Thoracic actinomycosis

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.

Pulmonary actinomycosis as a cause of chronic productive cough in a heavy smoker male with poor dental hygiene: A case report

Pulmonary actinomycosis is a rare chronic granulomatous bacterial disease caused by Actinomyces species. Given its nonspecific clinical and radiological manifestations, the diagnosis might be delayed or even missed. Pulmonary actinomycosis mimics tuberculosis, aspergillosis, or malignancy both clinically and radiographically, and it should be considered in patients with chronic lung diseases.

Hyalectanase Activities by the ADAMTS Metalloproteases

The hyalectan family is composed of the proteoglycans aggrecan, versican, brevican and neurocan. Hyalectans, also known as lecticans, are components of the extracellular matrix of different tissues and play essential roles in key biological processes including skeletal development, and they are related to the correct maintenance of the vascular and central nervous system. For instance, hyalectans participate in the organization of structures such as perineural nets and in the regulation of neurite outgrowth or brain recovery following a traumatic injury. The ADAMTS (A Disintegrin and Metalloprotease domains, with thrombospondin motifs) family consists of 19 secreted metalloproteases. These enzymes also perform important roles in the structural organization and function of the extracellular matrix through interactions with other matrix components or as a consequence of their catalytic activity. In this regard, some of their preferred substrates are the hyalectans. In fact, ADAMTSs cleave hyalectans not only as a mechanism for clearance or turnover of proteoglycans but also to generate bioactive fragments which display specific functions. In this article we review some of the physiological and pathological effects derived from cleavages of hyalectans mediated by ADAMTSs.

Pulmonary actinomycosis mimicking lung cancer on positron emission tomography

Pulmonary actinomycosis frequently mimics lung malignancy on radiologic imaging studies. Positron emission tomography-computed tomography (PET-CT) is a useful diagnostic modality for differentiating lung malignancy from benign diseases. However, few studies evaluated PET-CT findings of pulmonary actinomycosis. Therefore, it is unclear whether PET-CT is helpful to distinguish lung malignancy from benign lung disease when pulmonary actinomycosis is clinically suspected. We investigated PET-CT findings in 11 patients with pathologically confirmed pulmonary actinomycosis. The median maximal standardized uptake value (SUV) on PET-CT of pulmonary actinomycosis was increased to 5.5 (interquartile range, 4.2-8.8), which was higher than the threshold value of 2.5 indicating malignancy. Pulmonary actinomycosis without central necrosis demonstrated higher maximal SUV of 7.5 (4.9-12.2) compared to 4.8 (3.2-5.6) of ones with central necrosis. PET-CT might be not helpful in differentiating lung malignancy from benign lesions when pulmonary actinomycosis is clinically suspected.

Recurrent endobronchial actinomycosis following an interventional procedure

Actinomycosis is an indolent, slowly progressive infection caused by anaerobic or microaerophilic bacteria, primarily from the genus Actinomyces. Thoracic involvement is observed in approximately 15% of cases of infection with actinomycosis. Here, we present a case of a 61-year-old male who presented with recurrent endobronchial actinomycosis. The case is being presented because of its rarity on three counts - endobronchial involvement, which is uncommon, recurrence in different sites in the bronchial tree, which is even rarer and development of the disease following an endobronchial procedure.

Pulmonary actinomycosis during the first decade of 21st century: cases of 94 patients

Background

Pulmonary actinomycosis is a chronic pulmonary infection caused by Actinomyces. Both improving oral hygiene and early application of antibiotics to the case of suspicious pulmonary infections result in changes in incidences and presentations of pulmonary actinomycosis. However, there are little reports dealt with the recent clinical characteristics of pulmonary actinomycosis. This study aimed to review the characteristics of pulmonary actinomycosis occurred during the first decade of 21st century.

Methods

This retrospective study was performed on 94 subjects with pulmonary actinomycosis diagnosed pathologically from January 2000 to December 2010 in 13 hospitals in Korea.

Results

The data of the study showed that pulmonary actinomycosis occurs frequently in middle to old-aged males (mean age; 57.7 years old) and that the most common symptoms are cough, hemoptysis, and sputum production. Various radiologic features such as the consolidation with central low attenuation (74.5%) and no regional predominance were also observed. Most of patients recovered completely with medical and/or surgical treatment, reaching approximately 98% cure rate.

Conclusions

The results demonstrate that pulmonary actinomycosis is one of the cautious pulmonary diseases. More importantly, in cases of persistent hemoptysis or for differential diagnosis from lung malignancy, our data have revealed that surgical resection appears to be a useful intervention and that radiologic diagnosis may not provide decisive information. These findings indicate that it is important for the clinicians to include pulmonary actinomycosis as one of differential diagnoses for refractory pulmonary abnormal lesions to the current usual management.

Bronchoscopic view of a tuberculosis cavity with actinomyces

Coexistence of pulmonary actinomycosis with tuberculosis has rarely been reported. The presence of Actinomyces in sputum and bronchoalveolar lavage is inadequate for diagnosis, as it may represent mere colonization. Traditionally, excisional biopsy is considered to be the gold standard for histologic diagnosis. There are multiple case reports in which the diagnosis of pulmonary actinomycosis was based on bronchial biopsy and Wang needle aspiration. We describe an incidental finding of a bronchial communication with passage of a flexible bronchoscope into the tuberculosis cavity. The images reveal a 5-cm cavity with a whitish, stone-like structure noticed to move back and forth with respiration. Colonies of Actinomyces were seen on transbronchial brushing cytology. Bronchoalveolar lavage cultures were negative. To our knowledge such a detailed pictorial description of a tuberculosis cavity with Actinomyces has not been reported in the past.

Utility of Wang needle aspiration in the diagnosis of actinomycosis

An 85-year-old man had a 4-year history of recurrent pneumonia with a persistent pleural effusion. He underwent repeated bronchoscopy that revealed a right bronchus intermedius mass, but bronchial washes and biopsies remained nondiagnostic. A repeat bronchoscopy was performed, and a Wang needle aspiration of the mass was obtained that showed sulfur granules, diagnosing actinomycosis. The patient was started on appropriate antibiotic therapy. Actinomycosis must be considered in a patient with recurrent pneumonia and an endobronchial mass. Wang needle aspiration via bronchoscopy may be an important diagnostic tool.

Actinomycosis and other bronchopulmonary infections with bacterial granules

Pulmonary infections with formation of bacterial granules are rare. We reviewed the clinical and pathologic data from 18 cases diagnosed using surgical specimens in our department during the last 10 years. Three clinicopathologic forms were observed: endobronchial infections complicating tuberculous sequelae or bronchiectases (n = 7), tumor-like lesions (n = 8), and diffuse pneumonia (n = 3). The two latter forms contrasted with the former by a male predominance, association with general debilitating conditions and inflammatory syndrome, and pathologically by smaller granules often located in parenchymal abscesses or excavations. The pathologic examination of the bacteria forming the granules permitted the diagnoses of actinomycosis (n = 10), botryomycosis (n = 7), or nocardiosis (n = 1). The latter case corresponded to an endobronchial infection. Both actinomycosis and botryomycosis were encountered in every clinicopathologic form. At present, pulmonary actinomycosis and related infections rarely seems to present with chest wall invasion. On the contrary, purely endobronchial forms represented a large proportion of our cases. Cultures are often difficult and the clinical appearance is not specific. However, pathologic examination with special stains must indicate the type of involved microorganism.

Pleural effusion as the major manifestation of actinomycosis

Pleural effusion represents an unusual but significant manifestation of actinomycosis, as illustrated in this case presentation. The diagnosis was made after bronchoscopy and examination of bronchoalveolar fluid and culture. No parenchymal abnormality was noted on the chest film.

Case report: actinomycosis: multinodular pulmonary involvement

Previous computed tomography reports of pulmonary actinomycosis most commonly describe single, unilateral parenchymal or pleural masses with or without cavitation. The authors describe a thoracic computed tomograph of histologically proven actinomycosis that revealed multiple, bilateral, small pulmonary parenchymal nodules with an associated liver mass, suggesting hematogenous dissemination to the lungs from the liver via the hepatic veins.