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Robert Wood Johnson School of Medicine at Camden, Camden, NJ
INTRODUCTION: Endobronchial actinomycosis, a rare form of an uncommon disease, may represent a primary infectious process or a secondary invasion of tissues devitalized by other processes. We are reporting a case of actinomycosis in a broncholith.
CASE PRESENTATION: A 77-year-old woman was admitted to the hospital for fever, cough, and a pre-syncopal episode. The cough had started a week earlier. It had been dry initially and subsequently became productive of yellow sputum. A pre-syncopal episode while walking in the mall prompted admission to the hospital.
At time of admission, the patient denied dyspnea, hemoptysis, weight loss, and other respiratory or systemic symptoms. Her medical history was significant for multiple syncopal episodes in the preceding 2 years labeled as ‘neurocardiogenic syncope.’ She had been hospitalized 2 years prior for pneumonia. She was a non-smoker with no history of travel outside of New Jersey. There were no occupational exposures or pets at home. Medications were fosamax and atenolol.
On physical examination, the temperature was 102°. Dentition was poor. Chest examination revealed decreased breath sounds and dullness over left posterior lower lung. There were no wheezes or crackles.
Computed tomographic (CT) scan of chest done two years earlier and at time of admission are shown in Graphic 1. Hilar calcification and left lower lobe atelectasis are present on both scans. Graphic 2 demonstrates the bronchoscopic finding, a white mass completely obstructing the left lower lobe bronchus. Biopsy was performed – the mass was extremely hard. Microscopic examination of biopsy material revealed sulfur granules composed of colonies of filamentous/branching gram-positive bacteria which were negative on acid-fast staining, the typical appearance of actinomyces.
DISCUSSION: Broncholithiasis represents a calcified hilar lymph node eroding into a bronchus. Patients may present with hemoptysis, localized wheezing, and post-obstructive pneumonia. At times, "stones" may be coughed up. This patient probably obstructed slowy, leading to atelectasis of distal lung. The leading cause of broncholithiasis is histoplasmosis in the United States and tuberculosis in other parts of the world.(1) Actinomycosis may be a primary etiology in rare cases, but most commonly actinomyces, if present, tends to colonize broncholiths caused by either tuberculosis (2) or histoplasmosis.(34)
Actinomycetes are anaerobic, gram-positive, filamentous, branching bacilli that normally colonize the mouth, colon, and vagina. Actinomycosis is an indolent, slowly progressive infection. It was common in the pre-antibiotic era; the incidence decreased with the introduction of enicillin. Cervico-facial actinomycosis accounts for 60% of cases, while thoracic forms accounts for 15% of cases, with rare cases of endobronchial disease.
CONCLUSION: Broncholiths are rare and broncholiths from pulmonary actinomycosis even rarer. The most likely sequence of events is that this patient infected an underlying broncholith caused by a prior histoplasma infection with actinomyces delivered from the oral cavity to the lower airways during bouts of aspiration associated with syncope. The presence of the broncholith for at least 2 years without significant symptoms favors this sequence. Oddly, the patient’s initial event appears to have been asymptomatic; the true sequence of events can be surmised but not proven.
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