output increased sufficiently to produce a palpable blood pressure. A ccmechanism" was proposed by Pepe and Marini" when moderate to severe hypotension developed as changes in ventilator settings resulted in intrinsic· PEE'e~·OncEr positive pressure ventilation was temporarily discontinued, the patients hemodynamic indices improved and stabilized. 8 In a recent retrospective review of 261 cases of cardiac arrest,.1 the presence of COPD was associated with an increased risk of EMD. Although not discussed· by the authors, it may be auto-PEE~ not simply COPD, that is the important factor associated with the development of EMD. A primary goal of resuscitative therapy in patients with EMD should be to improve venous return with aggressive fluid administration. When fluid administration proves ineffective in patients with severe bronchospasm, it may be worthwhile to include auto-PEEP in the differential diagnosis of potentially reversible etiologic factors. A brief trial of apnea (15 to 30 s) may be beneficial in differentiating absent pulse due to auto-PEEP from other causes. Recognizing that patients with COPD may develop hyperinflationinduced hypotension after intubation and mechanical ventilation and being prepared for its occurrence appear to be essential in the effective care of these patients. REFERENCES

1 Albarran-Sotelo R, Atkins JM, Bloom RS, Campbell F. Textbook of advanced cardiac life support. Dallas: American Heart Association, 1987 2 Cumins RO, Graves JR. Clinical results of standard CPR: prehospital and inhospital. In: Kaye ~ Bircher NG, eds. Cardiopulmonary resuscitation: scientific basis for CPR, current standards and future trends. New York: Churchill Livingstone,

1989; 87-102 3 Friedman HS. Diagnostic considerations in electromechanical dissociation [editorial]. Am J Cardio11976; 38:268-69 4 Cournand A, Motley HL, Werko L, Richards DW Jr. Physiologic studies of the effects of intermittent positive pressure breathing on cardiac output in man. Am J Pbysioll948; 152:162-74 5 Fewell JE, Abendschein DR, Carlson CJ, Murray JF, Rapaport E. Continuous positive-pressure ventilation decreases right and left ventricular end-diastolic volumes in the dog. Cire Res 1980; 46:125-32 6 Morgan BC, Crawford E~ Guntheroth WG. The hemodynamic effects of changes in blood volume during intermittent positivepressure ventilation. Anesthesiology 1969; 30:297-305 7 Pontoppidan H, Geffin B, Lowenstein E. Acute respiratory failure in the adult. N Engl J Med 1972; 287:799-814 8 Pepe PE, Marini JJ. Occult positive end-expiratory pressure in mechanically ventilated patients with airftow obstruction: the auto-PEEP effect. Am Rev Respir Dis 1982; 126:166-70 9 Bergman NA. Intrapulmonary gas trapping during mechanical ventilation at rapid frequencies. Anesthesiology 1972; 37:626-33 10 Whittenberger JL, McGregor M, Berglund E, Borst HG. Influence of state of inflation of the lung on pulmonary vascular resistance. J Appl Physiol 1960; 15:878-82 11 Vincent JL, Pinsky MR. Cough-induced syncope. Intensive Care Med 1988; 14:591-94 12 Sutton-Tyrrell K, Abramson NS, Safar ~ Delre K. Predictors of electromechanical dissociation during cardiac arrest. Ann Emerg Med 1988; 17:572-75

Endobronchial Actinomycosis Simulating Bronchogenic carcinoma Diagnosis by Bronchial Biopsy llana Ariel~ M.D.;* Raphael Breuer; M.D.;t Nidal s. Kmnal~ M.D.;* ISStJChor Ben-Dov~ M.D.;§ lbul Mogle~ M.D.~I and Eliezer Ro"enmann~ M.D.'

Five cases of actinomycosis of the main bronchi or trachea which were suggestive clioicaUy of bronchogenic carciDoma are described. In four patients the correct diagnosis was made by a bronchial biopsy or wash, or both. Three of them recovered foUowiDg antibiotic treatment, and one died a few days after bronchoscopy. In one case the _ were found in the bronchial wash retrospectively foUowing diagnosis of pulmonary actinomycosis in the lobectomy specimen. A concomitant endobronchial lipoma was found in one of the patients. The diagnosis of pulmonary actinomycosis by bronchial biopsy may save the patient major (Che.t 1991; 99:493-95) surgical intervention.

T

he clinical presentation of thoracic actinomycosis has ,changed considerably over the last decades together with the reduction of its incidence. 1.2 Cases with extensive destruction of the chest wall and formation of discharging sinus tracts are now seldom seen. The presenting symptoms of actinomycosis nowadays are unresolved pneumonia or a pulmonary infiltrate or a mass evidenced on routine chest x-ray fil~s. When these are found in an elderly person they are naturally suspected to be bronchogenic carcinoma, unless proven otherwise. We present five cases of actinomycosis of the trachea or major bronchi, which were suggestive of bronchogenic carcinoma, that were diagnosed by bronchial biopsy or wash or both. CASE REPORTS CASE

1

A 59-year-old woman was admitted because ofa cough productive of purulent sputum for four months and a recent episode of bemoptysis. Chest x-ray films revealed a segmental infiltrate in the anterior medial segment of the left lower lobe. A diagnosis of *Deparbnent of Pathology, Hadassah University Hospital Mount Scopus. Senior Lecturer of Pathol~ the Hebrew UniversityHadassah Medical School, Jerusalem, Israel tPulmonary Unit, Hadassah University Hospital, Kiryat Hadassah. Lecturer of Internal Medicine, the Hebrew Unive..sity-Hadassah Medical School. *Pulmonary Unit, Ittihad Hospital, Nablus, Israel. §Deparbnent of Internal Medicine, Hadassah University Hospital Mount SCOpt1s. Lecturer of Internal Medicine, the Hebrew University-Hadassah Medical School. Presently at the Respiratory Division, Los Angeles County Harbor-UCLA Medical Center, Torrance, CA. IIDePartment of Radiology, Hadassah University Hospital Mount Scopus. Clinical Associate Professor of Radiology, the Hebrew University- Hadassah Medical School. 'Chairman and Director, Departments of Pathology, Hadassah University Hospitals. Professor of Pathology, the Hebrew University- Hadassah Medical School.

Reprint requests: Dr. Rosenmann, Department of Ibthology, Hadas861& University Hospital, PO Box 12000, jen.uJtJlem, Israel 91120 CHEST I 99 I 2 I FEBRUAR'Y. 1991

493

sweats, cough and hemoptysis of six weeks' duration, which were

not responsive to antibiotics. On admission he was febrile, with a temperature of39"C, and sweating. Pulse was 120 beats per minute and respiratory rate was 28 breaths per minute. Poor oral hygiene was noticed in addition to consolidation at the right lung base. The Hb level was 11 gldI and the WBC count was 7,000 to 21,OOOIcu mm with a normal differential ceD count. A chest x-ray film demonstrated opacities in the right lower lobes (Fig 2). A scan demonstrated a space-occupying lesion, surrounding and narrowing the right intermediate bronchus. On fiheroptic bronchoscopy, 70 percent of the intermediate bronchus lumen was occluded by an irregu\ar red polypoid mass which felt stony hard to the touch with biopsy forceps. Histologic examination revealed chronical\y inBamed bronchial mucosa and a neutrophilic exudate with a few round amphophilic structures. The Gram stain demonstrated slender somewhat fragmented positive rods, indicative ofactinomycosis. A culture was negative. Therapy with penicillin G and metronidazole was started. When metronidazole was stopped, fever recurred until the drug was restarted. A chest x-ray film taken three months after admission showed complete resolution of the infiltrates.

cr

FICURE 1. Case 1. Sulfur granule with eosinophilic peripheral clubbing in a bronchial biopsy (hematoxylin and eosin, original magnification x 440). pneumonia was made and she was treated with erythromycin for ten days. A dental procedure was performed four months before. On admission, laboratory tests were unremarlcable. A chest x-ray film and scan showed findings similar to the previous ones and were suggestive of a carcinoma of the lung. Bronchoscopy demonstrated an endobronchial occluding yellow-white mass in the anteromedial segment of the left lower lobe. The biopsy specimen disclosed chronically inBamed bronchial mucosa and a few sulfur granules with peripheral eosinophilic clubbing (Fig 1). Grampositive rods were found and the diagnosis of actinomycosis was made. Culture of the biopsy material was negative. Penicillin G therapy was instituted. Since there was no improvement, a second bronchoscopy was performed and an endobronchial polypoid mass which occluded two thirds ofthe lumen was removed. Histologically a submucosal bronchial lipoma was diagnosed. Therapy was continued with a high dose of penicillin for two months. After two years' follow-up, the patient is weD and her chest x-ray films are normal.

cr

CASE

2

A 43-yeaMlld man was admitted for evaluation of fever, night

CASE

3

A 69-YeaMlld man was admitted for investigation of an infiltrate of the right middle lobe, which had not improved foDowingantibiotic treatment, and was suggestive of a malignancy. Bronchoscopy revealed a soft yeUowish mass occluding the right main bronchus. The bronchial biopsy was not informative, but microscopic examination of a ceD block ofa bronchial washing disclosed sulfur granules surrounded by an acute inBammatory exudate. Gram-positive bacilli were demonstrated within the granules. The diagnosis of actinomycosis was verified by culture. The patient was unavailable for follow up; however, information was received that he was alive and weD two years afterward. CASE 4

A 62-YeaMlId man presented with dyspnea, cough producing yellow sputum and fever of two months' duration. He was cyanotic and had evidence of a right-sided pneumonia. The Hb value was 11.2 gldL and the WBC count was 15,OOOIcu mm with a shift to the left. Chest x-ray films revealed diffuse infiltration of the right lower lobe with involvement of the pleura and a round shadow in the hilum suggestive of hilar lymphadenopathy. Fiheroptic bronchoscopy showed an irregu\ar firm infiltrative raised lesion located in the trachea, just above the carina suggestive of bronchogenic carcinoma. Sputum culture grew Klebsiella organisms and therapy with gentamicin was started. Bronchial biopsy and washing disclosed an acute inBammatory infiltrate with sulfur granules. Branching gram-positive bacilli typical of Actinomyces mixed with grampositive cocci were demonstrated. The patient expired four days later. An autopsy was not performed. CASE

5

'A 4O-yeaMlld man presented with cough, purulent sputum and left pleuritic pain for three months. The physical examination was unremarkable except for faint dry rales over the left lower lobe. Interstitial infiltrate of the left lower lobe was found on chest x-ray films. Erythromycin was prescribed, but the patient was unavailable temporarily for follow-up. Ten months later he was admitted to the hospital with similar signs and symptoms as well as hemoptysis. The chest x-ray films and scan revealed an increase of the previous infiltrate to a 7-em mass in the posterior segment of the left lower lobe. Fiberoptic bronchoscopy demonstrated a fixed smooth whitish tumor, showing on biopsy chronic inBammation. A neutrophilic exudate and a few aggregates of bacteria were found in the ceD block of bronchial washing. Four months later, a lobectomy was performed. A hard yeDow mass with irregular contours, 5 cm

cr

FICURE 2. Case 2. Chest x-ray film demonstrating opacities of the right lower and middle lobes.

EudoblOllchlaJ Adlnomycoela SImulating 81ollchogelllc Carcinoma (ArIel et aI)

in diameter, was found. Histologically, the mass consisted ofclusters of foamy histiocytes within alveoli, alternating with small areas of suppuration and sulfur granules. The alveolar septa were markedly .,~eJial . thickened by fibrosis and lymphoplasmocytic infiltrate~ sections and gram stain of the ceO block of the bronchial wuhirig, done four months previously, disclosed branching filamentous, somewhat fragmented Gram-positive rods, typical of Actinomyces. DISCUSSION

Actinomyces is a filamentous Gram-positive rod-shaped bacterium which is a commensal habitant of the oropharynx and gastrointestinal tract. It is of low pathogenicity and clinical actinomycosis usually is preceded by an injury of the tissue. 2 Thoracic actinomycosis presumably is caused by aspiration of contaminated material from the mouth or oropharynx. 1·5 In two ofour cases there was a documentation of dental and gingival disease (case 2) or dental procedure (case 1) prior to the pulmonary disease. In fact, the improvement of dental hygiene of the population is thought to be the major cause for the reduction in the incidence of thoracic actinomycosis in the last decades. 1 Another factor may be the widespread use ofantibiotics which can presumably eradicate early infections.:5 The clinical presentation of thoracic actinomycosis, which used to be a discharging sinus tract with extensive destruction of lung parenchyma and chest wall," has changed considerably. Cases are now diagnosed at an earlier stage, most commonly as a pulmonary shadow on chest x-ray films l that are nowadays an integral part of a routine medical checkup. Actinomycosis is an invasive and destructive process not limited to anatomic boundaries, with a surrounding desmoplastic reaction which gives it the macroscopic appearance ofa tumor. This is why in most cases in the past, a neoplasm was suspected and the diagnosis of actinomycosis was made after a lobectomy or pneumonectomy,I....6-8 as in our case 5. In fact, the diagnosis of actinomycosis does not rule out a coexistent carcinoma and this coincidence has been documented. 1 In one of our cases, the actinomycotic lesion was overlying an endobronchial sllbmucosallipoma (case 1). The hallmark of actinomycosis is the formation of the yellow sulfur granules. The microorganisms are slender branching Gram-positive bacilli embedded in the matrix of the granule. Similar structures can be formed by groups of other bacteria (Streptomyces, Staphylococcus and Streptococcus) or hyphae. 3 Aggregates of Nocardia occasionally fonn granules similar to Actinomyces, though usually lacking the peripheral clubbing. Nocardia, however, differs from Actinomyces in that it is an aerobic and modified acid-fastpositive organism. In a true sulfur granule, the Actinomyces can be mixed with other microorganisms from the oral flora (Gram-positive cocci, gram-positive bacilli and fungi). 3 In case 2, the fact that the disease flared up when mitronidazole was discontinued could have been due to a mixed infection with anaerobes of the oral flora. In case 4, microscopic examination disclosed a mixture of Actinomyces and Grampositive cocci. A difficulty in identifying Actinomyces organisms is their pleomorphism and tendency to fragment and stain unevenly by the Gram method, simulating chains ofcocci. 3 Moreover, Actinomyces organisms are strictly anaerobic and will grow

in culture only in anaerobic conditions. This is why in four of our cases the sputum and bronchial washings which were cultured under aerobic conditions were negative. Also, the finding,or.Actinomyces by sputum cytology and/or culture, unless obtained directly from the bronchus, cannot be used as a definitive diagnosis due to its frequent presence as a commensal of the oral cavity. Sulfur granules are in many cases very hard to find, and in 26 percent in Brown's series3 the diagnosis was based on the finding of only a single sulfur granule in a lesion. The chance of finding it in a small biopsy is, of course, much smaller and the necessity for serial sections cannot be overemphasized. Another difficulty in the diagnosis of actinomycosis in a small, sometimes crushed bronchial biopsy is the morphologic appearance of the sulfur granule which is not always .as classic as the picture in a textbook taken from a large specimen. It is not surprising, therefore, that only two such cases diagnosed by bronchial biopsy were reported in the literature. 9 •1o We have found it especially useful to do serial sections and a Gram stain of the cell block of the bronchial washing. This may give positive results in the presence of a noninformative biopsy, as in two of five of our patients (cases 3 and 5). Pulmonary actinomycosis is rare nowadays, but it is a treatable disease and its diagnosis in a bronchial biopsy saves the patient a major surgical procedure and leads to a complete cure by antibiotic treatment. REFERENCES

1 Slade PR, Slesser

B~

Southgate J. Thoracic actinomycosis.

Thorax 1973; 28:73-85 2 Lerner PI. Pneumonia due to Actinomyces, ,Arachnia and Nocardia. In: Pennigton JE, ed. Respiratory infections: diagnosis and management. New York: Raven Press, 1983:387-96 3 Brown JR. Human actinomycosis: a study of 181 subjects. Human Patho11973; 4:319-30 4 Bates M, Cruickshank G. Thoracic actinomycosis. Thorax 1957; 12:99-124 5 Case Records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 45-1983: A young man with a mass involving the lung, pleura and chest wall. N Engl J Med 1983; 309:1171-78 6 Pritzker HG, MacKay JS. Pulmonary actinomycosis simulating bronchogenic carcinoma. Can Med Assoc J 1963; 88:785-91 7 Moore WR, Scannell JG. Pulmonary actinomycosis simulating cancer of the lung. J Thorac Cardiovasc Surg 1968; 55:193-95 8 Villegas AH, Sala CA. Pulmonary actinomycosis of pseudotumoral form. J Thorac Cardiovasc Surg 1965; 49:677-83 9 Lee M, Berger

H~

Fernandez AN, 1llwney S. Endobronchial

actinomycosis. Mt Sinai J

Moo 1982; 49:136-39

10 Broquetas J, Aram X, Moreno A. Pulmonary actinomycosis with endobronchial involvement. Eur J Clin Microhioll985; 4:508 CHEST I 99 I 2 I FEBRUAR'i. 1991

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