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Thoracic Actinomycosis P Thorax (1973), 28, 73. Thoracic actinomycosis P. R. SLADE, B. V. SLESSER, and J. SOUTHGATE Groby Road Hospital, Leicester Six cases of pulmonary infection with Actinomyces Israeli and one case of infection with Nocardia asteroides are described. The incidence of thoracic actinomycosis has declined recently and the classical presentation with chronic discharging sinuses is now uncommon. The cases described illustrate some of the forms which the disease may take. Actinomycotic infection has been noted, not infrequently, to co-exist with bronchial carcinoma and a case illustrating this association is described. Sputum cytology as practised for the diagnosis of bronchial carcinoma has helped to identify the fungi in the sputum. Treatment is discussed, particularly the possible use of oral antibiotics rather than penicillin by injection. Actinomycosis is not common in this country. showed only submucosal fibrosis. Cytological exam- The Table shows the number of cases reported to ination of the sputum showed the presence of fungus Health Laboratory Service from public (Figs 2 and 3) and cultures gave a growth of the Public Actinomyces Israeli. The patient was hypersensitive to health and hospital laboratories in the United penicillin and was treated with oral tetracycline, 2 g Kingdom and Republic of Ireland in recent years. daily for six months. There was marked reduction It is usually considered that the chest may be in the shadowing on the chest film after only six involved in about 15% of cases (Cecil and Loeb, weeks of treatment (Fig. 4) and subsequently com- 1963). But, of the 36 cases reported in 1970, the plete disappearance. The patient has remained well chest was involved in only one case. In 1957 for six years. published an account of Bates and Cruickshank Comment Carcinoma of the bronchus was originally 85 cases of thoracic actinomycosis collected from strongly suspected but sputum cytology gave the clue many thoracic centres in this country. One of the to the diagnosis. Complete resolution was obtained co-authors of this paper (G. C.) was formerly with oral tetracycline. senior surgeon of this unit. This series of cases is still widely regarded as giving the classical CASE 2 M. B., a 71-year-old housewife, had a six description of actinomycosis of the chest. Now, weeks' history of cough with shortness of breath on exertion. A chest radiograph (Fig. 5) showed an in addition to a reduced incidence, thoracic actino- opacity at the hilum of the left lung. Sputum cyto- mycosis may have a different clinical presentation. logy showed the presence of ray fungus and subse- Therefore, an account of a small recent series of quent sputum cultures gave a growth of A. Israeli. She cases may be of interest. was treated for one month with penicillin, 4 million units daily, by intramuscular injection and sulpha- TABLE methazine, 4 g daily. After this she received tetra- INCIDENCE OF ACTINOMYCOSIS AS REPORTED FROM cycline, 1 g daily for one month. PUBLIC HEALTH SERVICE AND HOSPITAL LABORATORIES After treatment sputum cultures have been per- (Central Public Health Laboratory, Colindale) sistently negative for fungi and she has lost her cough. The chest film (Fig. 6) showed clearing of 1966 1967 1968 1969 1970 Total the left hilar shadowing and her condition has been No. ofcases 25 27 21 60 36 169 satisfactory for the past three years. Comment Bronchial carcinoma was thought to be the CASE REPORTS most likely diagnosis from the appearance of the chest films. Cytological examination of the sputum ACTINOMYCOSIS was important. CASE 1 J. S., a 42-year-old man was a commercial traveller and a heavy smoker. A feblile illness was CASE 3 B. C. was a 34-year-old housewife. At the followed by cough, weight loss, and lassitude but age of 19 years, when a student nurse, she had no pain. A chest radiograph (Fig. 1) showed shadow- developed fever and cough. A chest radiograph ing in the region of the right lung hilum. On bron- (Fig. 7) showed collapse of the middle lobe of the choscopy the mucosa around the right upper lobe lung. Mycobacterium tuberculosis was not found in orifice was injected and swollen. Biopsy of this area the sputum, but the condition was regarded on clini- 73 74 P. R. Slade, B. V. Slesser and J. Southgate FIG. 1. Case 1. Initial chest film showing r-ight hi/ar shadowing. cal grounds as being due to tuberculosis. She was fibrosis around the hilum of the lung. There vxas an treated for three months with streptomycin, INAH, abscess cavity anteriorly between the upper and and PAS and for a further six months with INAH lower lobes of the lung. The anterior segment of the and PAS. After this time operation was performed, right upper lobe was solid and partially invaded by at another hospital, for resection of the middle lobe. the abscess cavity. The abscess contained pus with Unfortunately, the histological report on the opera- typical 'sulphur granules. Pus from the abscess grew tion specimen is not available. However, the opera- A. Israeli on culture. No tubercle bacilli were found tion notes record that there was such dense fibrosis on culture or on guinea-pig inoculation. Segmental that identification of the hilar structures was almost resection of the anterior segment of the right upper impossible. lobe was performed and as much as possible of the After the resection the patient remained well for thick-walled abscess cavity was excised. almost one year and then developed recurrent epi- After operation the patient was treated with peni- sodes of fever with cough and purulent sputum. She cillin by intramuscular injection. 8 million units daily was treated by numerous short courses of tetracycline for three weeks and then 6 million units daily for or ampicillin. Sputum cultures were negative for 14 weeks. After this she received tetracycline, 2-0 g tubercle bacilli and other pathogenic organisms. daily for 12 weeks. PAS and INAH were also given Chest films showed increased shadowing on the for the first eight months of the postoperative period. right side (Fig. 8). At bronchoscopy it was seen that She has remained well over the past five years. the stump of the middle lobe bronchus was present and a bronchogram (Fig. 9) demonstrated that the Comment This case illustrates the considerable opacity lay at the site of the middle lobe and showed technical difficulties of surgical treatment for pul- a deformity of the anterior segmental bronchus of monary actinomycosis because of the dense adhe- the upper lobe. A chronic abscess due to a fistula sions. The ineffectiveness of antibiotics in inter- from the middle lobe stump was suspected and mittent and low dosage is well shown. Probably the exploration was performed after a six weeks' course condition was due entirely to actinomycosis but of PAS and INAH. The pleural cavity was com- antituberculosis treatment was also given because pletely obliterated by adhesions and there was dense of the original diagnosis. p~~~~~~~~~~~~~~~~~~~N- . 2 - r,..IW% .rS~'. 0fi. ' CsW-'tro''f'- ;X3SS0.---+# s *+s~~~'' *rt4 £,~b.*;'_'.'i"k'4 ;Y%'iu *:v : 2 ~~~~~~~4Fa a *Af FIG. 2. Case 1. Section of vputum showing fungus 'granule'. (H. and E. x 80.) AP* .1. : , C: 4:S *k s .:: . I .4 4: xE..;..s *. FsG. 3. Case 1. Sputum section showing fungusfilaments. (Gram stain x 320.) FIG. 4. Case 1. Chest radiograph showing considerable diminution of shadowing after six weeks' treatment. FIG. 5. Case 2. Initial chest film showing left hilar opacity. Thoracic actinomycosis 77 :.. FIG. 6. Case 2. Clearing of left hilar opacity after two months' treatment. l : : FIG. 7. Case 3. Initial chest film showing middle lobe collapse. 78 P. R. Slade, B. V. Slesser and J. Southgate .......... .. FIG. 9. Case 3. Right lateral bronchogram. Thoracic actinomycosis 79 CASE 4 A. G., a 41-year-old housewife had a five (Fig. 11) demonstrated stenosis of the origin of the months' history of episodes of fever associated with middle lobe bronchus. No tubercle bacilli or other cough, purulent sputum, and occasional haemopty- pathogenic organisms were found on sputum cul- ses. A chest film (Fig. 10) showed consolidation in ture. The stenosis was considered to be most likely the area of the middle lob2 and a bronchogram due to compression of the middle lobe bronchus by tuberculous lymph nodes. Streptomycin, PAS, and INAH were given for six weeks and then a right thoracotomy was performed. The pleural cavity was obliterated by adhesions. The middle lobe was consolidated and there was very dense fibrosis around the lung hilum. There were calcified lymph nodes adherent to the root of the middle lobe bronchus in keeping with the diag- nosis of Brock's syndrome (Brock, 1950). A middle lobectomy was performed. The operation specimen showed a large abscess cavity in the medial segment. Histological examination of the abscess wall showed inflammatory granulation tissue with fungus granules present. Culture of the pus grew A. Israeli but no tubercle bacilli were found on smear or culture. After opzration the patient received penicillin by intramuscular injection, 8 million units daily for three weeks and then 6 million units daily for eight weeks. After this she had tetracycline, 2-0 g daily for four weeks. Postoperative antituberculosis cover was also given with PAS and INAH for six months. She has remained well over a period of five since the operation. years Comment The presence of calcified lymph nodes makes it that the FIG. 10. Case 4. Right lateral film showing middle lobe likely original middle lobe disease collapse and consolidation. was due to tuberculosis. Actinomycosis has a ten- dency to occur in the presence of devitalized tissues. The association of actinomycosis and tuberculosis has, however, not often been reported.
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