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Year : 2009  |  Volume : 52  |  Issue : 3  |  Page : 438-439
Pulmonary actinomycosis masquerading as tuberculosis


Department of Pathology, Topiwala National Medical College and B Y L Nair Charitable Hospital, Mumbai Central, Mumbai - 400 008, India

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Date of Web Publication12-Aug-2009
 

How to cite this article:
Rupani A, Amonkar G, Deshpande J. Pulmonary actinomycosis masquerading as tuberculosis. Indian J Pathol Microbiol 2009;52:438-9

How to cite this URL:
Rupani A, Amonkar G, Deshpande J. Pulmonary actinomycosis masquerading as tuberculosis. Indian J Pathol Microbiol [serial online] 2009 [cited 2019 Dec 12];52:438-9. Available from: http://www.ijpmonline.org/text.asp?2009/52/3/438/55021


Pulmonary actinomycosis (PA) is a rare disease and is often clinically confused with other chronic lung diseases like tuberculosis and malignancy. [1],[2],[3] The incidence of this infection has declined markedly in the last three to four decades and also appears to have turned less aggressive in nature as compared to the pre-antibiotic era. [3] However, once in a while we do encounter a case which is misdiagnosed due to lack of awareness and can result in fatality as in the case we are reporting here.


   Clinical History Top


A 45-year-old male, laborer by occupation, chronic smoker and alcoholic came with complaints of cough with mucopurulent sputum since three months. He also had gradually progressing dyspnea on exertion since six months. The patient was clinically diagnosed as pulmonary tuberculosis and was empirically started on anti-tuberculous treatment. He died suddenly and a complete autopsy was performed.

On external examination, the patient was poorly built and nourished with significant pallor. On in situ examination, the lungs were adherent to the chest wall and the pleura was markedly thickened. Both the lungs were firm in consistency and the parenchyma showed diffusely small white areas measuring 0.5 to 1 cm resembling tuberculous bronchopneumonia. The rest of the organs including adrenals showed no significant changes. Microscopic examination of the lungs showed fibrotically thickened pleura and the lung parenchyma showed extensive fibrosis in the intra-alveolar as well as in the interstitial spaces. Besides, there were focal dense aggregates of polymorphonuclear cells resembling abscesses amidst which were noted numerous colonies of actinomycetes. They were round, oval basophilic masses with a radiating arrangement of eosinophilic clubs towards the surface. Large bronchi showed ulceration of mucosa, focal squamous metaplasia and destruction of the walls with dense polymorphonuclear cell infiltrate. Smaller bronchioles showed peribronchiolar lymphocytic infiltrate. Adrenal medulla also showed similar inflammatory infiltrate and actinomycete colonies [Figure 1]. No evidence of tuberculosis was noted. Other organs showed no significant changes. Cause of death was given as respiratory failure due to extensive pulmonary actinomycosis with adrenal involvement.


   Discussion Top


The classic form of actinomycosis is that of cervicofacial type (50-60%) and pulmonary actinomycosis (PA) constitutes 15 to 20% of the cases. [3] Rarely, isolated endobronchial associated with inhaled infected foreign body and disseminated forms are described. [3],[4],[5] The pulmonary involvement along with the adrenal involvement as in our case has not been reported earlier in the literature as to best of our knowledge. PA can occur at any age but usually is seen in the second decade and later in the fourth to fifth decade. [3] The incidence of infection is two to four times greater in males. [2],[3] It presents with wet cough, prominent chest pain, dyspnea, hemoptysis and cutaneous fistulas. In a patient known to have PA, marked weight loss, malaise, skin abscesses and high fever may be suggestive of a disseminated disease. [1],[2],[3] The average duration of illness before definitive diagnosis is six months, a consistent figure in most series as seen in our case. [3] Higher incidences have been reported in patients with underlying respiratory disorders such as emphysema, chronic bronchitis and bronchiectasis and in alcoholics. [1],[2],[3] In alcoholics, there is a greater chance of aspiration of oropharyngeal or gastrointestinal secretions into the respiratory tract leading to pulmonary infection. Once established, the initial acute inflammation is followed by the characteristic chronic, indolent phase that generates local necrosis and fibrosis leading to misdiagnosis of tuberculosis as in our case. PA has not been convincingly shown to have an increased prevalence among immunocompromised hosts. [1],[2],[3] On radiology, PA can resemble a spectrum of lung pathologies ranging from benign infection to neoplasms. [3]

These are fastidious bacteria that are difficult to culture. [ 3] Culture studies are not available in our case as it was an autopsy case. While they are generally regarded as nonpathogenic, there is a possibility that actinomycosis may be caused by polymicrobial infection in which these organisms predominate as associated bacteria are isolated in two-thirds of these cases. [ 2],[3],[4] They are sensitive to standard antibacterial agents such as penicillin and others. [3],[4] The prognosis of the PA may be less favorable compared with the other commoner forms of actinomycosis as they have greater incidence of disseminated disease and are detected late in the course of the disease as in our case. [3] High index of suspicion is required to make the diagnosis with a combination of sputum examination and culture studies, correlation with the clinical and radiological features and rarely exploratory thoracotomy. However, when the infection is recognized early and adequate treatment is given the condition has an excellent prognosis and fatality can be avoided.

 
   References Top

1.Dontfraid F, Ramphal R. Disseminated Actinomycosis: Bilateral pulmonary infiltrates in association with disseminated actinomycosis. Clin Infect Dis 1994;19:143-5.  Back to cited text no. 1    
2.Apothιloz C, Regamey C. Disseminated infection due to Actinomyces meyeri: Case report and review. Clin Infect Dis 1996;22:621-5.  Back to cited text no. 2    
3.Mabeza GF, Macfarlane J. Pulmonary actinomycosis. Eur Respir J 2003;21:545-51.   Back to cited text no. 3    
4. Chouabe S, Perdu D, Deslιe G, Milosevic D, Marque E, Lebargy F. Endobronchial actinomycosis associated with foreign body: Four cases and a review of the literature. Chest 2002;121:2069-72.  Back to cited text no. 4    
5.Louerat C, Depagne C, Nesme P, Biron F, Guerin JC. Disseminated actinomycosis. Rev Mal Respir 2005;22:473-6.  Back to cited text no. 5    

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Correspondence Address:
Asha Rupani
Department of Pathology, 3rd Floor, College Building, T N Medical College and B Y L Nair Ch Hospital, Mumbai Central, Mumbai, Maharashtra - 400 008
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.55021

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