Pulmonary actinomycosis associated with endobronchial vegetable foreign body.

A 51-year-old woman visited our hospital with massive hemoptysis. She had suffered from recurrent hemoptysis for five years and had undergone bronchial artery embolization many times. The patient had a history of pulmonary tuberculosis and bronchiectasis. Chest radiography showed consolidation around the nodule in the lateral basal segment of the right lower lobe. We successfully performed a right lower lobectomy. The histological study of the resected specimen showed a vegetable foreign body and clumps of Actinomyces, indicating actinomycosis, which was suggested to be the cause of the hemoptysis. This was a very rare case of hemoptysis caused by a vegetable foreign body and actinomycosis.

CASE REPORT

In December 2011, a 51-year-old woman was admitted to our hospital due to massive hemoptysis. The patient was a nurse. She had suffered from recurrent hemoptysis for five years and had undergone bronchial artery embolization many times. The patient had a history of pulmonary tuberculosis and bronchiectasis. The patient’s vital signs were stable. On chest examination, decreased breathing sound and crackle were audible in the right lower lung field. Laboratory parameters were within normal limits. A chest X-ray showed patchy consolidation in the right lower lung (Fig. 1A). A computed tomography scan of the chest showed a small nodule, ground glass appearance, and consolidation around the nodule in the lateral basal segment of the right lower lobe (Fig. 1B). We performed an operation for the differential diagnosis between the possibility of a malignancy or life-threatening, massive hemoptysis. Under general anesthesia with a double lumen endotracheal tube, we resected the right lower lobe through a posterolateral thoracotomy at the sixth intercostal space. In the operation field, a dense pleural adhesion was observed on the entire surface of the lung. We could palpate a round, hard mass 2.0×3.0 cm in the lateral basal segment of the right lower lobe. The resected specimen consisted of the right lower lobe, weighed 177.5 g, and was sized 11.5×11.2×3.0 cm. On multiple serial sections, a cavity lesion measuring approximately 2.0×2.5 cm was identified (Fig. 2A). Foreign material was identified in the cavity (Fig. 2B). Histopathological examination confirmed it to be a vegetable foreign body, and clumps of Actinomyces, indicating actinomycosis, were present within the abscess cavity (Fig. 3). She was discharged on the twelfth postoperative day without any complications. Two years after surgery, she was healthy and free of recurrence.

Fig. 1

Radiologic studies of the patient. (A) A chest X-ray showed patchy consolidation in the right lower lobe. (B) Chest computed tomography showed a right lower lobe nodule with bronchiectasis.

Fig. 2

(A) The vegetable foreign body and (B) resected specimen (right lower lobe).

Fig. 3

(A) The granules are surrounded by a purulent exudate (H&E, ×40). (B) The filaments are clearly visible (H&E, ×400).

DISCUSSION

Actinomycosis is a chronic, suppurative pulmonary infection usually caused by Actinomyces israelii, which is present in the oropharynx of humans. Pulmonary infection with species of Actinomyces is uncommon, and usually results from aspiration of oropharyngeal secretions in those with chronic dental infections, extension from a cervicofacial infection, or hematogenous spread from a distant source [1]. Bronchial involvement, a rare form of thoracic actinomycosis, has been reported to be associated with foreign bodies. The first report of endobronchial pulmonary actinomycosis induced by a foreign body was the case of a Spanish patient in 1991, when a chicken bone was aspirated [2]. According to Chouabe et al. [3], eleven cases of pulmonary actinomycosis secondary to endobronchial foreign body aspiration have been described. Most cases have occurred in middle-aged males with known risk factors such as a chronic debilitated state and poor dentition. Most patients did not remember their choking spells. The main symptoms include cough, fever, expectoration of yellow pus, chest pain, and weight loss. Chest computed tomography shows a thickened bronchial wall, dense pulmonary alveolar opacity, atelectasis, pleural effusion, bronchiectasis, lymphadenopathy, or a radiopaque foreign body. Actinomyces tend to colonize and subsequently invade the tissue surrounding the foreign body. Obstructive endoluminal masses have been found on bronchoscopy, but the actual foreign bodies are not easily detected in some cases [3,4]. In the present case, the patient was a middle-aged female and did not have poor dentition. We had no information on an episode of aspiration before the operation. Usually the foreign body is likely to have become a host for subsequent Actinomyces contamination once the patient had developed poor dentition. Mucosal breaches secondary to foreign body impaction must occur for Actinomyces species to colonize and cause a marked granulomatous inflammatory reaction [5]. Pulmonary actinomycosis associated with a vegetable foreign material is extremely rare. We could find only one case of pulmonary actinomycosis induced by a vegetable foreign body [6]. Our case represents a very rare pathogenesis of pulmonary actinomycosis, which is an important disease in the differential diagnosis of a pulmonary mass.