Actinomycosis of the Thorax

Transcription

1 Actinomycosis of the Thorax Diagnosis and Treatment J. Richard Prather, M.D., Charles E. Eastridge, M.D., Felix A. Hughes, Jr., M.D., and J. J. McCaughan, Jr., M.D. A ctinomycosis of the thorax produces an acute and chronic inflammatory reaction characterized by abscess formation, sinus tracts, and dense scarring. This disease, having no respect for anatomical boundaries, may involve the lungs, pleura, mediastinum, or chest wall [lo, 151. An accurate diagnosis of actinomycotic infections is usually hampered by lack of suspicion of the disease, unfamiliarity with the clinical appearance, and difficulty in obtaining adequate culture material. The purpose of this paper is to review our experience in the diagnosis and treatment of this disease. MATERIAL AND METHODS Between 1946 and patients with proved actinomycosis were seen and treated. In 12 patients the disease was confined to the thorax. Of the 12 patients with thoracic actinomycosis, the disease was confined to the lung in 5, the chest wall in 2, and the lung and chest wall in the remaining 5. All patients were men ranging in age from 30 to 59 years (mean age 48.5 years). Seven were white, and 5 were Negro. In 5 patients the disease was confined to the lung and pleura and presented clinically as either an empyema (Fig. 1) or as a pulmonary infiltrate (Fig. 2) suggesting carcinoma [9, 121. The initial symptoms in those presenting with empyema were chest pain, productive cough, chills, and fever. The major complaint was chest pain resulting from the extensive pleural irritation. Physical findings included limitation of chest wall expansion, dullness to percussion, diminished breath sounds, and scattered rales, rhonchi, and wheezes. The admission temperatures ranged from 100.4' to 102'. In those presenting with pulmonary infiltrates, cough and hemoptysis were the predominant complaints. Chest pain did occur when the adjacent pleura was involved. Weight loss was noted in 2 patients. In these patients the physical examination was nonrevealing. In 2 patients with the disease limited to the chest wall, pain was the presenting symptom and was associated with either draining sinuses or a mass in the chest wall. Temperature elevations were absent in this group. The remaining 5 patients had involvement of the chest wall and lung. Chest From the Thoracic Surgical Section, Surgical Service, Veterans Administration Hospital, and the Department of Surgery, University of Tennessee College of Medicine, Memphis, Tenn. Presented at the Sixteenth Annual Meeting of the Southern Thoracic Surgical Association, Washington, D.C., Nov , Address reprint requests to Dr. Prather, Veterans Administration Hospital, 10%) Jefferson Ave., Memphis, Tenn VOL. 9, NO. 4, APRIL,

2 PRATHER ET AL. 1 2 FIG. 1. Chest roentgenogram reuealing a left hydropneumothorax. FIG. 2. Chest roentgenogram showing a right upper lobe infiltrative p~oc(:s.\ which was thought to be bronchogenic carcinoma. pain was the predominant symptom. Two patients complained of a productive cough, and 1 had occasional hemoptysis. One patient presented with superior vena caval obstruction manifested by distended veins over the upper portion of the body and edema of the upper extremities, neck, and face (Fig. 3A). Physical examination revealed chronic draining sinuses of the chest wall in 3 patients and a localized mass in chest wall in the other 2. The temperatures ranged from 98.6 to 102. One patient had a pleural effusion. No characteristic roentgenographic pattern was observed. In 2 patients the chest roentgenogram appeared normal, while in the other 10 it showed changes characteristic of an infiltrative process or a pleural effusion. DIAGNOSTIC CONSIDERA TIONS The clinical diagnosis was unsuspected in 9 patients. In the remaining 3 patients actinomycosis was strongly suspected because of the draining sinuses in the chest wall. One patient with a pulmonary infiltrate which was thought to be bronchogenic carcinoma later developed draining sinuses in the chest wall. It was not until then that the diagnosis of actinomycosis was suspected. Bronchoscopy in 7 patients and lymph node biopsy in 3 failed to aid in confirmation of the diagnosis. An accurate definitive diagnosis for the entire group depended upon either demonstrating the fungus in histological sections or growing the organisms in anaerobic culture media. The diagnosis was made in 5 of the 12 patients by observation of the ray fungus in histological section and in 7 patients by fungus culture taken from purulent material or tissue removed from the inflamed areas. 308 THE ANNALS OF THORACIC SURGERY

3 Actinomycosis of the Thorax A FZG. 3. (A) A 51-year-old man with chronic draining sinuses of the chest wall and superior uena caual obstruction. (B) Chest roentgenogram showing bilateral pulmonary infiltrates and a tumor mass in the right hemithorax. B TREATMENT AND RESULTS Nine patients received some form of surgical treatment. Resections carried out in 5 patients consisted of one lobectomy, two segmentals, and two excisions of chest wall abscesses. Of the 3 patients presenting with empyema, 1 was treated by aspirations alone; 1 by aspirations, tube thoracostomy drainage, and staged thoracoplasty; and 1 by a decortication. In 1 patient who received antibiotic treatment over a 2-month period, a mediastinal mass remained and was thought to be the pseudotumoral form [I61 of actinomycosis (Fig. 3B). In this patient a thoracotomy revealed a bronchogenic cyst, which was excised. In this group the only surgical complication was a bronchopleural fistula which occurred on the seventh postoperative day following the lobectomy. It was successfully managed by thoracostomy tube drainage and antibiotics. Either penicillin, penicillin and sulfadiazine, or erythromycin was used in the 12 patients as soon as the diagnosis was made. The penicillin dosage given was in the range of 2,000,000 to 20,000,000 units daily, with treatment periods ranging from 21 days to 45 months. Six patients received sulfadiazine in combination with penicillin, while 4 patients were given penicillin alone. The remaining 2 were treated with erythromycin because of a history of a previous penicillin reaction. The 1 patient who received treatment for 45 months required this prolonged course of therapy because of the severity of the disease, which involved the mediastinum, lung, and chest wall. Eleven patients were cured of their disease. One patient who had a decortication and received erythromycin was lost to follow-up. This patient has since been found to be living, but the status of his disease is unknown. VOL. 9, NO. 4, APRIL,

4 PKATHEK ET AL. COMMENT In 1882 Ponfick [113 first described thoracic actinomycosis. This followed the identification by Israel in 1878 [5] of the fungus in human necropsy material. The name nctino-myces or ray fungus had been suggested by Harz in 1877 [4] while studying specimens from diseased cattle. This organism was isolated in by Wolf and Israel [ 171 from human infections by means of anaerobic culture. The term Actinomycosis bovis was established by Wright in 1905 [18], and since that time there have been many cases reported. In 1949 the Medical Research Council decided that the anaerobic organism responsible for human infections should be called Actinomyces isrneli. Actinomycosis is an endogenous infection. In contrast to other fungi, this organism is unique in that it has never been recovered from any source in nature. The mouth and oropharynx are the natural habitats of anaerobic actinomycosis. Cultures may be obtained easily from the gums, tonsillar crypts, and carious teeth. It would appear that this is an opportunistic organism. In conjunction with some bacterial invader or as a result of some tissue injury, the fungus gains access to deep tissue, where it assumes a pathogenic role [14]. Thoracic infections probably result either from aspiration, swallowing with esophageal penetration, direct extension into the mediastinum from the neck, or retroperitoneal spread from below the diaphragm [13]. It is reported that about 15% of human actinomycotic infections involve the thorax. This was not true in our experience, since 54% (12 of 22 patients) had the disease involving the chest. In addition, 2 patients with extrathoracic actinomycosis also had pulmonary infiltrates. These infiltrates cleared during the treatment for their primary disease. The clinical manifestations were nonspecific. The most constant complaint was chest pain, which can occur with any infection within the thorax. Other manifestations such as cough, hemoptysis, and fever were present but are not specific for actinomycosis. The diagnosis was suspected more frequently when the patient was seen with draining sinuses in the chest wall. All but 1 patient with sinuses were suspected clinically of having actinomycosis on the initial examination. The diagnosis was confirmed by cultures of the purulent material from the sinuses. Chest roentgenograms were also nonspecific [8]. The infections that presented as infiltrative processes, either bilateral or unilateral, mimicked either bronchogenic carcinoma or tuberculosis. In some there was an associated pleural effusion which completely obscured the primary lung lesion. When the disease was confined predominantly to the chest wall, the chest roentgenogram showed no abnormalities. Because of the lack of clinical suspicion the diagnosis of actinoinycosis is usually difficult. Recovery of the fungus from sputum samples 310 THE ANNALS OF THORACIC SURGERY

5 Actinomycosis of the Thorax or bronchial washings does not substantiate the diagnosis, since the fungus is normally present in the mouth. Kay [7] was able to culture the organism from sputum in 109 of 240 patients with chronic bronchopulmonary infections. Bronchial washings were positive for Actinomyces in 65 patients from this same group. Lymph node biopsy is of no help in the diagnosis except to exclude metastatic neoplasm. The enlargement that may be found occasionally in the regional nodes is due to reactive hyperplasia. The diagnosis is best made by special culture technique. This fungus is also unique in that it will not grow except under anaerobic conditions and is difficult to isolate, especially after antibiotic treatment has been instituted. The diagnosis also may be confirmed by observation of the fungus in histological sections, but this requires surgical excision. In the past many methods have been used in the treatment of actinomycosis. These include the use of vaccines, radiotherapy, chemicals such as iodine and thymol, antibiotics, chemotherapeutic agents, and surgical techniques [l]. With the advent of effective chemotherapeutic drugs and antibiotics many previous methods of treatment became obsolete. One of the first effective drugs was sulfanilamide [3]. This was soon replaced by penicillin, which is now the drug of choice [2]. With the use of these effective drugs the high mortality has been markedly reduced, and total recovery is now the rule. All patients in this series received antibiotic treatment with good results. Penicillin alone or in combination with sulfadiazine was used in most of the patients. In 2 patients erythromycin was used because of a history of a previous allergic reaction to penicillin. The usual dosage recommended or penicillin is 10,000,000 to 20,000,000 units daily until the disease is eradicated. Nine patients required some form of surgical treatment. In the majority these procedures were performed because neoplastic disease was suspected. In the remainder surgical treatment was required to correct complications resulting from the disease process. The indications for operative intervention in the treatment of thoracic actinomycosis include destroyed lung tissue, residual disease following adequate antibacterial therapy, pseudotumor, isolated subcutaneous or intrapleural abscess, or suspicion of neoplasm. In any event, all types of surgical procedures must be combined with effective antibiotic therapy to accomplish satisfactory treatment of thoracic actinomycosis. SUMMARY A series of 12 patients with proved actinomycosis involving the thorax has been presented. The clinical picture and appearance of the disease on chest roentgenogram were nonspecific. When the patients VOL. 9, NO. 4, APRIL,

6 PRATHER ET AL. presented with chronic draining sinuses of the chest wall, clinical suspicion of the disease was more frequent. Diagnosis was confirmed by anaerobic fungus cultures in 7 patients and by histological tissue section in 5. All patients were treated with antibiotic therapy, and 9 underwent. some type of surgical procedure. A brief discussion of the diagnosis and treatment is presented. REFERENCES 1. Bates, M., and Cruickshank, G. Thoracic actinomycosis. Thorax 12:99, Dobson, L., and Cutting, W. Penicillin and sulfonamides in the therapy of actinomycoses. J.A.M.A. 128:856, Dobson, L., Holman, E., and Cutting, W. Sulfanilamide in the therapy of actinomycosis. J.A.M.A. 116:272, Harz, C. 0. Actinomyces bovis: Ein neue Schimmel in dem Gewebe des Rindes. Jahwsber. Konigl. Central Thierarzneischule Munchen p. 125, Israel, J. Neue Beobachtungen auf dem Gebiete der Mykosen des Menschen. Virchow. Arch. Path. Anat. 74:15, Israel, J. Neue Beitrage zu den mykotischen Erkrankungen des Menschen. Virchow. Arch. Path. Anat. 78:421, Kay, E. B. Actinomyces in chronic bronchopulmonary infections. Amer. Rev. Tuberc. 57:322, McQuarrie, D. G., and Hall, W. H. Actinomycosis of the lung and chest wall. Surgery 64:905, Moore, W. R., and Scannell, J. G. Pulmonary actinomycosis simulating cancer of the lung. J. Thorac. Cardiovasc. Surg. 55:193, Peabody, J. W., Jr., and Seabury, J. H. Actinomycosis and nocardiosis. Amer. J. Med. 28:99, Ponfick, E. Die Actinomykose des Menschen. Berlin: Hirschwald, Pritzker, H. G., and MacKay, J. S. Pulmonary actinomycosis simulating bronchogenic carcinoma. Canad. Med. Ass. J. 88:785, Spilsburg, B. W., and Johnstone, F. R. C. The clinical course of actinomycotic infections: A report of 14 cases. Canad J. Surg. 5~33, Steele, J. D. The Treatment of Mycotic and Parasitic Diseases of the Chest. Springfield, Ill.: Thomas, Takaro, T. Mycotic infections of interest to thoracic surgeons. Ann. Thorac. Surg. 3:71, Villegas, A. H., and Sala, C. A. Pulmonary actinomycosis of pseudotumoral form. J. Thorac. Cardiovasc. Surg. 49:677, Wolf, M., and Israel, J. Ueber Reinkultur des Actinomyces und seine Uebertragbarkeit auf Thiere. Virchow. Arch. Path. Anat. 126: 11, Wright, J. H. The biology of the microorganisms of actinomycosis. J. Med. Res. 13: THE ANNALS OF THORACIC SURGERY