By Ray, Pallab; Mandal, Jharna; Gautam, Vikas; Singh, Kundan; Gupta, Dheeraj
Sir,
Actinomycosis is a progressive glaucomatous disease with local or systemic manifestations and a tendency to produce draining sinuses. Pulmonary actinomycosis by Actinomyces odontolyticus is a rare but an important and challenging diagnosis to make. Due to highly variable presentation, it is commonly confused with malignancy and other chronic suppurative lung diseases’4. Actinomycotic agents are commensals in the mouth, colon and vagina. The portal of entry is usually a breach in the mucosal integrity or pulmonary aspiration15. Thoracic involvement accounts tor approximately 15 per cent of the cases of actinomycosis. The most common clinical picture is an indolent slowly progressive process that involves some complication of the pulmonary parenchyma and pleural space. The spontaneous drainage of an empyema should raise the suspicion of this disease. It is most commonly mistaken for malignant disease. Tuberculosis, nocardiosis, histoplasmosis, blastomycosis, mixed anaerobic infections, bronchogenic carcinoma, lymphoma. mesothelioma and pulmonary infarction are among the entities confused with pulmonary actinomycosis1. We report here a case of pulmonary actinomycosis due to A. odontolyticus.
A 59 yr old man was admitted to the Department of Pulmonary Medicine Postgraduate Institute of Medical Education & Research, Chandigarh in March 2004 with the complaints of cough and chest pain for four months; fever and moderate (~100 ml/day), foul smelling, mucopurulent expectoration for 15 days prior to hospitalization. He was a treated (details not available) case of pulmonary tuberculosis (16 yr back) and was under treatment for bronchial asthma for the last 10 yr. He was obese, had no pallor, icterus, or cyanosis. The sinuses had no detectable abnormality. Despite poor oral hygiene, most of his teeth were in place and no lesion was present. The patient had generalized lymphadenopathy and was tachypnoeic at rest. Respiratory system examination revealed reduced to absent air entry in right infrascapular area, which was dull on percussion; bilateral rhonchi were present. Provisional diagnosis was empyema of the right lung. Laboratory data included white blood cell count of 20,300 cells/l; 72 neutrophils, 23 lymphocytes, 3 monocytes and 2 per cent eosinophils. Computerised tomography scan revealed loculated collection of fluid in the right infrascapular area. Roentgenogram indicated obliteration of the right costophrenic angle. Pleural fluid was drained and sent for bacteriological examination. Patient was on bronchodilator (metered dose inhaler- salbutamol). and intravenous cefotaxime and clindamycin.
Gram stain of pus revealed branching Grampositive bacilli with an exudative response, predominantly neutrophils. The organism was non acid-fast. Some Gram-positive cocci in chains and Gram-negative bacilli were also seen. On aerobic incubation after 24 h at 37C culture was sterile. Anaerobic incubation for 48 h grew pin-point haemolytic, metronidazole resistant colonies. After 4 days of incubation anaerobically. the colonies developed a red (rust-brown/ burnt-red) pigment. The organism was identified as A. odontolyticus based on standard biochemical tests5. Anaerobic culture also grew Bacteroides spp. and Peptostreptococcus spp. The patient stayed for 4 wk in the hospital and received 10 MU of intravenous penicillin daily and responded well.
Clinical disease produced by A. odontolyticus closely resembles that produced by other actinomyces species. It primarily involves the craniofacial regions, the chest, abdomen and the pelvis with rare involvement of the central nervous system, bones and joints, and affects middle-aged men more frequently than women67. In the present case the patient had a productive cough with associated chest pain. The effusion was an exudate with the presence of A. odontolyticus. No lesions were seen in the oral cavity and sinuses were normal excluding possibility of contamination. Quick resolution of symptoms was noted following the initiation of penicillin therapy.
Pulmonary actinomycosis has not been shown to have increased prevalence among immunocompromised hosts and the manifestations and treatment response are essentially similar to the immunocompetent ones8. Certain contaminants namely species of Bacteroides, Streptococcus and Staphylococcus etc., are usually found in association with the causative actinomycete. These organisms enhance the pathogenicity of actinomycetes by creating an anaerobic milieu in which the actinomyces thrive1. In 1957, Bates and Cruickshank described a fairly dramatic presentation of pulmonary actinomycosis with chest pain and cutaneous fistulae discharging sulphur granules9. In a recent study the commonest presentations were reported to be chest pain, cough, sputum and patch in chest X- ray8.’ Penicillin is the drug of choice. In cases of penicillin allergy alternative therapies include erythromycin, tetracycline, doxycycline or minocycline and clindamycin1.
Since the first isolation from a case of advanced dental caries by Batty in 1958(10), 26 cases of actinomycosis due to A. odontolyticus have been described worldwide47. Of these cases, only 14 cases of pulmonary infection due to A. odontolyticus have been reported world wide and we reported here a case from India.
References
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Pallab Ray*, Jharna Mandai Vikas Gautam, Kundan Singh & Dheeraj Gupta+
Department of Medical Microbiology & + Pulmonary Medicine, Postgraduate Institute of Medical Education & Research
Chandigarh 160012, India
*Corresponding author:
e-mail: [email protected]
Copyright Indian Council of Medical Research Dec 2005
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