Pulmonary, Critical Care, and Sleep Pearls
A 37-Year-Old Man With Nonresolving Pneumonia and Endobronchial Lesion Merlin Thomas, MD; Tasleem Raza, MD, FCCP; and Mona Al Langawi, MD, FCCP
A previously healthy, immunocompetent 37-year-old man was hospitalized with a 3-month history of intermittent fevers and cough with mucopurulent sputum preceded by ﬂu-like symptoms. Five episodes of similar symptoms had prompted two hospitalizations and three courses of outpatient antibiotics. The fever would subside with treatment but intermittent dry cough persisted. There was no history of weight loss, night sweats, wheezing, arthralgia, skin rash, hemoptysis, recent travel, sick contacts, or high-risk sexual behavior. He was a nonsmoker with no alcohol or recreational drug use. He was an accountant in the military with no history CHEST 2015; 148(2):e52-e55
of signiﬁcant organic or inorganic dust exposures.
Physical Examination Findings Vital signs at admission were significant for a temperature of 39°C, pulse of 100 beats/min, and respiratory rate of 18 breaths/min. Chest examination revealed bronchial breath sounds with coarse crepitations at the right posterior basal region. Other systemic examination was within normal limits.
Diagnostic Studies Hemogram results were significant for leucocytosis of 27 3 103/mL with left shift. Renal and liver parameters were normal. C-reactive protein level was 130 mg/L, and erythrocyte sedimentation rate was 85 mm/h. Sputum Gram stain and culture and blood cultures revealed no growth. Chest radiograph at admission revealed right lower zone air space opacities (Fig 1). Similar chest radiograph findings were seen in two outpatient visits over the previous 3 months. The patient was admitted with a presumed diagnosis of nonresolving community-acquired pneumonia and was started empirically on parenteral ceftriaxone 2 g once daily with azithromycin 500 mg once daily, resulting in improvement of fever after 2 days, although cough
Manuscript received September 22, 2014; revision accepted January 29, 2015. AFFILIATIONS: From Hamad General Hospital - Pulmonary, Doha, Qatar. CORRESPONDENCE TO: Merlin Thomas, MD, Hamad General Hospital Pulmonary, Doha 3050, Qatar; e-mail: [email protected]
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Figure 1 – Airspace opacity in right lower zone.
persisted. Sputum smear and culture were negative for acid-fast bacilli. A CT scan of the chest revealed an endobronchial lesion in the right lower lobe bronchus with consolidation of the right lower lobe and right hilar lymphadenopathy (Fig 2). Bronchoscopy revealed a globular endobronchial lesion obstructing the right lower lobe bronchus (Fig 3). Gram stain results of BAL
Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.14-1963 © 2015 AMERICAN COLLEGE OF CHEST PHYSICIANS.
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Figure 2 – A, B, Chest CT scan. A, Parenchymal window. Multisegmental consolidation of right lower lobe with obstructing lesion in right lower lobe bronchus. B, Mediastinal window. Globular-shaped dense structure obstructing right lower lobe bronchus with relative enhancement and right hilar lymphadenopathy.
showed profuse polymorphonuclear cells with normal flora, and cultures grew a sensitive strain of Klebsiella pneumonia. Endobronchial biopsy pathology is shown (Fig 4).
What is the diagnosis?
Figure 3 – Bronchoscopy image. Multiple glistening, globular endobronchial lesions obstructing the right lower lobe bronchus.
Figure 4 – Endobronchial biopsy specimen. Intense acute inflammation with granulation tissue reaction, inflammatory exudate, amorphous material, and dense collections of filamentous organisms (hematoxylin and eosin, original magnification 3 400).
Diagnosis: Nonresolving pneumonia with endobronchial actinomycosis secondary to aspiration of vegetable matter Discussion Nonresolving pneumonia, also termed pneumonia with “slow resolution,” has been defined as the failure of radiographic resolution by 50% in 2 weeks or the failure of complete resolution by 1 month despite adequate antibiotic therapy in a clinically improved patient. It accounts for 10% to 15% of hospitalized patients with community-acquired pneumonia. The mortality rate of nonresolving pneumonia ranges from 27% to 49%. The persistence of pulmonary infiltrates is attributed to complications of pneumonia, defects in host immune defense mechanisms, the presence of unusual or resistant organisms, or diseases that mimic pneumonia. The most common chest symptom in nonresolving pneumonia is cough, followed by fever, seen in almost all patients, and hemoptysis, chest pain, and breathlessness, seen in 30% to 50% of patients. The right lung is more at risk, and the right upper lobe is the most commonly involved site. A lapse in host defense from occult tracheobronchial foreign body aspiration as a cause for nonresolving pneumonia is rarely seen in adults. Neurologic disorders, loss of consciousness, and alcohol or sedative use predispose to foreign body aspiration. A history of choking is reported in only 50% of cases, and, hence, the diagnosis of foreign body aspiration is complicated. The type of food aspirated depends on dietary habits and varies from vegetable matter to bones and watermelon seeds. Acute presentation in adults is rare, because the foreign body is usually wedged distally in the lower lobe bronchi. The most common symptom in foreign body aspiration is cough, whereas dyspnea is uncommon. If not acutely retrieved, the foreign body can initiate an inflammatory reaction with granulation tissue formation and is a focus for repeated infections. Primary endobronchial actinomycosis is rare and is uncommon with foreign body aspiration. Most patients are . 55 years of age with a male predominance and a definite predisposition such as diabetes, alcoholism, poor dental hygiene, or a high risk of aspiration. Cough is the most common symptom, whereas hemoptysis and recurrent pneumonia are seen in around 30% of cases. A chest CT scan shows a thickened bronchial wall, dense pulmonary alveolar opacity, atelectasis, pleural effusion, bronchiectasis, lymphadenopathy, or a radiopaque foreign body. Bronchoscopy usually reveals an obstructing e54 Pulmonary, Critical Care, and Sleep Pearls
endoluminal mass and can closely mimic endobronchial carcinoma, but foreign bodies are detected in only 45% of cases. Hence, a follow-up bronchoscopy after antibiotic therapy should be done to exclude a foreign body. Actinomyces almost always requires other types of bacteria to proliferate, and colonization with other species such as enterobacteriacea is a typical finding. These coexisting bacteria act synergistically by reducing oxygen tension, impairing the host defense, or both, which leads to enhanced growth of actinomyces. Because actinomyces is found in 30% to 50% of normal saliva specimens, potentially contaminated bronchial washings or sputum studies cannot diagnose endobronchial actinomycosis, and because it is a strict anaerobe, routine culture findings are usually negative. The method of obtaining a bronchial sample is important. The sample should be procured anaerobically with a protected specimen brush and ordinary BAL culture may be falsely negative if exposed to air for . 20 min. Fine-needle aspiration, transbronchial biopsy, and CT scan or ultrasound-guided biopsies lead to accurate diagnoses. The presence of sulfur granules in a biopsy sample is highly suggestive of actinomycosis but is not diagnostic because they are also seen in nocardiosis, chromomycosis, eumycetoma, and botryomycosis. The name “sulfur granule” has its origin in the small nodules that are round or oval basophilic masses with a radiating arrangement of eosinophilic clubs on the surface that resemble elemental sulfur. In most studies, the diagnosis of actinomycosis was confirmed by histologic visualization of actinomyces colonies surrounded by necrotic mass, suppuration, and inflammatory cells. The cornerstone therapy for actinomycosis is high-dose penicillin administered over a prolonged period (6 months to 1 year) with a minimal recommended duration of 45 days. Shortcourse antibiotic therapy of 1 month after removal of the foreign body (aspirated buttons/bone) led to a good outcome in some reported cases. Lack of clinical response to penicillin usually indicates a resistant copathogen because penicillin-resistant actinomyces is rare. Treatment success with fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin) has been cited in few case reports. Drug choices in penicillin-allergic patients are lincosamides, tetracyclines, macrolides, and cephalosporin. Treating the copathogens associated with actinomyces is still a debatable topic, although some advocate designing initial antibiotic regimens to target these organisms as well. Interestingly, although most of these organisms are not sensitive to penicillin in vitro, they are usually eradicated (clinical cure) when the antibiotic is administered. Early antibiotic treatment can prevent disease progression.
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The disease can spread to involve the blood vessels, causing massive hemoptysis, lung parenchyma with abscess formation, or bronchoesopageal fistula. These complications will need a surgical intervention such as lobectomy, segmentectomy, or bronchial artery embolization as indicated. Actinomycosis has little regard for anatomic barriers and in later stages can destroy the lung parenchyma and extend across fissures to a neighboring pulmonary lobe (transfissural extension), the pleura, or chest wall, with abscess formation in these areas. Overall, the prognosis of pulmonary actinomycosis is excellent when diagnosed early and treated with appropriate antibiotics. Prognostic factors associated with poor outcome (death or relapse) include disease duration of . 2 months prior to diagnosis, neurologic involvement, and lack of appropriate antibiotic therapy or surgical therapy. Clinical Course
No foreign body was noted under bronchoscopy visualization, but aspiration of foreign material was confirmed by pathology. Endobronchial biopsy (Fig 4) showed actinomyces organisms with vegetable matter on a background of acute inflammatory changes. The patient received a total of 10 weeks of antibiotics that were tailored to include the copathogen Klebsiella pneumonia. After 4 weeks of parenteral ceftriaxone, repeat chest CT scan revealed significant resolution of the pneumonic process and bronchoscopy revealed patent right lower lobe bronchus with no granulation tissue. There was no growth in BAL cultures. Treatment with oral amoxicillin was continued for 6 weeks. The patient remained well on follow-up at 3 months.
Clinical Pearls 1. Adults may present with foreign-body aspiration without any predisposing factors or symptoms of cough or choking.
2. Endobronchial actinomycosis should be considered in patients with an aspirated foreign body or a nonneoplastic endobronchial mass. 3. Biopsies with adequate sampling lead to accurate diagnosis of endobronchial actinomycosis, whereas the yield is less with a culture of expectorated sputum and bronchoscopy aspirates. 4. Although nonactinomyces organisms that create a favorable anaerobic environment are commonly isolated from airways of patients with endobronchial actinomycosis, these coexisting pathogens usually do not require specific antibiotic therapy. 5. Short-course antibiotics can successfully treat endobronchial actinomycosis provided the foreign body is removed.
Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/ organizations whose products or services may be discussed in this article. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.
Suggested Readings Hsieh MJ, Liu HP, Chang JP, Chang CH. Thoracic actinomycosis. Chest. 1993;104(2);366-370. Rome L, Murali G, Lippmann M. Nonresolving pneumonia and mimics of pneumonia. Med Clin North Am. 2001;85(6):1511-1530. Chouabe S, Perdu D, Deslée G, Milosevic D, Marque E, Lebargy F. Endobronchial actinomycosis associated with foreign body: four cases and a review of the literature. Chest. 2002;121(6):2069-2072. Choi JC, Koh WJ, Kim TS, et al. Optimal duration of IV and oral antibiotics in the treatment of thoracic actinomycosis. Chest. 2005;128(4): 2211-2217. Maki K, Shinagawa N, Nasuhara Y, et al. Endobronchial actinomycosis associated with a foreign body—successful short-term treatment with antibiotics. Intern Med. 2010;49(13):1293-1296. Chaudhuri AD, Mukherjee S, Nandi S, Bhuniya S, Tapadar SR, Saha M. A study on non-resolving pneumonia with special reference to role of fiberoptic bronchoscopy. Lung India. 2013;30(1):27-32.