The most critical finding is the chest wall pain and swelling.
What are your considerations?
In the absence of history of trauma, I have encountered this mode of presentation with chest wall pain and swelling in
Rapid progression of swelling speaks more in favour of an inflammatory process.
Review and give me your findings on CXR and CT chest.
What diagnostic procedure would you like to do?
are considerations. Patient had a non diagnostic FNAB. A core biopsy of the mass lesion was obtained.
Review the lung mass biopsy. What do you see?
Those were sulfur granules.
Review closeup of sulfur granules and tissue sections
What is your diagnosis?
Note filamentous bacteria which are beaded and non branching
A diagnosis of Actnomycosis was made.
Is Actnomycosis a fungus or Bacteria?
Actino is a Gram-positive bacteria. Actino exhibits some features typical of fungus branching mycelia formation However they are Gram-positive bacteria. Lack of nuclear membrane, the cell wall charecteristics and absence of mitochondria are all bacterial charecteristics. It reproduces by bacterial fission than sporogenic or filamentous budding.
What is the source for Actnomyces infection of humans? Is it from soil, or is there an animal source?
Actinomyces are normal inhabitants of the oral cavity. They are commensal organisms and frequently found in dental caries and at gingival margins with poor oral hygine. Not found in soil. They do not thrive at temperature below 30 degree C. They are extremely host specific and A israelli causing infection in humans is never found in animals.
Identify the correct statement regarding Actinomyces.
Disease is relatively uncommon. Actinomycosis occurs worldwide with no racial predeliction. It is more common in patients with poor oral hygiene. There is a male predominance of 4:1.
Identify the individual who is most likely to develop Actinomyces.
Patient with siezure disorder. It is not an opportunistic infection. It is an uncommon infection in transplanted patients. It is due to aspiration of organisms from oral cavity. Patients with a predispoition to aspiration eg siezure disorder, mental retardation, episodes of unconsciousness, alchoholism etc are more prone to develop infection.
What are the common organs or regions affected by Actinomycosis?
Identify the incorrect statement of Actinomycosis of Thorax.
Cavitation does not occur is incorrect. The indolent infecetion progresses to necrotizing pneumonia. If untreated abscesses develop with extensive parenchymal destruction. Predeliction to bases and peripheral portion of lungs is due to aspiration as the initiating process. Disease spreads through pleura to chest wall as in our patient. In untreated cases sinus tracts can form with charecteristic sulfur granules.
With regard to diagnosis of Actinomycosis identify the incorrect statement.
Must be cultured in strictly aerobic envirinment is incorrect. They must be cultured strictly in anaerobic environment for at leasst one week. In only 50% of cases organisms are succsessfully cultured. The other concomitant organisms perhaps work in synergy to produce the necessary anaerobic environment for Actinomyces.
How would do you treat this patient?
Actonomycosis needs to be treated with Penicillin for protracted period of time. This patient was treated with Penicillin 2 million units q4hrs for one month and was given 500mg po qid for the next 4 weeks. He became afebrile with resolution of constituitional symptoms and weight gain.
His CXR ......
Case discussion completed.
Take home message: Think Actino whenever a lesion crosses
fissure or pleura, extends to contiguous mediastinum or chest wall.