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Thoracic actinomycosis
Thoracic Actinomycosis K. E. Tomm, MD, Houston, Texas J. W. Raleigh, MD, Houston, Texas Gene A. Guinn, MD, Houston, Texas
Actinomycosis is a chronic suppurative fungal infection characterized by extensive necrosis, fibrosis, and sinus formation without regard to normal tissue planes [I]. The causative organism in human infection is Actinomyces israeli [2]. The thorax was involved in 15 per cent of 1,330 cases reviewed by Cope [3]. Prather et al [4] and McQuarrie and Hall [5] reported that the thorax was involved more commonly than other areas in their series. The lungs are primarily involved in most patients with thoracic involvement, but heart and pericardial infection has also been reported [S]. The protean manifestations of thoracic disease have often mimicked tuberculosis or malignant disease, posing difficult diagnostic problems. Diagnosis has been made most often by culture of pleural fluid or draining sinuses. Isolation of the organism from the pleural biopsy and resected specimens has also been reported. Prior to the use of antibiotics, thoracic actinomycosis was associated with high mortality; however, control of clinical infection has since been reported in 90 per cent of patients [7]. Surgical treatment has been valuable to drain purulent material from the pleural cavity and to resect mass lesions when a correct preoperative diagnosis was not made. The purpose of this paper is to review our experience in the recognition and management of the thoracic form of actinomycosis. Clinical Data
Nine patients were seen in a five year period ending in March 1971 at the Houston Veterans AdminisFrom the Cora and Webb Mading Department of Surgery, Baylor College of Medicine, and the Department of Medicine, Baylor College of Medicine; and the Surgical and Medical Service, Veterans Administration Hospital, Houston, Texas. Reprint requests should be addressed to Dr Guinn. Chief, Thoracic and Cardiovascular Surgery, Veterans Administration Hospital, Houston, Texas 77031. Presented at the 1971 Annual Meeting of the South Texas Chapter of the American College of Surgeons, Galveston, Texas, November 1971.
46
tration Hospital with infections due to Actinomyces israeli. All were male patients living in Houston and none had engaged in an agricultural occupation. The cervical region was involved in two patients, the thorax in five patients, and the abdomen in two. The disease was easily classified into these regions and no mixed cases were seen. Those patients having thoracic involvement showed primary involvement in the lung in three cases, in the lung and pleural cavity in one case, and in the lung and chest wall in one. (Table I.) Constitutional symptoms were prominent in all patients with thoracic involvement but were nonspecific for actinomycosis. All five patients had a productive cough and weight loss from 6 to 40 pounds. Chest pain occurred in three patients, two of whom had pleural or chest wall involvement. Fever was present in three patients and hemoptysis occurred in one patient. One patient had an area of erythematous suppuration and sinus formation on the anterior chest wall. All but one of the patients had poor oral hygiene with multiple carious teeth. Laboratory studies were necessary to establish a diagnosis of actinomycosis. A definitive diagnosis was made when A israeli was demonstrated in the resected specimen or cultured from purulent material obtained from an empyema cavity or a draining chest wall sinus. A presumptive diagnosis of actinomycosis was made when “sulphur granules” were identified in histologic sections of the two resected specimens and in one pleural biopsy specimen. Roentgenographic findings were nonspecific. The areas of involvement usually appeared as a consolidation pneumonia containing many small round lucent areas. Two patients had indeterminate lesions confined to the right upper lobe and left lower lobe, respectively. These were central in location and were thought to represent bronchogenic carcinoma. One had an infiltrate in the middle lobe underlying an
The American Journal of Surgery
Thoracic Actinomycosis
area of rib erosion and a chest wall sinus, and the diagnosis was suspected on clinical examination. Two patients had bilateral infiltrates involving most of a lobe. The first had right lower lobe consolidation and empyema associated with left upper lobe infiltration. The other patient had consolidation pneumonia in the right upper lobe that progressed to cavitation in spite of therapy. Subsequently, consolidation developed in the left upper lobe and this also progressed to a large cavity. An aspergilloma developed in the large cavity. Many diagnostic procedures which were often of value in elucidating the etiology of intrathoracic disease were not helpful in our patients with actinomycosis. All patients had bronchoscopy, although in each case it was noncontributory. Mediastinoscopy was carried out in one patient, revealing only nonspecific inflammation in a lymph node. All skin tests gave negative results and fungal serologic studies were noncontributory. Anaerobic sputum culture was positive for A israeli in the one patient in which this study was carried out. Antibiotic therapy was useful in treatment of the actinomycotic infection or its resultant complications. Penicillin was used in all but one of the five patients. Tetracycline was employed in the other patient because of an allergy to penicillin. The dose of penicillin varied from as low as 1.2 million units daily for seven days in one patient to 20,000,OOO units daily for four months in another. Duration of therapy and dose were adjusted to the clinical response. The patients treated more recently received more prolonged treatment at higher doses, but in each instance the disease was severe and bilateral. The response to tetracycline in one patient treated for three months was excellent. The disease appeared to have been cured in all five patients but the followup period has been less than one year in two patients. TABLE II
TABLE I
Experience with Thoracic Actinomycosis at Veterans Administration Hospital, Houston, Texas (1966-l 971) Age WI.
Case Number
Sex, and Race
Occupation
Location of Disease
Oil field worker
Mass in left lower lobe Mass in right middle lobe and sinus Bilateral infiltrate and empyema Mass in right upper lobe Sequential bilateral upper lobe involvement
1 2
54, M, W 60, M, W
Salesman
3
48, M, W
Laborer
4 5
50, M, W 52, M, N
Carpenter Truck driver
___
Surgery was used in four of the five patients. Two had indeterminate lesions for which resection was performed with an incorrect preoperative diagnosis of carcinoma. Antibiotic therapy was used postoperatively and no complications occurred. Tube thoracostomy was effective in evacuating an empyema and, when combined with large doses of antibiotics, resulted in control of the infection. The fourth patient had simple debridement of a chest wall sinus which aided in diagnosis more than it influenced the course of the disease. The sinus healed rapidly on antibiotic treatment. Table II summarizes the method of treatment in this series. Comments
Actinomyces israeli is an anaerobic or microaerophilic gram-positive branching filamentous fungus. It occurs as a normal inhabitant of the oral cavity and is identified in material obtained from scrapings of the teeth, gingiva, and tonsillar crypts [S]. Human disease is due to endogenous infection thought to occur symbiotically with a bacterial infection after tissue injury or with bronchial obstruction [9]. Acti-
Diagnosis and Management of Thoracic Actinomycosis
Case Number 1
5
Volume 124,July1972
Location of Primary Disease
Provisional Diagnosis
Surgical Procedure
Mass in left lower lobe
Carcinoma
Lobectomy
Mass in right middle lobe and chest wall sinus Infiltrates in right middle lobe and left upper lobe; empyema on right Mass in right upper lobe
Carcinoma
Debridement
Bacterial pneumonia
Tube thoracostomy
Carcinoma
Lobectomy
Infiltrates in right and left upper lobes
Tuberculosis
None
Anhbiotic Therapy Penicillin, 7 days Penicillin, 180 days Tetracycline, 90 days Penicillin, 90 days Penicillin, 180 days
47
Tomm, Raleigh, and Guinn
nomycosis of the thorax has been presumed to be due to aspiration of the fungus, especially in patients with poor oral hygiene [IO]. It may also result from direct spread from the tonsillar crypts and cervical lymph nodes. Esophageal penetration with mediastinal infection and retroperitoneal spread to the thorax from below the diaphragm have also been described. Chest roentgenograms have been nonspecific. They have shown an infiltrative process, a cavitary lesion, or a mass suggesting malignancy. Flynn and Felson [II] have stressed the protean manifestations, but have emphasized the importance of bone changes, pleural involvement, and the frequency with which the disease extends across the interlobar septum or through the pleura to involve the chest wall. Because of the nonspecific roentgenographic appearance, a definitive diagnosis is usually delayed until material is available from bacteriologic study. The significance of A israeli isolated from sputum or bronchial washings has been difficult to determine since the fungus may be a normal inhabitant of the oral cavity. Kay [IO] was able to culture the organism from sputum in 109 of 240 patients with chronic lung infections and from bronchoscopic washings in sixty-five of these 240 patients. Similarly, mediastinoscopy and biopsy of mediastinal lymph nodes have been useful only to exclude metastatic neoplasm. The disease does not involve lymph nodes
[121. Treatment of thoracic actinomycosis was unsatisfactory until the advent of antibiotics. In the pre-antibiotic era, therapy included the use of vaccines, radiotherapy, and various chemical agents such as iodine and thymol. Surgical technics included rib resections, unroofing procedures, and curettage. Death or persistent disease was the usual result in all but the most localized cases. Since the introduction of effective drug therapy, cure in 90 per cent of patients has been reported [13]. Sulfonamides were the first employed [14], but penicillin proved to be a more effective therapeutic agent [15]. Broad spectrum antibiotics have also proved effective. Surgical intervention for thoracic actinomycosis has been suggested for removal of residual disease, destroyed lung tissue, or lesions suspicious of bronchogenic carcinoma (161. Drainage of intrapleural or chest wall suppuration has proved necessary in some cases. The two pulmonary resections in our series were carried out with an incorrect provisional diagnosis. Recovery was uneventful in these cases and this has been the experience of others when antibiotic therapy is used with surgery [4,5,15]. The results in our cases and those of others indicate that lobec-
48
tomy or pneumonectomy can be carried out in the presence of active actinomycotic infection without complications or undue operative risk, but should not be necessary when a correct diagnosis is available. Adequate and prolonged antibiotic therapy is important after surgery. Summary
Thoracic actinomycosis was treated in five patients presenting a varied clinical spectrum. Constitutional symptoms were prominent and roentgenograms of the chest were nonspecific. Diagnosis was established in all patients by isolation of A israeli from involved tissue. All patients had lung infiltrates, two of which were bilateral. In two patients lung resection was performed before a correct diagnosis was made. Tube thoracostomy was beneficial in one patient with empyema. Four patients received penicillin and, another, who was allergic to penicillin, received tetracycline. Clinical cure was obtained in all patients and it was believed that antibiotic therapy was responsible for the successful results. References 1. Steele JD (ed): Treatment of Mycotic and Parasitic Diseases of the Chest. Springfield, Illinois, Charles C Thomas, 1964. 2. Thompson L: Isolation and comparison of actinomyces from human and bovine infection. Proc Staff Meet Mayo C/in 25: 81,195O. 3. Cope VZ: Actinomycosis. Practifioner 142: 319, 1939. 4. Prather JR, Eastridge CE, Hughes FA, McCaughan JJ: Actinomycosis of the thorax: diagnosis and treatment. Ann Thorac Surg 9: 307, 1970. 5. McQuarrie DG, Hall WH: Actinomycosis of the lung and chest wall. Surgery 64: 905, 1968. 6. Dutton WP, lndan AP: Cardiac actinomycosis. Dis Chest 54: 463,1966. 7. Spilsbury BW, Johnstone FRC: The clinical course of actinomycotic infections: a report of 14 cases. Canad J Surg 5: 33, 1962. 6. Peabody JW, Washington DC, Seabury JH: Actinomycosis and nocardiosis. J Chronic Dis 5: 374, 1957. 9. Bates M, Cruickschank G: Thoracic actinomycosis. Thorax 12: 99. 1957. 10. Kay EB:. Actinomyces in chronic bronchopulmonary infections. Amer Rev Tuberc 57: 322, 1948. 11. Flynn MW, Felson B: The roentgen manifestations of thoracic actinomycosis. Amer J Roentgen 110: 707, 1970. 12. Pritzker HG, McKay JS: Pulmonary actinomycosis simulating bronchogenic carcinoma. Canad Med Assoc J 88: 785, 1963. 13. Moses J, Bonomo GR, Wendlund DE: Actinomycosis in childhood: historical review and case presentation. C/in Pediat 6: 221, 1967. 14. Morton HS: Actinomycosis. Canad Med Assoc J 42: 231, 1940. 15. Dobson L, Cutting W: Penicillin and sulfonamades in the therapy of actinomycosis. JAMA 126: 858. 1945. 16. Takaro T: Mycotic infections of interest to thoracic surgeons. Ann Thorac Surg 3: 71, 1967.
The American Journal of Surgery
Actinomycosis is a chronic suppurative fungal infection characterized by extensive necrosis, fibrosis, and sinus formation without regard to normal tissue planes [I]. The causative organism in human infection is Actinomyces israeli [2]. The thorax was involved in 15 per cent of 1,330 cases reviewed by Cope [3]. Prather et al [4] and McQuarrie and Hall [5] reported that the thorax was involved more commonly than other areas in their series. The lungs are primarily involved in most patients with thoracic involvement, but heart and pericardial infection has also been reported [S]. The protean manifestations of thoracic disease have often mimicked tuberculosis or malignant disease, posing difficult diagnostic problems. Diagnosis has been made most often by culture of pleural fluid or draining sinuses. Isolation of the organism from the pleural biopsy and resected specimens has also been reported. Prior to the use of antibiotics, thoracic actinomycosis was associated with high mortality; however, control of clinical infection has since been reported in 90 per cent of patients [7]. Surgical treatment has been valuable to drain purulent material from the pleural cavity and to resect mass lesions when a correct preoperative diagnosis was not made. The purpose of this paper is to review our experience in the recognition and management of the thoracic form of actinomycosis. Clinical Data
Nine patients were seen in a five year period ending in March 1971 at the Houston Veterans AdminisFrom the Cora and Webb Mading Department of Surgery, Baylor College of Medicine, and the Department of Medicine, Baylor College of Medicine; and the Surgical and Medical Service, Veterans Administration Hospital, Houston, Texas. Reprint requests should be addressed to Dr Guinn. Chief, Thoracic and Cardiovascular Surgery, Veterans Administration Hospital, Houston, Texas 77031. Presented at the 1971 Annual Meeting of the South Texas Chapter of the American College of Surgeons, Galveston, Texas, November 1971.
46
tration Hospital with infections due to Actinomyces israeli. All were male patients living in Houston and none had engaged in an agricultural occupation. The cervical region was involved in two patients, the thorax in five patients, and the abdomen in two. The disease was easily classified into these regions and no mixed cases were seen. Those patients having thoracic involvement showed primary involvement in the lung in three cases, in the lung and pleural cavity in one case, and in the lung and chest wall in one. (Table I.) Constitutional symptoms were prominent in all patients with thoracic involvement but were nonspecific for actinomycosis. All five patients had a productive cough and weight loss from 6 to 40 pounds. Chest pain occurred in three patients, two of whom had pleural or chest wall involvement. Fever was present in three patients and hemoptysis occurred in one patient. One patient had an area of erythematous suppuration and sinus formation on the anterior chest wall. All but one of the patients had poor oral hygiene with multiple carious teeth. Laboratory studies were necessary to establish a diagnosis of actinomycosis. A definitive diagnosis was made when A israeli was demonstrated in the resected specimen or cultured from purulent material obtained from an empyema cavity or a draining chest wall sinus. A presumptive diagnosis of actinomycosis was made when “sulphur granules” were identified in histologic sections of the two resected specimens and in one pleural biopsy specimen. Roentgenographic findings were nonspecific. The areas of involvement usually appeared as a consolidation pneumonia containing many small round lucent areas. Two patients had indeterminate lesions confined to the right upper lobe and left lower lobe, respectively. These were central in location and were thought to represent bronchogenic carcinoma. One had an infiltrate in the middle lobe underlying an
The American Journal of Surgery
Thoracic Actinomycosis
area of rib erosion and a chest wall sinus, and the diagnosis was suspected on clinical examination. Two patients had bilateral infiltrates involving most of a lobe. The first had right lower lobe consolidation and empyema associated with left upper lobe infiltration. The other patient had consolidation pneumonia in the right upper lobe that progressed to cavitation in spite of therapy. Subsequently, consolidation developed in the left upper lobe and this also progressed to a large cavity. An aspergilloma developed in the large cavity. Many diagnostic procedures which were often of value in elucidating the etiology of intrathoracic disease were not helpful in our patients with actinomycosis. All patients had bronchoscopy, although in each case it was noncontributory. Mediastinoscopy was carried out in one patient, revealing only nonspecific inflammation in a lymph node. All skin tests gave negative results and fungal serologic studies were noncontributory. Anaerobic sputum culture was positive for A israeli in the one patient in which this study was carried out. Antibiotic therapy was useful in treatment of the actinomycotic infection or its resultant complications. Penicillin was used in all but one of the five patients. Tetracycline was employed in the other patient because of an allergy to penicillin. The dose of penicillin varied from as low as 1.2 million units daily for seven days in one patient to 20,000,OOO units daily for four months in another. Duration of therapy and dose were adjusted to the clinical response. The patients treated more recently received more prolonged treatment at higher doses, but in each instance the disease was severe and bilateral. The response to tetracycline in one patient treated for three months was excellent. The disease appeared to have been cured in all five patients but the followup period has been less than one year in two patients. TABLE II
TABLE I
Experience with Thoracic Actinomycosis at Veterans Administration Hospital, Houston, Texas (1966-l 971) Age WI.
Case Number
Sex, and Race
Occupation
Location of Disease
Oil field worker
Mass in left lower lobe Mass in right middle lobe and sinus Bilateral infiltrate and empyema Mass in right upper lobe Sequential bilateral upper lobe involvement
1 2
54, M, W 60, M, W
Salesman
3
48, M, W
Laborer
4 5
50, M, W 52, M, N
Carpenter Truck driver
___
Surgery was used in four of the five patients. Two had indeterminate lesions for which resection was performed with an incorrect preoperative diagnosis of carcinoma. Antibiotic therapy was used postoperatively and no complications occurred. Tube thoracostomy was effective in evacuating an empyema and, when combined with large doses of antibiotics, resulted in control of the infection. The fourth patient had simple debridement of a chest wall sinus which aided in diagnosis more than it influenced the course of the disease. The sinus healed rapidly on antibiotic treatment. Table II summarizes the method of treatment in this series. Comments
Actinomyces israeli is an anaerobic or microaerophilic gram-positive branching filamentous fungus. It occurs as a normal inhabitant of the oral cavity and is identified in material obtained from scrapings of the teeth, gingiva, and tonsillar crypts [S]. Human disease is due to endogenous infection thought to occur symbiotically with a bacterial infection after tissue injury or with bronchial obstruction [9]. Acti-
Diagnosis and Management of Thoracic Actinomycosis
Case Number 1
5
Volume 124,July1972
Location of Primary Disease
Provisional Diagnosis
Surgical Procedure
Mass in left lower lobe
Carcinoma
Lobectomy
Mass in right middle lobe and chest wall sinus Infiltrates in right middle lobe and left upper lobe; empyema on right Mass in right upper lobe
Carcinoma
Debridement
Bacterial pneumonia
Tube thoracostomy
Carcinoma
Lobectomy
Infiltrates in right and left upper lobes
Tuberculosis
None
Anhbiotic Therapy Penicillin, 7 days Penicillin, 180 days Tetracycline, 90 days Penicillin, 90 days Penicillin, 180 days
47
Tomm, Raleigh, and Guinn
nomycosis of the thorax has been presumed to be due to aspiration of the fungus, especially in patients with poor oral hygiene [IO]. It may also result from direct spread from the tonsillar crypts and cervical lymph nodes. Esophageal penetration with mediastinal infection and retroperitoneal spread to the thorax from below the diaphragm have also been described. Chest roentgenograms have been nonspecific. They have shown an infiltrative process, a cavitary lesion, or a mass suggesting malignancy. Flynn and Felson [II] have stressed the protean manifestations, but have emphasized the importance of bone changes, pleural involvement, and the frequency with which the disease extends across the interlobar septum or through the pleura to involve the chest wall. Because of the nonspecific roentgenographic appearance, a definitive diagnosis is usually delayed until material is available from bacteriologic study. The significance of A israeli isolated from sputum or bronchial washings has been difficult to determine since the fungus may be a normal inhabitant of the oral cavity. Kay [IO] was able to culture the organism from sputum in 109 of 240 patients with chronic lung infections and from bronchoscopic washings in sixty-five of these 240 patients. Similarly, mediastinoscopy and biopsy of mediastinal lymph nodes have been useful only to exclude metastatic neoplasm. The disease does not involve lymph nodes
[121. Treatment of thoracic actinomycosis was unsatisfactory until the advent of antibiotics. In the pre-antibiotic era, therapy included the use of vaccines, radiotherapy, and various chemical agents such as iodine and thymol. Surgical technics included rib resections, unroofing procedures, and curettage. Death or persistent disease was the usual result in all but the most localized cases. Since the introduction of effective drug therapy, cure in 90 per cent of patients has been reported [13]. Sulfonamides were the first employed [14], but penicillin proved to be a more effective therapeutic agent [15]. Broad spectrum antibiotics have also proved effective. Surgical intervention for thoracic actinomycosis has been suggested for removal of residual disease, destroyed lung tissue, or lesions suspicious of bronchogenic carcinoma (161. Drainage of intrapleural or chest wall suppuration has proved necessary in some cases. The two pulmonary resections in our series were carried out with an incorrect provisional diagnosis. Recovery was uneventful in these cases and this has been the experience of others when antibiotic therapy is used with surgery [4,5,15]. The results in our cases and those of others indicate that lobec-
48
tomy or pneumonectomy can be carried out in the presence of active actinomycotic infection without complications or undue operative risk, but should not be necessary when a correct diagnosis is available. Adequate and prolonged antibiotic therapy is important after surgery. Summary
Thoracic actinomycosis was treated in five patients presenting a varied clinical spectrum. Constitutional symptoms were prominent and roentgenograms of the chest were nonspecific. Diagnosis was established in all patients by isolation of A israeli from involved tissue. All patients had lung infiltrates, two of which were bilateral. In two patients lung resection was performed before a correct diagnosis was made. Tube thoracostomy was beneficial in one patient with empyema. Four patients received penicillin and, another, who was allergic to penicillin, received tetracycline. Clinical cure was obtained in all patients and it was believed that antibiotic therapy was responsible for the successful results. References 1. Steele JD (ed): Treatment of Mycotic and Parasitic Diseases of the Chest. Springfield, Illinois, Charles C Thomas, 1964. 2. Thompson L: Isolation and comparison of actinomyces from human and bovine infection. Proc Staff Meet Mayo C/in 25: 81,195O. 3. Cope VZ: Actinomycosis. Practifioner 142: 319, 1939. 4. Prather JR, Eastridge CE, Hughes FA, McCaughan JJ: Actinomycosis of the thorax: diagnosis and treatment. Ann Thorac Surg 9: 307, 1970. 5. McQuarrie DG, Hall WH: Actinomycosis of the lung and chest wall. Surgery 64: 905, 1968. 6. Dutton WP, lndan AP: Cardiac actinomycosis. Dis Chest 54: 463,1966. 7. Spilsbury BW, Johnstone FRC: The clinical course of actinomycotic infections: a report of 14 cases. Canad J Surg 5: 33, 1962. 6. Peabody JW, Washington DC, Seabury JH: Actinomycosis and nocardiosis. J Chronic Dis 5: 374, 1957. 9. Bates M, Cruickschank G: Thoracic actinomycosis. Thorax 12: 99. 1957. 10. Kay EB:. Actinomyces in chronic bronchopulmonary infections. Amer Rev Tuberc 57: 322, 1948. 11. Flynn MW, Felson B: The roentgen manifestations of thoracic actinomycosis. Amer J Roentgen 110: 707, 1970. 12. Pritzker HG, McKay JS: Pulmonary actinomycosis simulating bronchogenic carcinoma. Canad Med Assoc J 88: 785, 1963. 13. Moses J, Bonomo GR, Wendlund DE: Actinomycosis in childhood: historical review and case presentation. C/in Pediat 6: 221, 1967. 14. Morton HS: Actinomycosis. Canad Med Assoc J 42: 231, 1940. 15. Dobson L, Cutting W: Penicillin and sulfonamades in the therapy of actinomycosis. JAMA 126: 858. 1945. 16. Takaro T: Mycotic infections of interest to thoracic surgeons. Ann Thorac Surg 3: 71, 1967.
The American Journal of Surgery