- Email: [email protected]
Our first winner! Case of the winter season
Our First Winner! Case of the Winter Season Stanford
M. Goldman,
M.D.
CASE HISTORY
T
HIS 15-yr-old southwestern Indian boy was first seen as an outpatient because of severe right chest pain. He was treated with analgesics. A chest x-ray, in retrospect, showed early periosteal new bone formation. One month later, he was hospitalized at the USPHS Phoenix Indian Medical Center because of a right-sided pleural “effusion” and weight loss. The admitting diagnosis was tuberculosis or neoplasm. A coned-down view of the right upper chest (Fig. 1) shows the pertinent x-ray findings present at that time. The left chest was normal. A mild
Fig. 1
anemia was present. All skin tests were negative at 24 hr, when the patient signed himself out against medical advice. All cultures and serologic tests were noncontributory. He returned 25 mo later with spiking fever, continued weight loss, and an obvious complaint that can be deduced from the PA chest (Fig. 2). On the basis of the information above, the radiologist suggested the correct diagnosis, which was proven by special laboratory studies. After appropriate therapy, the patient was discharged asymptomatic.
Fig. 2
Stanford M. Goldman, M.D.: Former Chief of Radiology, USPHS Phoenix Indian Medical Center; presently Associate Radiologist, Sinai Hospital, and Instructor in Radiology, Johns Hopkins University School of Medicine, Baltimore, Md. 01974 bv Crune & Stratton, Inc. Seminars in Roenrgenology,
Vol. IX, No. 1 (January),
1974
3
4
CASE
DIAGNOSIS: ACTINOMYCOSIS
The lateral film (Fig. 3) merely confirms the findings seenon the PA chest of a huge extrapulmanic process(i.e., air-fluid levels that cross the midline and fail to be defined by any known intrapulmonic structure). The findings of a bronchopleurocutaneous fistula, a pleural effusion, and periosteal new bone formation, in the presenceof negative skin and laboratory tests, suggestedthe correct diagnosis.Yellow sulfur granuleson smears of the chest wall lesion were seen. An anerobic culture sent to the Communicable DiseaseCenter in Atlanta confirmed the radiologic diagnosis. The thoracic form of actinomycosis should be suspected whenever a pulmonic processis found to spread without regard to tissue planes and boundaries.’ It usually starts as an infiltrate in the lung periphery indistinguishable from an acute
OF
THE
WINTER
SEASON
ISRAELI
diploccoccal pneumonia.2 Untreated, lung abcessesdevelop with a characteristic progressionto an empyema,rib osteomyelitis, and chest wall infection. The mediastinum may also be affected, as evidencedby cardiac involvement, tracheo-esophageal fistula, or vertebral destruction. Rarely, miliary spread occurs. Actinomycosis may mimic a tumor or chronic fibrocavitary tuberculosis. The differential diagnosis includes nocardiosis, an acid-fast aerobic organism; tuberculosis; blastomycosis;sporotrichosis; coccidioidomycosis,which has a definitive serologic test; cryptococcosis; and neoplasm.3 Unfortunately, the mortality rate is still high even today because the diagnosis is usually not considered. Penicillin is the treatment of choice and yields excellent results.
Fig. 3
REFERENCES 1. Flynn MW, Felson B: The roentgen manifestations of thoracic acti nomycosis. Am J Roentgen01 110:707716,197O 2. Fraser RG, Par6 JAP: Diagnosis of Diseases of the
Chest. Philadelphia, Saunders, 1970, pp 662-663 3. Greer AE: Disseminating Fungus Diseases of the Lung. Springfield, Ill, Thomas, 1962, pp 3-26
M. Goldman,
M.D.
CASE HISTORY
T
HIS 15-yr-old southwestern Indian boy was first seen as an outpatient because of severe right chest pain. He was treated with analgesics. A chest x-ray, in retrospect, showed early periosteal new bone formation. One month later, he was hospitalized at the USPHS Phoenix Indian Medical Center because of a right-sided pleural “effusion” and weight loss. The admitting diagnosis was tuberculosis or neoplasm. A coned-down view of the right upper chest (Fig. 1) shows the pertinent x-ray findings present at that time. The left chest was normal. A mild
Fig. 1
anemia was present. All skin tests were negative at 24 hr, when the patient signed himself out against medical advice. All cultures and serologic tests were noncontributory. He returned 25 mo later with spiking fever, continued weight loss, and an obvious complaint that can be deduced from the PA chest (Fig. 2). On the basis of the information above, the radiologist suggested the correct diagnosis, which was proven by special laboratory studies. After appropriate therapy, the patient was discharged asymptomatic.
Fig. 2
Stanford M. Goldman, M.D.: Former Chief of Radiology, USPHS Phoenix Indian Medical Center; presently Associate Radiologist, Sinai Hospital, and Instructor in Radiology, Johns Hopkins University School of Medicine, Baltimore, Md. 01974 bv Crune & Stratton, Inc. Seminars in Roenrgenology,
Vol. IX, No. 1 (January),
1974
3
4
CASE
DIAGNOSIS: ACTINOMYCOSIS
The lateral film (Fig. 3) merely confirms the findings seenon the PA chest of a huge extrapulmanic process(i.e., air-fluid levels that cross the midline and fail to be defined by any known intrapulmonic structure). The findings of a bronchopleurocutaneous fistula, a pleural effusion, and periosteal new bone formation, in the presenceof negative skin and laboratory tests, suggestedthe correct diagnosis.Yellow sulfur granuleson smears of the chest wall lesion were seen. An anerobic culture sent to the Communicable DiseaseCenter in Atlanta confirmed the radiologic diagnosis. The thoracic form of actinomycosis should be suspected whenever a pulmonic processis found to spread without regard to tissue planes and boundaries.’ It usually starts as an infiltrate in the lung periphery indistinguishable from an acute
OF
THE
WINTER
SEASON
ISRAELI
diploccoccal pneumonia.2 Untreated, lung abcessesdevelop with a characteristic progressionto an empyema,rib osteomyelitis, and chest wall infection. The mediastinum may also be affected, as evidencedby cardiac involvement, tracheo-esophageal fistula, or vertebral destruction. Rarely, miliary spread occurs. Actinomycosis may mimic a tumor or chronic fibrocavitary tuberculosis. The differential diagnosis includes nocardiosis, an acid-fast aerobic organism; tuberculosis; blastomycosis;sporotrichosis; coccidioidomycosis,which has a definitive serologic test; cryptococcosis; and neoplasm.3 Unfortunately, the mortality rate is still high even today because the diagnosis is usually not considered. Penicillin is the treatment of choice and yields excellent results.
Fig. 3
REFERENCES 1. Flynn MW, Felson B: The roentgen manifestations of thoracic acti nomycosis. Am J Roentgen01 110:707716,197O 2. Fraser RG, Par6 JAP: Diagnosis of Diseases of the
Chest. Philadelphia, Saunders, 1970, pp 662-663 3. Greer AE: Disseminating Fungus Diseases of the Lung. Springfield, Ill, Thomas, 1962, pp 3-26