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Actinomycosis of the Chest Wall
medlcallmaaina Actinomycosis of the Chest Wall* Ultrasound Findings in Empyema Necessitans D. David Dershaw, M.D.
Sonography in the evaluation of superficial masses and pleural space disease is a well established diagnostic modality. The principles involved in this type of scanning were used in evaluating a patient with pleuropulmonary actinomycosis and a breast mass. CASE REPORT
A 54-year old white man presented with an exacerbation of pulmonary symptoms. He had a history of ethanol abuse , stopped two years prior to discover y of abnormal findings on chest x-ray film of a right upper lobe infiltrate. Bronchoscopic examination showed only inflammatory changes. Two years later he de veloped dyspnea, productive cough , fever and pain . The chest x-ray film now showed right upper and middle lobe infiltrates with air fluid levels. On bronchoscopic examination, Gram-positive, filamentou s branching rods interpreted as "probably actinomycosis" sensit ive to penicillin were found . He was treated with long-term therapy. Three years later he complained of a one -and-a-half week history of productive cough and fever. At the onset of these symptoms. a tender, right breast mass de veloped . On examinat ion, he had a temperature of 39°C with a respiratory rate of 3O/min. Breath sounds were diminished over the right lung anteriorly with inspiratory rhonchi heard posteriorly. Under the right breast a 10x 10 cm tender. tense and fluctulant mass was palpable. Clubbing of the digits was also apparent. Chest x-ray examination showed extensive right pleural disease and an infiltrate involving most of the right upper and middle lobes (Fig 1). Rib films were normal . Sonography of the right chest wall demonstrated a complex, largely cystic, mass in the right breast. Soft tissue planes overlying this collection were separated with decreased echoes . In the pleural space underlying this mass a similar collection was found. The chest wall between the se two collections was interrupted (Fig 2). Images were interpreted as demonstrating acute. inflammatory change in superficial tissues with an underlying chest wall abscess communicating with a pleural collection through the chest wall. A diagnosis of "empyema neeessitans" was made with Actinomycosis israelii considered the likely etiology. A drain was placed surgically. Empyema necessitans with superficial abscess communicating with a right empyema was found. Culture of purulent material was positive for branching. beaded filamentous Gram positive rods. The patient was treated with long-term penicillin therapy. *From Memorial Sloan-Kettering Cancer Center, New York. Reprint requests: Dr: Dershau; 1275 York Avenue. New York 10021
DISCUSSION
The differentiation of solid from cystic masses is widely appreciated as an important role of sonography. The classic criteria for differentiating these masses may be more difficult to apply in the chest than elsewhere in the body. 1.2 However, subtle changes in the quality and distribution of echoes within masses or collections can be made and may add important diagnostic information. On the basis of the chest radiograph it was impossible to determine whether or not pleural thickening in the right chest represented solid tissue or had a fluid component. The presence of echo-free space with a shaggy border in this clinical setting strongly suggested an empyema. This pattern is not unique to empyema. It may also be seen with pleural tumor and associated effusion or necrosis , hemothorax or with previous sclerosis of the pleural space with reaccumulation of pleural fluid." Usually the clinical setting will narrow the differential. The identification of fluid
FIGURE 1. PA chest x-ray film demonstrates extensive right upper and middle lobe infiltrates with right pleural disease . Minimal left basilar pleural thickening is also present. CHEST I 86 I 5 I NOVEMBER. 1984
779
FIGURE 2. Upper: Transvers e scan over the entire thorax shows a large cystic mass (arrowheads) in the right breast and underlying empyema (E) in the pleural space . Lower: Transverse section at the level of the right breast mass again shows a complex, largel y cystic mass superficially (la rge arrowheads) and a collection with a similar pattern (E) in the pleural space . The chest wall between this superficial abscess and empyema is interrupted (small arrowheads) at the site of the sinus tracts .
pockets within the pleural space also allows identification of a site for diagnostic thoracocentesis or pleural biopsy. 4.5 The characterization of tissue planes within the chest wall and in overlying soft tissues confirmed the diagnosis of empyema necessitans. As sound waves travel through successive tissue planes, the interfaces between these planes produce bright, well-defined echoes. Interruption of these planes leads to loss of these echoes. Communication between pleural and superficial chest wall collections could therefore be diagnosed. The similar echo pattern in these two collections confirmed that they represented the same communicating process. The major limitation in evaluating chest wall disease with sonography is the failure of diagnostic sound to
transverse bone. Ribs can significantly limit the examination, as can the scapulae and spine if disease is in areas adjacent to these structures. Involvement of these bony structures is also impossible to determine sonographically, REFERENCES
2 3 4 5
Donst BD , Baum JK, Maklad NF, Dons VL. Ultrasonic evaluation of pleural opacities. Radiology 1975; 114:135-40 Rosenberg E. Ultrasound in the assessment of ple ural disease . Chest 1983; 84:283-85 Taylor KJW. Atlas of Gray scale ultrasound. New York: ChurchillLivingstone, 1978; 404-11 Hir sch J, Rogers JV, Mack L. Real-time sonography of pleural opacities. Am J RoentgenoI1981 ; 136:297-301 Jen sen E Miscellaneous ultrasonically guided punctures. In : Holms HH, Kristensen JK, eds . Ultrason ically gu ided puncture technique. Philadelphia: WB Saunders, 1980
Contributions to the section, Medical Imaging , should be mailed to the Editor: Carl Racin, M.D., FCCp, Director, Diagnostic Radiology , Duke Unicers ity Medical Center, Durham 27710.
780
Actinomycosis ollhe ChestWall(D. David Dershaw)
Sonography in the evaluation of superficial masses and pleural space disease is a well established diagnostic modality. The principles involved in this type of scanning were used in evaluating a patient with pleuropulmonary actinomycosis and a breast mass. CASE REPORT
A 54-year old white man presented with an exacerbation of pulmonary symptoms. He had a history of ethanol abuse , stopped two years prior to discover y of abnormal findings on chest x-ray film of a right upper lobe infiltrate. Bronchoscopic examination showed only inflammatory changes. Two years later he de veloped dyspnea, productive cough , fever and pain . The chest x-ray film now showed right upper and middle lobe infiltrates with air fluid levels. On bronchoscopic examination, Gram-positive, filamentou s branching rods interpreted as "probably actinomycosis" sensit ive to penicillin were found . He was treated with long-term therapy. Three years later he complained of a one -and-a-half week history of productive cough and fever. At the onset of these symptoms. a tender, right breast mass de veloped . On examinat ion, he had a temperature of 39°C with a respiratory rate of 3O/min. Breath sounds were diminished over the right lung anteriorly with inspiratory rhonchi heard posteriorly. Under the right breast a 10x 10 cm tender. tense and fluctulant mass was palpable. Clubbing of the digits was also apparent. Chest x-ray examination showed extensive right pleural disease and an infiltrate involving most of the right upper and middle lobes (Fig 1). Rib films were normal . Sonography of the right chest wall demonstrated a complex, largely cystic, mass in the right breast. Soft tissue planes overlying this collection were separated with decreased echoes . In the pleural space underlying this mass a similar collection was found. The chest wall between the se two collections was interrupted (Fig 2). Images were interpreted as demonstrating acute. inflammatory change in superficial tissues with an underlying chest wall abscess communicating with a pleural collection through the chest wall. A diagnosis of "empyema neeessitans" was made with Actinomycosis israelii considered the likely etiology. A drain was placed surgically. Empyema necessitans with superficial abscess communicating with a right empyema was found. Culture of purulent material was positive for branching. beaded filamentous Gram positive rods. The patient was treated with long-term penicillin therapy. *From Memorial Sloan-Kettering Cancer Center, New York. Reprint requests: Dr: Dershau; 1275 York Avenue. New York 10021
DISCUSSION
The differentiation of solid from cystic masses is widely appreciated as an important role of sonography. The classic criteria for differentiating these masses may be more difficult to apply in the chest than elsewhere in the body. 1.2 However, subtle changes in the quality and distribution of echoes within masses or collections can be made and may add important diagnostic information. On the basis of the chest radiograph it was impossible to determine whether or not pleural thickening in the right chest represented solid tissue or had a fluid component. The presence of echo-free space with a shaggy border in this clinical setting strongly suggested an empyema. This pattern is not unique to empyema. It may also be seen with pleural tumor and associated effusion or necrosis , hemothorax or with previous sclerosis of the pleural space with reaccumulation of pleural fluid." Usually the clinical setting will narrow the differential. The identification of fluid
FIGURE 1. PA chest x-ray film demonstrates extensive right upper and middle lobe infiltrates with right pleural disease . Minimal left basilar pleural thickening is also present. CHEST I 86 I 5 I NOVEMBER. 1984
779
FIGURE 2. Upper: Transvers e scan over the entire thorax shows a large cystic mass (arrowheads) in the right breast and underlying empyema (E) in the pleural space . Lower: Transverse section at the level of the right breast mass again shows a complex, largel y cystic mass superficially (la rge arrowheads) and a collection with a similar pattern (E) in the pleural space . The chest wall between this superficial abscess and empyema is interrupted (small arrowheads) at the site of the sinus tracts .
pockets within the pleural space also allows identification of a site for diagnostic thoracocentesis or pleural biopsy. 4.5 The characterization of tissue planes within the chest wall and in overlying soft tissues confirmed the diagnosis of empyema necessitans. As sound waves travel through successive tissue planes, the interfaces between these planes produce bright, well-defined echoes. Interruption of these planes leads to loss of these echoes. Communication between pleural and superficial chest wall collections could therefore be diagnosed. The similar echo pattern in these two collections confirmed that they represented the same communicating process. The major limitation in evaluating chest wall disease with sonography is the failure of diagnostic sound to
transverse bone. Ribs can significantly limit the examination, as can the scapulae and spine if disease is in areas adjacent to these structures. Involvement of these bony structures is also impossible to determine sonographically, REFERENCES
2 3 4 5
Donst BD , Baum JK, Maklad NF, Dons VL. Ultrasonic evaluation of pleural opacities. Radiology 1975; 114:135-40 Rosenberg E. Ultrasound in the assessment of ple ural disease . Chest 1983; 84:283-85 Taylor KJW. Atlas of Gray scale ultrasound. New York: ChurchillLivingstone, 1978; 404-11 Hir sch J, Rogers JV, Mack L. Real-time sonography of pleural opacities. Am J RoentgenoI1981 ; 136:297-301 Jen sen E Miscellaneous ultrasonically guided punctures. In : Holms HH, Kristensen JK, eds . Ultrason ically gu ided puncture technique. Philadelphia: WB Saunders, 1980
Contributions to the section, Medical Imaging , should be mailed to the Editor: Carl Racin, M.D., FCCp, Director, Diagnostic Radiology , Duke Unicers ity Medical Center, Durham 27710.
780
Actinomycosis ollhe ChestWall(D. David Dershaw)