© 1991S. K arger A G . Basel 0025-7931/91/0584-0229 $2.75/0
Respiration 1991;58:229-230
Endobronchial Actinomycosis Associated with a Foreign Body G. Julia3, F. Rodríguez de Castro3, J. Caminero3. A. Reyb, R Cabrera3 a Sección de Neumologiay h Anatomía Patológica, Hospital‘Ntra.Sra.de! Pino’, Universidad de Las Palmas, Las Palmas de Gran Canaria, Spain
Key Words. Actinomycosis • Foreign body • Fiber-optic bronchoscopy Abstract. We describe our findings in a 58-year-old mentally retarded patient with endobronchial actinomy cosis surrounding an aspirated chicken bone foreign body. To our knowledge, this is the first report of such an occurrence.
Case Report A 58-year-old mentally retarded patient was transferred to this hospital because of a persistent cough. He was a heavy smoker and a non-insulin-dependent diabetic. Twenty months prior to ad mission, he entered another hospital where X-ray films of the chest disclosed consolidation of the right lower lobe. He was given penicillin with clinical and radiologic improvement. Two months before entry, he began to complain of a nonproductive cough, re ferring an isolated bout of hemoptysis. The outpatient physician treated this patient with erythromycin and an X-ray film of the chest taken then, showed a small infiltrate in the right base. Be cause of an unresponding cough, the patient was admitted to this hospital for further evaluation. Physical examination was unre markable except for poor dental hygiene. Abnormal findings in cluded an erythrocyte sedimentation rate of 72 mm in the first hour, Hb 12.4 g/dl and fasting blood glucose of 175 mg/dl. His chest X-ray showed a small infiltrate of the lower part of the right lung and computerized axial tomography confirmed the presence of cy lindrical bronchiectasis in the posterior and lateral segments of the right lower lobe. Flexible fiber-optic bronchoscopy revealed some pinkish polypoid formations with intact mucosa protruding from the medial wall of the bronchus of the right lower lobe. Im mediately distal to these lesions, a yellowish firm mass occluding the bronchus was present. Tissue fragments were taken for histo
logical examination, and microscopical section disclosed an in flammatory infiltrate (mainly plasma cells and lymphocytes) with granules containing actinomyccs (fig. 1). As the macroscopic aspect strongly suggested a neoplasm, a new fiber-optic bronchoscopic examination was performed show ing identical endoscopic and histologic findings. Biopsy specimen culture in anaerobic media grew Actinomyces israelii. Therapy was initiated with aqueous penicillin G sodium (12 million units/day), administered intravenously for 4 weeks, and phenoxymethyl penicillin (1.6 million units/day p.o.) for an addi tional 6 months. A bronchoscopic examination performed after the antibiotic therapy showed a regression of the polypoid lesions; a yellowish, hard lesion filling the bronchus of the right lower lobe persisted. A rigid bronchoscopy was then carried out and a foreign body removed (chicken bone).
Discussion
Human actinomycosis is in general caused by A is raelii. It is a gram-positive, filamentous, anaerobic bacterium which forms sulfur granules. The organism is a frequent commensal in the mouth and is common ly related to poor oral hygiene. Infections spread by direct invasion of contiguous structures without re gard to tissue planes and boundaries. The three pri mary sites of the infection are usually the cervicofa cial region, next the abdomen and then the thorax [1]. The primary thoracic lesion usually presents in the lung parenchyma and is believed to arise from inhal-
Downloaded by: King's College London 137.73.144.138 - 1/16/2019 5:41:23 PM
Actinomycosis is a rare cause of an endobronchial mass and may strongly suggest a neoplasm. We report our clinical, endoscopic and pathologic findings in a case of solitary bronchial actinomycosis which was, presumably, caused by aspiration of a foreign body.
230
Julia/Roüriguez de Castro/Caminero/Rey/Cabrcra
Aspiration of foreign bodies into the airways is a common problem in pediatric and mentally retarded patients and may cause atelectasis, recurrent respira tory infections, bronchiectasis or overinflation of a lung or lobe [5]. Recently, a case of endobronchial pa pilloma associated with a foreign body was reported [6]. Some believe that an anaerobic infection, such as actinomycosis, cannot be limited to the wall of the major bronchi [7]. Probably, the aspiration of a for eign body might play some role in the initiation of the infection by distorting the bronchus, thus making the environment more suitable for the growth of the Acti nomyces. In our patient, this might have been the mechanism of the infection, although we cannot definitely discard an extension of intrapulmonary disease into the bron chial submucosa. Whatever the case, no other local ization could be detected in this patient and, to our knowledge, this is the first report of endobronchial actinomycosis associated with a foreign body.
References
ing infected material from the oral cavity. Clinically, the disease is characterized by an insidious presenta tion. Predisposing factors include chronic bronchitis, emphysema and bronchiectasis. Empyema, osteo myelitis of the ribs and spine, sinus tract formations, mediastinal involvement and chronic infiltrates with cavitations are the most common clinical and radio logical manifestations [1, 2], Endobronchial actinomycosis is considered an ex ceptional event. It may spread from an intrapulmonary disease into the bronchial submucusa [3], or re ach the bronchial wall directly from the oral cavity producing a bronchial mass mimicking lung cancer
t4J.
Received: January 17. 1991 Accepted after revision: May 2, 1991 Dr. Rodríguez de Castro Sección de Neumología Hospital ‘Ntra. Sra. del Pino’ C/ Angel Guimeni, 93 E-35005 Las Palmas de Gran Canaria/Islas Canarias (Spain)
Downloaded by: King's College London 137.73.144.138 - 1/16/2019 5:41:23 PM
Fig. 1. Fragments of the bronchial wall with many balls of tan gled actinomycètes (arrows), a Some mucous glands on the de tached superficial epithelium. HE. x 40. b Cotton-like balls of acti nomycètes with a typical fibrillary appearance. HE. x 200.
1 Brown JR: Human actinomycosis: A study of 181 subjects. Hum Pathol 1973;4:319-330. 2 Baliklan JP. Cheng TH. Costello P, Herman PG: Pulmonary actinomycosis: A report of three cases. Radiology 1978; 128: 613-4)16. 3 Lee M. Berger HW. Fernández NA, Tawnwey S: Endobron chial actinomycosis. Ml Sinai J Med (NY) 1982;49:136-139. 4 Miracco C, Marino M. Lio R, Cornetti M, Luzi P: Primary en dobronchial actinomycosis. Eur Respir J 1988;1:670-671. 5 Weissberg D. Schwartz I: Foreign bodies in the tracheobron chial tree. Chest 1987;91:730-733. 6 Greene JG, Tassin L, Saberi A: Endobronchial epithelial papil loma associated with a foreign body. Chest 1990;97:229-230. 7 Bates M. Cruikshank G: Thbfacic actinomycosis. Thorax 1957; 12:99-124.
Respiration 1991;58:229-230
Endobronchial Actinomycosis Associated with a Foreign Body G. Julia3, F. Rodríguez de Castro3, J. Caminero3. A. Reyb, R Cabrera3 a Sección de Neumologiay h Anatomía Patológica, Hospital‘Ntra.Sra.de! Pino’, Universidad de Las Palmas, Las Palmas de Gran Canaria, Spain
Key Words. Actinomycosis • Foreign body • Fiber-optic bronchoscopy Abstract. We describe our findings in a 58-year-old mentally retarded patient with endobronchial actinomy cosis surrounding an aspirated chicken bone foreign body. To our knowledge, this is the first report of such an occurrence.
Case Report A 58-year-old mentally retarded patient was transferred to this hospital because of a persistent cough. He was a heavy smoker and a non-insulin-dependent diabetic. Twenty months prior to ad mission, he entered another hospital where X-ray films of the chest disclosed consolidation of the right lower lobe. He was given penicillin with clinical and radiologic improvement. Two months before entry, he began to complain of a nonproductive cough, re ferring an isolated bout of hemoptysis. The outpatient physician treated this patient with erythromycin and an X-ray film of the chest taken then, showed a small infiltrate in the right base. Be cause of an unresponding cough, the patient was admitted to this hospital for further evaluation. Physical examination was unre markable except for poor dental hygiene. Abnormal findings in cluded an erythrocyte sedimentation rate of 72 mm in the first hour, Hb 12.4 g/dl and fasting blood glucose of 175 mg/dl. His chest X-ray showed a small infiltrate of the lower part of the right lung and computerized axial tomography confirmed the presence of cy lindrical bronchiectasis in the posterior and lateral segments of the right lower lobe. Flexible fiber-optic bronchoscopy revealed some pinkish polypoid formations with intact mucosa protruding from the medial wall of the bronchus of the right lower lobe. Im mediately distal to these lesions, a yellowish firm mass occluding the bronchus was present. Tissue fragments were taken for histo
logical examination, and microscopical section disclosed an in flammatory infiltrate (mainly plasma cells and lymphocytes) with granules containing actinomyccs (fig. 1). As the macroscopic aspect strongly suggested a neoplasm, a new fiber-optic bronchoscopic examination was performed show ing identical endoscopic and histologic findings. Biopsy specimen culture in anaerobic media grew Actinomyces israelii. Therapy was initiated with aqueous penicillin G sodium (12 million units/day), administered intravenously for 4 weeks, and phenoxymethyl penicillin (1.6 million units/day p.o.) for an addi tional 6 months. A bronchoscopic examination performed after the antibiotic therapy showed a regression of the polypoid lesions; a yellowish, hard lesion filling the bronchus of the right lower lobe persisted. A rigid bronchoscopy was then carried out and a foreign body removed (chicken bone).
Discussion
Human actinomycosis is in general caused by A is raelii. It is a gram-positive, filamentous, anaerobic bacterium which forms sulfur granules. The organism is a frequent commensal in the mouth and is common ly related to poor oral hygiene. Infections spread by direct invasion of contiguous structures without re gard to tissue planes and boundaries. The three pri mary sites of the infection are usually the cervicofa cial region, next the abdomen and then the thorax [1]. The primary thoracic lesion usually presents in the lung parenchyma and is believed to arise from inhal-
Downloaded by: King's College London 137.73.144.138 - 1/16/2019 5:41:23 PM
Actinomycosis is a rare cause of an endobronchial mass and may strongly suggest a neoplasm. We report our clinical, endoscopic and pathologic findings in a case of solitary bronchial actinomycosis which was, presumably, caused by aspiration of a foreign body.
230
Julia/Roüriguez de Castro/Caminero/Rey/Cabrcra
Aspiration of foreign bodies into the airways is a common problem in pediatric and mentally retarded patients and may cause atelectasis, recurrent respira tory infections, bronchiectasis or overinflation of a lung or lobe [5]. Recently, a case of endobronchial pa pilloma associated with a foreign body was reported [6]. Some believe that an anaerobic infection, such as actinomycosis, cannot be limited to the wall of the major bronchi [7]. Probably, the aspiration of a for eign body might play some role in the initiation of the infection by distorting the bronchus, thus making the environment more suitable for the growth of the Acti nomyces. In our patient, this might have been the mechanism of the infection, although we cannot definitely discard an extension of intrapulmonary disease into the bron chial submucosa. Whatever the case, no other local ization could be detected in this patient and, to our knowledge, this is the first report of endobronchial actinomycosis associated with a foreign body.
References
ing infected material from the oral cavity. Clinically, the disease is characterized by an insidious presenta tion. Predisposing factors include chronic bronchitis, emphysema and bronchiectasis. Empyema, osteo myelitis of the ribs and spine, sinus tract formations, mediastinal involvement and chronic infiltrates with cavitations are the most common clinical and radio logical manifestations [1, 2], Endobronchial actinomycosis is considered an ex ceptional event. It may spread from an intrapulmonary disease into the bronchial submucusa [3], or re ach the bronchial wall directly from the oral cavity producing a bronchial mass mimicking lung cancer
t4J.
Received: January 17. 1991 Accepted after revision: May 2, 1991 Dr. Rodríguez de Castro Sección de Neumología Hospital ‘Ntra. Sra. del Pino’ C/ Angel Guimeni, 93 E-35005 Las Palmas de Gran Canaria/Islas Canarias (Spain)
Downloaded by: King's College London 137.73.144.138 - 1/16/2019 5:41:23 PM
Fig. 1. Fragments of the bronchial wall with many balls of tan gled actinomycètes (arrows), a Some mucous glands on the de tached superficial epithelium. HE. x 40. b Cotton-like balls of acti nomycètes with a typical fibrillary appearance. HE. x 200.
1 Brown JR: Human actinomycosis: A study of 181 subjects. Hum Pathol 1973;4:319-330. 2 Baliklan JP. Cheng TH. Costello P, Herman PG: Pulmonary actinomycosis: A report of three cases. Radiology 1978; 128: 613-4)16. 3 Lee M. Berger HW. Fernández NA, Tawnwey S: Endobron chial actinomycosis. Ml Sinai J Med (NY) 1982;49:136-139. 4 Miracco C, Marino M. Lio R, Cornetti M, Luzi P: Primary en dobronchial actinomycosis. Eur Respir J 1988;1:670-671. 5 Weissberg D. Schwartz I: Foreign bodies in the tracheobron chial tree. Chest 1987;91:730-733. 6 Greene JG, Tassin L, Saberi A: Endobronchial epithelial papil loma associated with a foreign body. Chest 1990;97:229-230. 7 Bates M. Cruikshank G: Thbfacic actinomycosis. Thorax 1957; 12:99-124.
