A case of endobronchial actinomycosis as a challenging cause of lung atelectasis

Bronchiectatic Actinomycosis with Osseous Metaplasia Masquerading as Lung Cancer

Bronchial involvement in pulmonary actinomycosis is rare and has been reported in the literature rarely. However, these reports describe endobronchial actinomycosis secondary to foreign body aspiration (for example, a fish bone). Our case did not have any history or clinical evidence suggesting foreign body aspiration, which makes it even more rare. A 55-year-old woman presented with complaints of on and off haemoptysis and cough for three weeks. In view of the haemoptysis and consolidation seen on imaging, a bronchoalveolar lavage was done and sent for cytological assessment. Few atypical cells with nuclear hyperchromasia and prominent nucleoli were noted. In view of the persistent haemoptysis, worsening symptoms, and non-resolution of the consolidation despite antibiotics, and the finding of atypical cells, segmental resection was done. A final diagnosis of bronchiectatic actinomycosis with osseous metaplasia was given. The patient was started on prolonged antibiotics with good response and recovery. Other risk factors associated with pulmonary actinomycosis include alcoholism, diabetes, haematological diseases, human immunodeficiency viral infection, use of immunosuppressants, and rarely chronic lung diseases, such as bronchiectasis. Our case had this rare association of bronchiectasis with bronchial actinomycosis. Bronchiectatic actinomycosis is a rare infection and it can mimic several lung disorders like unresolving pneumonia, pulmonary tuberculosis, foreign body, and even lung tumours. The pathologists and clinicians should be aware of this entity and thus help in the early diagnosis and better management of patients with this disease.

The diagnosis and management of pulmonary actinomycosis

Pulmonary actinomycosis is a rare infection caused by the bacterial species actinomyces. This paper aims to provide a comprehensive review of pulmonary actinomycosis to improve awareness and knowledge. The literature was analysed using databases including Pubmed, Medline and Embase from 1974 to 2021. After inclusion and exclusion, a total of 142 papers were reviewed. Pulmonary actinomycosis is a rare disease occurring in approximately 1 per 3,000,000 people annually. Historically, pulmonary actinomycosis was a common infection with high mortality; however, the infection has become rarer since the widespread use of penicillins. Actinomycosis is known as "the great masquerade"; however, it can be differentiated from other diseases with acid-fast negative ray-like bacilli and sulphur granules being pathognomonic. Complications of the infection include empyema, endocarditis, pericarditis, pericardial effusion, and sepsis. The mainstay of treatment is prolonged antibiotic therapy, with adjuvant surgery in severe cases. Future research should focus on multiple areas, including the potential risk secondary to immunosuppression from newer immunotherapies, the utility of newer diagnostic techniques and ongoing surveillance post-therapy.

Paediatric pulmonary actinomycosis: A forgotten disease

Actinomycosis is a rare, indolent and invasive infection caused by Actinomyces species. Actinomycosis develops when there is disruption of the mucosal barrier, and invasion and systemic spread of the organism, which can lead to endogenous infection affecting numerous organs. It is known to spread in tissue through fascial planes and most often involves the cervicofacial (55%), abdominopelvic (20%) and thoracic (15%) soft tissue. Pulmonary actinomycosis is rare in patients under the age of five years, with the median reported age in the fifth decade. Clinical findings include chest wall mass (49%), cough (40%), pain (back, chest, shoulders) (36%), weight loss (19%), fever (19%), Draining sinuses (15%) and hemoptysis (9%). Chest x-ray findings in pulmonary actinomycosis are mostly nonspecific and can overlap with pulmonary tuberculosis, foreign body aspiration and malignancy. Endobronchial tissue aggregates may show sulphur granules, with yellow to white conglomerate areas of gram positive Actinomyces. Removal or biopsy of these large endobronchial masses must be done with care, because of the risk of bleeding and large airway obstruction. The cytology on bronchoalveolar lavage fluid may show Periodic acid-Schiff (PAS) positive stain, ZN negative and Gram-positive filamentous bacilli which is morphologically suggestive of Actinomycosis. Actinomyces spp is highly susceptible to beta lactam antibiotics, penicillin G, and amoxicillin. A minimum of 3-6 months is needed but up to 20 months of treatment may be needed. Early diagnosis and correct treatment can lead to a good prognosis with a low mortality.