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Eur J Cardiothorac Surg 1998;14:578-583
© 1998 Elsevier Science NL

Thoracic actinomycosis

Abdullah rfan Tatepe, Neslihan Gülay Ulaan, erife Tuba Liman, Sedat Demircan, Ali Uzar

Atatürk Centre For Chest Disease and Chest Surgery 06280 Keçiören, Ankara, Turkey

Received 26 May 1998; received in revised form 19 August 1998; accepted 15 September 1998.

Corresponding author. Tel.: +90-312-355-2110/1425/1332; fax: +90-312-355-2135.

	Abstract

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Objective: Thoracic actinomycosis is a disease that is difficult to diagnose because its appearance varies from similarities with bronchogenic carcinoma to pneumonitis-like tuberculosis infections. Therefore the majority of patients undergo operations for diagnosis. We had seven patients with thoracic actinomycosis which were not diagnosed before operation. Methods: Between July 1990 and November 1997, seven patients with thoracic actinomycosis were diagnosed after thoracotomy in our centre. They all had non-specific symptoms and radiographic findings, so we failed to diagnose the disease during preoperative examinations. Therefore they all underwent thoracotomy for diagnosis. Four patients were operated because of suspicion of malignancy, two patients were operated because of pulmonary infiltration and abscess formation and one patient because of undiagnosed pulmonary infiltration. Lobectomy was performed in five of them because of destroyed lobes, and wedge resection was performed in two patients. In two patients the disease was diagnosed by fresh smears obtained from specimens in the course of operation and confirmed histopathologically and in the others histopathologically in the postoperative period. Results: Three major complications, acute renal failure, empyema and persistent air leakage developed in three cases after the operations. Bronchopleural fistula was found in only one of them and the patient died because of uncontrolled infection and sepsis on the 26th postoperative day. All of the other six cases are still alive. We did not observe any other problem in their long-term follow-up. All patients regularly took 20 million units/day of intravenous crystalline penicillin G when they were in the hospital. After that, antibiotic treatment was completed up to 2 months with procaine penicillin. Conclusions: Sometimes diagnosis of the actinomycosis of the lung is very difficult although it is an infection. In that case thoracotomy is needed for the diagnosis and sometimes for the treatment. In some cases because of the irreversible parenchymal change resective surgery may be needed. Actinomyces israelii infections should be suspected of in chronic infiltrative, nodular, cavitary process and tumour-like mass lesions besides other most probable causes. After diagnosed, it is treated using penicillin chemotherapy at least for 2 months.

Key Words: Thoracic • Actinomycosis • Surgery • Treatment

	Introduction

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Actinomycosis is a chronic, suppurative granulomatous infection which is usually caused by Actinomyces israelii. They may form an abscess and sinus tract formation and cause purulent discharge with yellowish sulphur granules. It classically involves cervicofacial (55%), abdominopelvic (20%), thoracic (15%) and mixed organs (10%) including skin, brain, pericardium and extremities [1] [2] [3] [4]. Thoracic involvement may be seen as bronchopulmonary disease and may extend to pleura and the chest wall. It is very difficult to diagnose actinomycosis because its appearance varies from similarities with bronchogenic carcinoma to pneumonitis-like tuberculosis infections. Actinomyces israelii is a bacterium that may be normally found in the oral flora, so it is difficult to determine whether the cultured organism is pathogenic or not and patients usually have to undergo operations for diagnosis.

In the Atatürk Centre For Chest Disease and Chest Surgery, seven patients were diagnosed with actinomycosis via thoracotomy in a 7-year period. We reviewed our experiences comparing with the literature.

	Materials and methods

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Between July 1990 and November 1997 we operated on seven patients with pulmonary actinomycosis in our centre. There were six male patients and one female patient. Their ages ranged from 34 to 65 years with a mean age of 49. The duration of symptoms varied from 1 year to 10 years.

Chronic cough and sputum were the most common complaints. Three patients suffered from minor hemoptysis. One patient was dyspneic. In physical examinations one patient had poor oral hygiene with multiple carious teeth.

Roentgenographic findings were non-specific. Radiographic examination demonstrated a mass-like appearance in four patients ( Fig. 1 ). The involved area appeared as a pulmonary infiltration in one patient. Pulmonary infiltration and abscess formation were seen in two patients ( Fig. 2 a,b and Fig. 3 ).

View larger version (117K): [in this window] [in a new window]   Fig. 1. CT scan of a 60-year-old male. An irregular mass is seen in the middle lobe. Note extension of infiltrates into the pleura; a characteristic feature of actinomycosis but it may also be seen in tuberculosis and infections with other fungi.

View larger version (69K): [in this window] [in a new window]   Fig. 2. (a) Posteroanterior chest roentgenogram of a 49-year-old male. An irregular heterogeneous mass with spiculations is seen in the right upper lobe. Note right displacement of the trachea and elevation of the minor fissure; atelectasis of the right upper lobe. (b) CT scan of the same patient. Extension of disease into the pleura and pleural thickening are seen. These findings are consistent with cicatrizing atelectasis that may be seen in many kinds of interstitial pneumonitis mainly in tuberculosis but a localized disease in the absence of calcification may suggest actinomycosis.

View larger version (86K): [in this window] [in a new window]   Fig. 3. CT scan of a 43-year-old male. Consolidation in the posterior segment of the right upper lobe with pleural extensions and thickening; a common pattern that may be seen in interstitial pneumonitis.

Many diagnostic procedures were not helpful in our patients with actinomycosis. Acid-fast bacillus on sputum smears were negative, skin tests for tuberculosis gave negative results. All patients had bronchoscopy, but there was no diagnostic finding and bronchoscopic lavage specimen cultures were negative. Also, cytology was not helpful.

There was no sign of mediastinal lymph node enlargement in these patients' radiographic examinations. Therefore we did not think about performing mediastinoscopy in any patient. Thoracoscopy might be the alternative method for taking tissue specimens. Due to the probability of dense adhesions, we chose exploratory thracotomy.

All patients underwent exploratory thoracotomy for diagnosis. In the patients whose radiographic findings showed a tumour-like mass we performed two middle lobectomies and one left lower lobectomy and one right upper lobectomy because of their destroyed lung parenchyma.

According to the operation findings, one right upper lobectomy and two wedge biopsies were performed in the other three patients that were thought to have pulmonary infections with the greatest probability of tuberculosis.

Patients' data are summarized in Table 1.

	Results

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All patients took penicillin treatment for 2 months. During their hospitalization time we used 20 million units of intravenous crystalline penicillin G for between 2 week and 1 month. After they were discharged from the hospital, antibiotic treatment was completed up to 2 months with procaine penicillin.

Finally, major complications were seen in three of the patients (3/7, 42.8%). One of them died (1/7, 14.2%) and two of them improved without any problem. We did not encounter with any other problem in their long-term follow-up.

	Discussion

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Thoracic actinomycosis is rarely seen during thoracic surgery practice. Rizzi et al. [9] identify 13 pulmonary actinomycosis in 2247 patients with a radiological pulmonary opacity. It is caused by Actinomycosis israelii which is normally found in the orofarengeal flora. It is an anaerobic and microaerofilic fungus and contains Gram positive branching filaments [4] [5] [6] [7] [8].

Thoracic actinomycosis is believed to occur due to aspiration of the fungus, especially in patients with poor oral hygiene [10]. One of our patients had poor oral hygiene and he was epileptic. So we thought, it was most probably because of aspiration. In the others we could not find any definite etiologic factor. Direct spread from tonsiller crypts and cervical lymph nodes may cause this disease. Oesophageal penetration with mediastinal infection and retroperitoneal spread from below the diaphragm to the thorax have also been described [8].

Fever, cough, hemoptysis, pleuretic chest pain, weight loss, anaemia, leukocytosis are common symptoms [2] [4] [7]. In all of our patients cough was the most common symptom. Three of our patients suffered from hemoptysis but this was not life-threatening.

The disease begins as a chronic pneumonitis and after months it may extend across the fissure and may extent to the chest wall [7].

In advanced disease, empyema, empyema necessitates, chronic draining sinus, vena cava superior syndrome and pericardial effusion may develop [2] [11] [12].

Radiographic examinations demonstrate pulmonary infiltration, cavitary lesion, tumour-like mass [3] [6] [8] [13]. Also they may demonstrate bone changes and pleural involvement [11] [13]. However, these findings are not specific. Also typical clinical presentation with pulmonary infiltrates, chest wall involvement and bony lesions become uncommon. That is why it is very difficult to diagnose actinomycosis. In our patients, chest roentgenograms showed pulmonary infiltration in one of our patients, pulmonary infiltration and abscess formation in two of our patients and tumour-like mass in four of our patients but we did not observe any bone changes and pleural involvement. In a similar study of 17 patients it was stated that actinomycosis mimicked chronic pneumonia in eight patients and carcinoma in nine patients [2]. Actinomyces israelii often infects pre-existing cavitary disease in the lung, it mimics tuberculosis. If the infection progresses in spite of using adequate medical treatment, surgery should be taken into consideration for definite diagnosis. Actinomyces israelii isolated from sputum or bronchial lavage does not necessarily indicate a problem to physicians since it is a normal inhabitant of the oral cavity [4] [8]. Actinomycosis israelli was cultured from sputum in 109 of 240 patients with bronchopulmonary infections and from bronchial washings in 65 of these 240 patients in another chest centre [10]. Contamination of sputum and bronchial washings with oral flora was the reason of these results. It is very difficult to diagnose actinomycosis without histologic and microscopic examination of tissues taken via operation. Diagnosis of actinomycosis is achieved when histologic examination reveals sulphur granules containing filamentous organisms characteristic of actinomyces species.

Surgery is the best method to achieve diagnosis and also the appropriate and ultimate treatment. Thoracoscopy may be the way of taking tissue example in appropriate cases.

Suspicion of malignancy is the commonest indication for exploratory thoracotomy [14]. Other indications for surgery may be drainage an abscess or pleural empyema [15] decortication, radical excision of sinus tracts [15], control of massive haemorrhage [16].

Actinomycosis is treated by using appropriate and prolonged antibiotics. Penicillin is a drug of choice but tetracycline may be an alternative drug when the patient is allergic to penicillin. Surgical intervention for patients with thoracic actinomycosis is frequently limited to diagnostic purposes especially to rule out any malignancy.

It is very difficult to perform resections in actinomyces infections similar to the other chronic infections. Therefore to diagnose this disease peroperatively is very important for avoiding wide resections. Examinations of tissue specimens microscopically is more useful and valuable method than frozen section examinations. We diagnosed this disease by using direct microscopic examination in our last two cases and then it was confirmed histopathologicaly. Surgical procedure may be also required for complications such an empyema thoracic, chronic sinus discharge, hemoptysis and destroyed lung parenchyma [2] [5] [8] [12] [17].

We diagnosed actinomycosis in all of our patients via operations. Postoperatively they all took penicillin treatment. We recommended that using penicillin treatment for 2 months is adequate. Also it is needed to treat the oropharyngeal or dental abscess to avoid recurrences. We had some complications in early periods but in late periods we did not see any other problem.

In summary, pulmonary actinomycosis is a rare disease but should always be considered in the differential diagnosis of pulmonary neoplasm [18] and tuberculosis especially in young adults. Actinomyces israelii infection should be considered in chronic infiltrative, nodular or chronic lesions like cavitary processes of the lung besides the other most probable causes. The probability of diagnosis and treatment of actinomycosis are sometimes difficult without any operation. In these cases surgical procedures may be used safely and postoperative penicillin therapy for 2 months will be adequate.

	Acknowledgments

 
We would like to express thanks to Ali Özgen, M.D. for his contribution in reviewing roentgenograms.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Abdullah Irfan Tastepe Neslihan Gülay Ulasan Ali Uzar Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Tastepe, A. I. Articles by Uzar, A. Search for Related Content PubMed PubMed Citation Articles by Tastepe, A. I. Articles by Uzar, A.