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First Case of Actinomyces Odontolyticus Pleural Effusion
Disorders of the Pleura SESSION TITLE: Student/Resident Case Report Poster - Disorders of the Pleura SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
First Case of Actinomyces Odontolyticus Pleural Effusion Rizwan Malik MD* Najiba Keshwani MBA; and Scott Beegle MD Albany Medical Center, Albany, NY
DISORDERS OF THE PLEURA
INTRODUCTION: Isolated pleural effusion without evidence of pulmonary parenchymal actinomyces has not been reported. We present a case of Actinomyces Odontolyticus pleural effusion. CASE PRESENTATION: The patient is a 53 year-old female with past medical history of HIV (CD4 Count 312), seizures, and poor dental hygiene presenting to the hospital with encephalopathy secondary to seizures. After resolution of encephalopathy, in three weeks, she developed dyspnea associated with right-sided pleural effusion and required 2 Litres of supplemental oxygen. Chest x-ray revealed large left-sided pleural effusion. Patient underwent thoracentesis, and 1 Litre of serous fluid was obtained. She had relief of dyspnea, and no longer required oxygen. A chest tube was placed to allow fluid drainage. Pleural Fluid Analysis showed lactate dehydrogenase of 359 IU/L, protein of 4.1 g/dL, pH of 7.37, white blood cell count of 899/mm3 (97% lymphocytes), red blood cell count of 15000/mm3, and no Acid Fast Bacilli. The flow cytometry was negative for B or T cell malignancy. CT scan of chest (Figure. 1) revealed no parenchymal lung lesions. Since her exudative pleural effusion was predominantly lymphocytic, we wanted to rule out pleural malignancy or tuberculosis via thoracoscopy. However, after two days of drainage, pleural fluid grew actinomyces odontolyticus and our treatment plan shifted to medical management. The chest tube was removed due to minimal drainage over a 48 hour period. Patient was treated with 4 weeks of intravenous Ampicillin 1 gram every 8 hours, followed by Amoxicillin 500 mg three times a day. At three months follow up, patient had no pulmonary symptoms and chest x-ray (Figure. 2) showed resolution of pleural effusion. We lost further follow up of patient. DISCUSSION: Pulmonary actinomyces is associated with poor oral hygiene, alcoholism, HIV infections, and underlying lung disease. 1It commonly presents in the fourth or fifth decade of life, with a higher incidence in males. Symptoms include fever, weight loss, productive cough, hemoptysis, dyspnea, and chest pain. Pleural thickening, effusion, or empyema is present in 15 % of cases of pulmonary actinomyces. CT Chest findings include mass with or without cavitation, pleural effusion, lymphadenopathy, and/or ground glass opacity. Diagnosis is made by bacterial culture of lung tissue, however, it can rarely be cultured from pleural fluid.Treatment involves a course of 6-12 months of high-dose beta-lactam antibiotics.2 CONCLUSIONS: Isolated pleural effusion in absence of lung parenchymal disease is a very rare manifestation of actinomyces odontolyticus. Reference #1: Suri, Arvind, Apurva Shah, Ronald Lis, and Marilou Corpuz. “Pulmonary Actinomycosis With Empyema.” Infectious Diseases in Clinical Practice 16.4 (2008): 270. Reference #2: Valour F, Sénéchal A, Dupieux C, Karsenty J, Lustig S, Breton P, et al. Actinomycosis: etiology, clinical features, diagnosis, treatment, and management. Infect Drug Resist. 2014;7:183. DISCLOSURE: The following authors have nothing to disclose: Rizwan Malik, Najiba Keshwani, Scott Beegle No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.679
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
590A
[
150#4S CHEST OCTOBER 2016
]
First Case of Actinomyces Odontolyticus Pleural Effusion Rizwan Malik MD* Najiba Keshwani MBA; and Scott Beegle MD Albany Medical Center, Albany, NY
DISORDERS OF THE PLEURA
INTRODUCTION: Isolated pleural effusion without evidence of pulmonary parenchymal actinomyces has not been reported. We present a case of Actinomyces Odontolyticus pleural effusion. CASE PRESENTATION: The patient is a 53 year-old female with past medical history of HIV (CD4 Count 312), seizures, and poor dental hygiene presenting to the hospital with encephalopathy secondary to seizures. After resolution of encephalopathy, in three weeks, she developed dyspnea associated with right-sided pleural effusion and required 2 Litres of supplemental oxygen. Chest x-ray revealed large left-sided pleural effusion. Patient underwent thoracentesis, and 1 Litre of serous fluid was obtained. She had relief of dyspnea, and no longer required oxygen. A chest tube was placed to allow fluid drainage. Pleural Fluid Analysis showed lactate dehydrogenase of 359 IU/L, protein of 4.1 g/dL, pH of 7.37, white blood cell count of 899/mm3 (97% lymphocytes), red blood cell count of 15000/mm3, and no Acid Fast Bacilli. The flow cytometry was negative for B or T cell malignancy. CT scan of chest (Figure. 1) revealed no parenchymal lung lesions. Since her exudative pleural effusion was predominantly lymphocytic, we wanted to rule out pleural malignancy or tuberculosis via thoracoscopy. However, after two days of drainage, pleural fluid grew actinomyces odontolyticus and our treatment plan shifted to medical management. The chest tube was removed due to minimal drainage over a 48 hour period. Patient was treated with 4 weeks of intravenous Ampicillin 1 gram every 8 hours, followed by Amoxicillin 500 mg three times a day. At three months follow up, patient had no pulmonary symptoms and chest x-ray (Figure. 2) showed resolution of pleural effusion. We lost further follow up of patient. DISCUSSION: Pulmonary actinomyces is associated with poor oral hygiene, alcoholism, HIV infections, and underlying lung disease. 1It commonly presents in the fourth or fifth decade of life, with a higher incidence in males. Symptoms include fever, weight loss, productive cough, hemoptysis, dyspnea, and chest pain. Pleural thickening, effusion, or empyema is present in 15 % of cases of pulmonary actinomyces. CT Chest findings include mass with or without cavitation, pleural effusion, lymphadenopathy, and/or ground glass opacity. Diagnosis is made by bacterial culture of lung tissue, however, it can rarely be cultured from pleural fluid.Treatment involves a course of 6-12 months of high-dose beta-lactam antibiotics.2 CONCLUSIONS: Isolated pleural effusion in absence of lung parenchymal disease is a very rare manifestation of actinomyces odontolyticus. Reference #1: Suri, Arvind, Apurva Shah, Ronald Lis, and Marilou Corpuz. “Pulmonary Actinomycosis With Empyema.” Infectious Diseases in Clinical Practice 16.4 (2008): 270. Reference #2: Valour F, Sénéchal A, Dupieux C, Karsenty J, Lustig S, Breton P, et al. Actinomycosis: etiology, clinical features, diagnosis, treatment, and management. Infect Drug Resist. 2014;7:183. DISCLOSURE: The following authors have nothing to disclose: Rizwan Malik, Najiba Keshwani, Scott Beegle No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.679
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
590A
[
150#4S CHEST OCTOBER 2016
]