18 February 2024: Articles
A Case of Thoracic Empyema Caused by
Rare disease
Yuta Matsubayashi1ABDEF, Kiyomichi Mizuno2ABE, Takashi Yamashita1ABE, Katsuyuki Asai2ABE*DOI: 10.12659/AJCR.943030
Am J Case Rep 2024; 25:e943030
Abstract
BACKGROUND: Actinomycosis is a clinically significant but uncommon infectious disease caused by anaerobic commensals of Actinomyces species, and the incidence of thoracic empyema is rare. We report an extremely rare case of empyema caused by Actinomyces naeslundii (A. naeslundii).
CASE REPORT: A 39-year-old man presented to our hospital with fever and dyspnea. He had massive pleural effusion and was diagnosed with a left lower-lobe abscess and left thoracic empyema. Thoracic drainage was performed and Ampicillin/Sulbactam was administered for 3 weeks. Four years later, the patient presented with back pain, and chest X-ray showed increased left pleural effusion. After close examination, malignant pleural mesothelioma was suspected, and computed tomography-guided needle biopsy was performed, which yielded a viscous purulent pleural effusion with numerous greenish-yellow sulfur granules. A. naeslundii was identified through anaerobic culture. Thoracoscopic surgery of the empyema cavity was conducted, and Ampicillin/Sulbactam followed by Amoxicillin/Clavulanate was administered for approximately 6 months. No recurrence has been observed for 1 year since the surgical procedure.
CONCLUSIONS: Actinomyces empyema is a rare condition, and this case is the second reported occurrence of empyema caused by A. naeslundii. The visual identification of sulfur granules contributed to the diagnosis. Long-term antibiotic therapy plays a crucial role in treatment.
Keywords: Actinomyces naeslundii, Actinomycosis, Empyema, Pleural
Background
Actinomycosis is an infrequent but clinically important chronic granulomatous disease caused by anaerobic commensal bacteria of the
Case Report
A 39-year-old man presented to our hospital with fever and dyspnea. He had a history of an 8-pack-years smoking history and occasional alcohol consumption. Furthermore, he had a medical background indicating bronchial asthma and a mild form of periodontal disease. Chest X-ray revealed significant left pleural effusion, while chest computed tomography (CT) demonstrated a low-attenuation area within the atelectasis of the left lower lobe (Figure 1A). Laboratory data indicated leukocytosis (24.83×103/μL) and elevated C-reactive protein (CRP 32.04 mg/dL). He was diagnosed with a left lower-lobe lung abscess and thoracic empyema, and subsequently underwent thoracic drainage. The pleural fluid culture yielded negative results. Empirical treatment was initiated with Ampicillin/Sulbactam (ABPC/SBT) at a dosage of 12 g/day, alongside pleural lavage. After 2 weeks, the chest tube was removed following improvements in leukocytosis and C-reactive protein levels. The antibiotic was changed to Amoxicillin/Clavulanate (AMPC/CVA) at a dose of 750 mg/day, and he was discharged. One week later, although a small residual empyema cavity was still evident on chest X-ray, the antibiotic course was completed.
Four years later, the patient visited a clinic due to back pain that had persisted for a month. Chest X-ray revealed increased left pleural effusion, resulting in referral to our hospital. Chest CT revealed a mass with pleural thickening and an internal low-attenuation area at the site of the previous empyema cavity (Figure 1B). Given the suspicion of malignancy or lymphoma, positron emission tomography-CT was conducted, revealing enhanced 18F-fluorodeoxyglucose uptake in the mass with a maximal standardized uptake value of 18.61 (Figure 2). Laboratory data demonstrated no elevation in leukocytes (10.92×103/μL), CRP (1.10 mg/dL), carcinoembryonic antigen (1.2 ng/mL), or soluble interleukin-2 receptor (445 U/mL). Based on the aforementioned findings, malignant pleural mesothelioma was suspected, prompting CT-guided needle biopsy. The initial histopathological examination revealed granulation tissue with collagenic fibers, without apparent malignant cells. Consequently, another CT-guided needle biopsy was performed, involving puncture of the low-attenuation area, which yielded a viscous purulent pleural effusion containing greenish-yellow sulfur granules (Figure 3A). Histopathological examination confirmed the presence of inflammatory cell infiltration surrounding the actinomycotic granules (Figure 3B). Additionally,
Discussion
Actinomycosis commonly affects the cervicofacial and abdominopelvic organs [1]. Thoracic involvement is less frequent, accounting for approximately 10–20% of cases. Among the
The diagnosis of actinomycosis is difficult and often delayed due to nonspecific clinical manifestations. A definitive diagnosis necessitates the culturing and identification of
Long-term antibiotic therapy is recommended for the management of thoracic actinomycosis, due to the high recurrence rate [1]. The suggested duration consists of 2–6 weeks of intravenous therapy, followed by 6–12 months of oral therapy. Penicillin is the preferred medication, while doxycycline, clindamycin, erythromycin, and clarithromycin can serve as alternative agents. An extended duration of 12–18 months is necessary in immunocompromised patients and in severe cases, including dense necrosis abscess, pleural effusions, empyema, fistula, and bone involvement [10]. Prolonging the duration may increase the length of hospitalization, cost of care, and risk of antibiotic resistance. Nevertheless, given the potential for recurrence or exacerbation of the condition, extended antibiotic therapy remains essential for high-risk cases. Although antibiotic therapy is the cornerstone treatment, there are some instances where surgical intervention becomes necessary. Surgical excision is indicated when uncontrollable massive hemoptysis, extensive necrotic tissues, or fistulas are present [6,10,11]. Moreover, surgical treatment may be considered in cases of an inadequate response to antibiotics, ineffective drainage due to abscess formation or empyema, or when malignancy cannot be ruled out.
As
Conclusions
Figures
Figure 1.. Chest computed tomography (CT) images upon hospital arrival. Pre-admission chest CT showing left pleural effusion (arrow head) and a lung abscess (arrow) within the atelectasis of the left lower lobe (A). CT upon recurrence showing a mass at the site of the previous empyema cavity, along with pleural thickening and a low-attenuation area inside (B). Figure 2.. Positron emission tomography-CT prior to CT-guided needle biopsy. Positron emission tomography-CT revealing enhanced 18F-fluorodeoxyglucose uptake in the mass, with a maximal standardized uptake value of 18.61. Figure 3.. The specimen obtained through the second CT-guided biopsy. During the second CT-guided biopsy, viscous purulent pleural effusion was aspirated, and greenish-yellow sulfur granules were confirmed macroscopically (A). Microphotography of the sulfur granules, showing actinomycotic granules (arrow) surrounded by inflammatory cell infiltration (B) (hematoxylin and eosin stain, magnification ×20). Figure 4.. Contrast-enhanced CT prior to the surgical procedure. Contrast-enhanced CT showing a small area of low attenuation inside the enhanced thickened pleura (arrow). The empyema cavity exhibited slight reduction compared with the plain chest CT obtained prior to the initiation of antibiotic therapy.References:
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