PulmonaryactinomycosisCasereportandretrospectivean

Pulmonaryactinomycosis:CasereportandretrospectiveanalysisoftheliteratureinChinaBaiquanYu1*,YaxinLiu1*,FuzhenLv1#1DepartmentofRespiratory,theSecondAffiliatedHospitalofHarbinMedicalUniversity,Harbin,150081,China*Thesetwoauthorscontributeequallytothiswork.#CorrespondingAuthor:Fuzhenlv,M.D.,Ph.D.Emailaddresses:BaiquanYu:[e-mail]:[e-mail]:[e-mail]:Pulmonaryactinomycosisisararebutfrequentlymisdiagnoseddiseasethatiscommonlyconfusedwithotherchronicinflammatorydiseasesandmalignancies.Inthisreport,weaimedtoevaluatetheclinicalmanifestationsandimagingfeaturesofpulmonaryactinomycosisforearlyrecognitionwhichcouldpreventtheconsiderablephysicaldamagecausedbydelayeddiagnosis.Wereporteda52-year-oldChineseman,sufferedbya15-dayhistoryofcough,copiouspurulentsputumandintermittentfever,wasfinaldiagnosedaspulmonaryactinomycosisbyB-modeultrasonic-guidedtransthoracicneedlebiopsy.Then24confirmedcases,includingourpatientfromyear2005to2010,werereviewedandtheirclinicalmanifestations,diagnosisandtreatmentwereanalyzed.Inourseriesthemedianageofthepatientswas46.5years,andthemale-to-femaleratiowas3:1.Themostcommonsymptomsincludecough,sputum,haemoptysis,feverandchestpain.Themainradiologicalfeatureswereperipheralmassornodulecomplicatedcavity,burr,pleuraleffusion.Malignancypossessedthehighestrateformisdiagnosis(33.3%),followedbypneumonia(25%)andtuberculosis(16.7%)amongthesecases.Patientswereconfirmedbyfiberopticbronchoscopy(20.8%),transthoracicneedlebiopsy(33.3%),orsurgery(33.3%).Withregardtothetreatment,12cases(50%)weretreatedbyantibioticsonlyand5cases(20.8%)bysurgeryonly,and4cases(16.7%)bysurgerycombinedwithantibiotics.Whenamiddle-agedmalepatientpresentswithcough,sputumandhaemoptysis,togetherwithradiologicfindingsofaperipheralmassormediastinallymphadenopathy,respiratoryphysiciansshouldsuspectpulmonaryactinomycosisandgivethepropertreatmenttopreventunwarrantedsurgeryorunnecessarydeath.Keywords:Actinomyces,pulmomaryactinomycosis,bronchoscopy,antibioticsIntroductionPulmonaryactinomycosisisararerespiratorydiseaseswithchronic,progressive,andsuppurativecharacteristics.Recentlytheincidenceofpulmonaryactinomycosishasincreasedalongwiththewideapplicationofantibiotics,hormones,cytotoxicdrugsandimmunosuppressants(1).Becauseoffewtypicalclinicalfeaturesandlimitedspecificlaboratorytestsavailablefordiagnosisofhumanactinomycosis,theprobabilityofmisdiagnosisandmisseddiagnosisofthediseaseincreased.Inthepresentstudy,wereviewed24casesofpulmonaryactinomycosisinChina,including1casefromourhospitaland23casesreportedfromdomesticliteraturesfrom2005to2010(2-13),andanalyzedclinicalmanifestations,diagnosisandtreatmentofthediseasewithintenttohelpearlydiagnosisandtreatment.CasereportA52-year-oldmanwasadmittedtotheSecondaffiliatedHospitalofHarbinMedicalUniversitywitha15-dayhistoryofcough,copiouspurulentsputumandintermittentirregularfeverwithchills.Histemperaturepeakedat39.0°C.Hehadnootherdiseasesbeforeandhadnoanyassociatedcomplainssuchasdyspnea,exerciselimitation,chestpain,haemoptysis,nightsweats,skinrash,orjointpainsbesidesanorexia,weightlossandfatigue.Hehadbeendiagnosedpneumoniaaccordingtohisclinicalmanifestationsandhadreceivedantibioticstreatmentsbutfailedinotherhospitalbeforehecametoourdepartment.Physicalexaminationrevealedthathegotahightemperatureat38.7°C,pulseratewas82beats/min,respirationswasat18/minandbloodpressurewas110/70mmHg.Withnormaldevelopment,hewaspoorlynourished.Respiratorysystemexaminationrevealedthatbreathsoundsweredecreasedandmoistralescouldbeheardintwoupperlobes.Therestofthephysicalexaminationwasunremarkable.Laboratoryexaminationshowedhiswhitebloodcellcount(WBC)wasincreasedto19.3×109/L(normal,4.0-10.0×109/L),differentialcountofpolymorphsandlymphyocyteswere85.2%and10.9%respectively.Plateletcountwas441×109/L(normal,100-300×109/L).Aspartateaminotransferase(AST)was44U/L(normal,40U/L),Alanineaminotransferase(ALT)was89U/L(normal,40U/L),Albuminwas30.8g/L(normal,35-55g/L).Fecaloccultbloodwaspositive.Theresultsfromotherlaboratoryexaminations,includinghemoglobin,serumelectrolytes,renalfunction,coagulationprofile,urineanalysis,roomairarterialbloodgasesandsputumdetectionofacid-fastbacilli,werewithinnormalrange.Resultsofsputumbacterialandfungalcultivationwerealsonormalornegative.Cytologyofbronchialwashingandbrushingspecimenswasnegativeformalignancy.Postero-anteriorchestX-rayviewrevealedamasswithacavitynexttoheartinleftlowerlobeofthelung(Fig.1).Arounduniformmasswithclearborders,measuring7.5×5.0cm,locatedinthelowerlobeofleftlungandenlargedmediastinallymphnodeswasconfirmedwithCTscanofthechest(Fig.2A.B).HistopathologicexaminationwascarriedoutwiththetissuetakenfromleftlowerlobelesionbyB-modeultrasonic-guidedtransthoracicneedlebiopsy.Thetissuewastranslucentandjelly-likewithsulfurgranules.Actinomycetesgroupswererevealedunderamicroscope(Fig.3A.B),thusthediagnosiswasconfirmedasactinomycosis.ThepatientwastreatedwithcontinuousIVamoxicillin/sulbactam6.0gram/predaydividedinto2dosesfor20days,thencoughandfeverrelievedsignificantl