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THORACIC ACTINOMYCOSIS by MICHAEL BATES and GORDON CRUICKSHANK from the North Middlesex Hospital and the Leicester Chest Unit

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THORACIC ACTINOMYCOSIS by MICHAEL BATES and GORDON CRUICKSHANK from the North Middlesex Hospital and the Leicester Chest Unit Thorax: first published as 10.1136/thx.12.2.99 on 1 June 1957. Downloaded from Thorax (1957), 12, 99. THORACIC ACTINOMYCOSIS BY MICHAEL BATES AND GORDON CRUICKSHANK From the North Middlesex Hospital and the Leicester Chest Unit (RECEIVED FOR PUBLICATION JANUARY 9, 1957) Thoracic actinomycosis was first described by which grew at body temperature, and showed true Ponfick in 1882. It has been a serious disease, and, branching. Nocard (1888) described the pathogenic until recent years, there has been no satisfactory aerobic genus which was subsequently called treatment. The literature is extensive and various Nocardia. Eppinger (1890) isolated a further forms of therapy have been claimed as successful, aerobic form which was acid-fast called Actinomyces but the failures have been more impressive. The asteroides from a human brain abscess, and this mortality rates quoted by different authors have type is also occasionally found in lung infections. varied from 75% to 100%; but since 1940 the In 1905 Wright established the term Actinomyces results of treatment have improved. It is now bovis for the anaerobic form, and this nomenclature reasonable to expect a 90% cure rate for all cases continued until 1949 when the Medical Research of thoracic actinomycosis, provided that antibiotic Council (memorandum No. 23, 1949) decided that treatment is given in sufficient quantity and for the anaerobic organism responsible for all human an adequate length of time. There has been infections should subsequently be known as uncertainty both in the nomenclature of the causa- Actinomyces israeli. tive organism and also in the aetiology and classi- http://thorax.bmj.com/ fication of the thoracic manifestations in man. It is because of this radical change in treatment and REVIEW OF THE LITERATURE improvement in the mortality rate that we now Before 1940 thoracic actinomycosis was treated review the subject. by various methods; occasionally one of these was used alone but more often in conjunction with HISTORICAL SURVEY other types of treatment. We have reviewed the Bollinger (1877) first used the term " actinomyco- literature on this subject under the different types sis" with reference to a disease of cattle in which of therapy used rather than in their chronological there was a woody swelling of the tongue and order of trial. The majority of papers concern a on September 26, 2021 by guest. Protected copyright. diffuse enlargement of the jaw. In the same year small number of cases, and there are few articles Harz (1877) suggested the use of the term " ray in which a significant number have been treated fungus" or Actinomyces bovis for the delicate, by any one method. branching mycelial filaments which caused the Trevithick (1906) reported an interesting case of disease in cattle. Israel (1878, 1879) was the first actinomycotic lung abscess which was expectorated, to find the organism in human necropsy material and resolved spontaneously without treatment. and in 1887 gave a clinical description. Bostroem A year later this patient developed abdominal (1890) described an aerobic form of the organism actinomycosis which was cured by iodine and radio- in cattle and in man; this form was not acid-fast therapy. At the beginning of a long list of specific and subsequently became known as Actinomyces therapeutic measures this case report serves to graminis. Acland reported the first case of human remind us of the body's natural resistance to the actinomycosis in this country in 1884 (quoted by disease provided it is given some help in the way Foulerton, 1913). Hodenpyl (1890) wrote the first of general supportive measures. Vinson and report from America of two fatal cases of thoracic Sutherland (1926) also mention a case where a actinomycosis. Bostroem (1890) gave the first resistance to the disease had been acquired. In bacteriological description of the organism, while 1897 their patient developed an actinomycotic in the same year Wolff and Israel (1891) wrote a ulcer of the tibia and not until 1924 did the disease description of the pathology based upon two manifest itself again by the development of an human cases; they isolated an anaerobic form oesophago-bronchial fistula. Thorax: first published as 10.1136/thx.12.2.99 on 1 June 1957. Downloaded from 100 MICHAEL BATES and GORDON CRUICKSHANK TREATMENT 20 cases; but in eight cases of abdominal and VACCINES pulmonary disease it had no effect and all the patients died. Williams (1944) considered radio- Wynn (1908) reported a case ofthoraco-abdominal therapy to be the most useful therapeutic agent and actinomycosis successfully treated with a vaccine. reported two thoracic cases so treated, one of Neuber (1940) also claimed satisfactory results which was cured. from vaccine therapy in cervical and pulmonary actinomycotic infections. In 1949 Suteev treated THYMOL 12 patients by immunization with " actino-filtrate" Myers (1937) reported five cases of actinomycosis and seven were apparently cured, including one treated with 10% thymol, two of them being thoracic pulmonary case. cases; one of these died and the other was alive and well a year later. Etter and Schumacher (1939) IODINE IN VARIOUS FORMS also claimed a satisfactory response in treating a For many years it was thought that iodine had case with 0.65 g. of thymol by mouth daily for a specific action upon the Actinomyces israeli; but 17 days. it is now realized that the benefit gained from iodine therapy is the result of resorption of fibrous SURGICAL DRAINAGE AND EXCISION tissue, which is always abundant in actino- any There are few reports of cases trnated by surgery mycotic lesion, thus allowing other agents such as alone, most having been treated by surgery in the sulphonamides or penicillin to get into imme- conjunction with other forms of diate contact with the causative therapy. The two organism. Fouler- types of thoracic disease most likely to respond to ton (1913) reported a pleuropulmonary infection surgical drainage alone are the chest wall abscess presenting as a breast abscess and finally healing without underlying pleuropulmonary infection, and after treatment with large doses of potassium the pleural empyema. Excision of the lung, by iodide for a year. Preston (1928) reported two lobectomy or pneumonectomy, has only proved cases of actinomycotic lung abscess and severe successful in conjunction with sulphonamide or http://thorax.bmj.com/ bronchitis which showed marked improvement on penicillin therapy. iodides by mouth in conjunction with 20 ml. of " Cutler and Gross (1940) considered surgery the lipiodol" injected into the trachea. Another only treatment likely to be successful in this case in which endotracheal iodine was considered condition, and mention a mortality rate of over to be of importance was reported by McHardy 95% for all other methods of treatment. and Browne (1943). Their patient had an actino- mycotic granuloma obstructing the middle lobe bronchus and was treated wlth 300 grains of SURGERY IN CONJUNCTION WITH VACCINE, IODINE, potassium iodide daily for 80 days in conjunction THYMOL, OR RADIOTHERAPY on September 26, 2021 by guest. Protected copyright. with two bronchograms. Colebrook (1921) advocated surgery in conjunc- tion with vaccine in doses of 4 to 10 million frag- RADIOTHERAPY AND RADIUM IMPLANTS ments. Six thoracic cases so treated all died. Bigland and Sergeant (1923) reported a case of Harsha, of Chicago (1904), first treated a case of actinomycotic empyema and staphylococcal peri- actinomycosis with radiotherapy, and this form of carditis satisfactorily treated by rib resection in treatment was later popularized by Heyerdahl in conjunction with collosol iodine injected intra- 1914. Cope (1915) described a case with multiple venously and into the pleural and pericardial sacs chest-wall sinuses treated by radium implantations. together with potassium iodide by mouth. Torek Desjardins (1928) reported a pulmonary case cured (1926) produced improvement in a case with mul- by a large dosage of radiotherapy, and Smith tiple chest wall abscesses and a bronchocutaneous (1934) similarly treated 21 pulmonary cases, result- fistula by incision in conjunction with large doses ing in the cure of two, the improvement of two of potassium iodide. Harris and Priestley (1944) others, and the death of the remainder. He reported a fatal case originating in the skin with considered that the exact action of the x rays miliary pulmonary lesions which showed no upon the actinomyces in vivo was not known, and response to iodides, thymol, and radiotherapy. that as large a dose as possible should be given Benbow, Smith, and Grimson (1944) collected 26 without causing permanent damage to the skin. thoracic cases from the literature, 25 of which Stewart-Harrison (1934) demonstrated the efficacy were dead at that time. They also reported two of radiotherapy for cervical infections by curing cases of infection with Nocardia asteroides which Thorax: first published as 10.1136/thx.12.2.99 on 1 June 1957. Downloaded from THORACIC ACTINOMYCOSIS 101 were well a year after treatment with sulphonamides, and sulphathiazole had been given continuously radiotherapy, iodides, and surgery. A case of for 14 months without producing any toxic effects. actinomycotic empyema and pulmonary infection A dramatic cure with sulphadiazine was claimed was reported by Jacob (1944) as being cured by by Ladd and Bill (1943). Lyons, Owen, and Ayers iodides in conjunction with open drainage. Six (1943) report two cases, one being well two years others reported by Kolouch and Peltier (1946), after treatment with iodides, surgery, sulphathiazole, which were treated by surgery, iodides, and irradia- and sulphanilamide, the other being improved tion, all died. Wangensteen (1932) reported a case after five months' treatment with sulphadiazine. with extensive involvement of the lung and chest Watkins (1944) reported two children aged 3 years wall treated satisfactorily by repeated surgery and and 18 months respectively suffering from actino- iodides, until the patient eventually died of a mycotic empyemata who were treated successfully cerebral abscess.
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