recommended that clinicians should consider pulmonary actinomycosis as one of the differential diagnoses for refractory pulmonary shadowing not responding to usual treatment.


  Conclusion Top


Actinomycosis should be considered in a case of an Intrathoracic mass as a differential diagnosis. Formal tissue diagnosis should be obtained whenever possible to confirm this and also to rule out any other possibilities. Empirical cancer chemo-therapy suspecting any Intrathoracic mass as BACA should not be practiced or promoted.

 
  References Top

1.
Bennhoff DF. Actinomycosis: Diagnostic and therapeutic considerations and a review of 32 cases. Laryngoscope 1984;94:1198-217.  Back to cited text no. 1
    
2.
Rippon JW. Medical mycology. In: Wonsiewicz MJ, editor. The Pathogenic Fungi and the Pathogenic Actinomycetes. 3 rd ed. Philadelphia: W.B. Saunders Co.; 1988. p. 30-52.  Back to cited text no. 2
    
3.
Mabeza GF, Macfarlane J. Pulmonary actinomycosis. Eur Respir J 2003;21:545-51.  Back to cited text no. 3
    
4.
Webb WR, Sagel SS. Actinomycosis involving the chest wall: CT findings. AJR Am J Roentgenol 1982;139:1007-9.  Back to cited text no. 4
    
5.
Tomm KE, Raleigh JW, Guinn GA. Thoracic actinomycosis. Am J Surg 1972;124:46-8.  Back to cited text no. 5
    
6.
Rolston KV, Rodriguez S, Dholakia N, Whimbey E, Raad I. Pulmonary infections mimicking cancer: A retrospective, three-year review. Support Care Cancer 1997;5:90-3.  Back to cited text no. 6
    
7.
Frank P, Strickland B. Pulmonary actinomycosis. Br J Radiol 1974;47:373-8.  Back to cited text no. 7
    
8.
He LX. Differential diagnosis between tuberculosis and cancer of lung. Analysis of 65 tuberculosis cases diagnosed by fiber-bronchoscopy. Zhonghua Jie He He Hu Xi Za Zhi 1991;14:69-70, 125.  Back to cited text no. 8
    
9.
Hsieh MJ, Liu HP, Chang JP, Chang CH. Thoracic actinomycosis. Chest 1993;104:366-70.  Back to cited text no. 9
    
10.
Slade PR, Slesser BV, Southgate J. Thoracic actinomycosis. Thora×1973;28:73-85.  Back to cited text no. 10
    
11.
Kim SR, Jung LY, Oh IJ, Kim YC, Shin KC, Lee MK, et al. Pulmonary actinomycosis during the first decade of 21 st century: Cases of 94 patients. BMC Infect Dis 2013;13:216.  Back to cited text no. 11
    
12.
Cheon JE, Im JG, Kim MY, Lee JS, Choi GM, Yeon KM. Thoracic actinomycosis: CT findings. Radiology 1998;209:229-33.  Back to cited text no. 12
    
13.
Poey C, Giron J, Verhaegen F, Levenes H, Gruels S, Fajadet P, et al. X-ray computed tomographic and radiographic aspects of thoracic actinomycosis. J Radiol 1996;77:177-83.  Back to cited text no. 13
    
14.
Kim TS, Han J, Koh WJ, Choi JC, Chung MJ, Lee JH, et al. Thoracic actinomycosis: CT features with histopathologic correlation. AJR Am J Roentgenol 2006;186:225-31.  Back to cited text no. 14
    
15.
Dujneungkunakorn T, Riantawan P, Tungsagunwattana S. Pulmonary actinomycosis: A study of 16 cases from Central Chest Hospital. J Med Assoc Thai 1999;82:531-5.  Back to cited text no. 15
    
16.
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;63:839-41.  Back to cited text no. 16
    
17.
Montazeri V, Sokouti M, Fakhrju A. Pulmonary Actinomycosis Mimicking Lung Cancer. Iran J Med Sci 2007;3:4-249.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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