(Chest. 2001;119:1966-1968.)
© 2001
American College of Chest Physicians
Utility of Wang Needle Aspiration in the Diagnosis of Actinomycosis*
Iram Bakhtawar, MBBS;
Robert F. Schaefer, MD and
Nagesh Salian, MD, FCCP
*
From the Division of Pulmonary and Critical Care Medicine (Drs. Bakhtawar and Salian), Department of Medicine; and Department of Pathology (Dr. Schaefer), University of Arkansas for Medical Sciences, Little Rock, AR.
Correspondence to: Iram Bakhtawar, MBBS, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham, Slot 555, Little Rock, AR 72205; e-mail: Bakhtawariram{at}UAMS.edu
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Abstract
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An 85-year-old man
had a 4-year history of recurrent pneumonia with a persistent pleural
effusion. He underwent repeated bronchoscopy that revealed a right
bronchus intermedius mass, but bronchial washes and biopsies remained
nondiagnostic. A repeat bronchoscopy was performed, and a Wang needle
aspiration of the mass was obtained that showed sulfur granules,
diagnosing actinomycosis. The patient was started on appropriate
antibiotic therapy. Actinomycosis must be considered in a patient with
recurrent pneumonia and an endobronchial mass. Wang needle aspiration
via bronchoscopy may be an important diagnostic tool.
Key Words: actinomycosis • bronchoscopy • endobronchial • pneumonia • Wang needle aspiration.
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Introduction
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Actinomycosis is a chronic suppurative bacterial infection.
The causative agents are Gram-positive, nonspore-forming anaerobic or
microaerophilic rods. They are endogenous oral saprophytes that dwell
in carious teeth, dental plaque, and gingival and tonsillar
crypts.1
Pulmonary actinomycosis is mainly acquired
through aspiration of organisms from the oropharynx.1
The
thoracic disease accounts for approximately 15 to 20% of actinomycosis
cases. The thoracic disease classically presents as either a mass
lesion or pneumonitis with or without pleural involvement. Primary
endobronchial actinomycosis is an exceptionally uncommon cause of a
mass lesion obstructing the trachea or bronchi. We present a case of
endobronchial actinomycosis diagnosed using Wang needle aspiration.
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Case Report
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An 85-year-old black man was admitted in August 1999 with a
1-day history of nausea, vomiting, and left flank pain. On review of
symptoms, he reported having mild shortness of breath at rest off and
on for the past 4 years. Since February 1996, he has had recurrent
episodes of pneumonias and persistent bilateral pleural effusions. An
extensive workup had been done over time, which included a CT scan of
the chest showing right middle and lower lobe atelectasis with
bilateral pleural effusion, and calcified lymph nodes in the precarinal
and right hilar areas. Repeated bronchoscopy revealed a right bronchus
intermedius (RBI) mass occluding 90% of its orifice. However, sputum
obtained, mucosal biopsies of the mass and wash collected from the RBI,
multiple thoracentesis, and a pleural biopsy remained nondiagnostic.
His medical history was also significant for a tooth abscess in
February 1996 preceding his initial pneumonia, diabetes mellitus type
II, hypertension, atrial fibrillation, chronic renal insufficiency, a
30-pack/year history of smoking ending in 1976, and a moderate history
of alcohol use. On physical examination, the significant findings were
mild respiratory distress and pallor. The lungs had percussion dullness
in the right base with decreased air entry on auscultation and
decreased tactile fremitus. The pulse was irregular. There was mild
palpation tenderness over the left costovertebral angle and left lower
quadrant. There was two-plus edema on the lower extremities.
Laboratory analysis revealed a urinary tract infection and low
hemoglobin. Chest radiography showed increased right pleural effusion
compared to June 1999. A CT scan of the chest done 3 weeks prior to
hospital admission showed interval increase in right-sided pleural
effusion and nonvisualization of a short segment of the bronchus
intermedius. Bronchoscopy was repeated, and the mass obstructing the
RBI was seen again (Fig 1
). Wash was collected from the RBI, and Wang needle aspiration was done
of the mass. The Wang needle aspirate showed colonies of Actinomyces
with sulfur granules (Fig 2
). Thoracentesis was not repeated. He was started on penicillin G, 2
million U q6h, and then switched to ceftriaxone, 2 g once daily
for 4 weeks, and then switched to amoxicillin for an additional 5
months.
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Figure 2.. Fine-needle aspirate. Granule of actinomycosis
surrounded by an intense reaction of leukocytes (hematoxylin-eosin,
original x 40). Insert: Higher magnification of the
organized aggregate of filamentous bacteria forming a spherule with an
eosinophilic rim representing the Splendose-Hoeppli phenomena
(hematoxylin-eosin, original x 450).
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Discussion
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A diagnosis of actinomycosis cannot be made from sputum cytology
and/or culture unless obtained directly from the bronchus, as it can be
found in 30 to 50% of normal saliva specimens.2
Thoracic
Actinomyces were diagnosed by thoracotomy in the past.3
4
Fiberoptic bronchoscopy allows a minimally invasive approach to make
the diagnosis. However, the reported diagnostic yields on BAL,
bronchial wash, and bronchial biopsies reported have been
low.3
5
It has been reported that physiologic saline
solution, which is commonly used for BAL, inhibits the growth of
pathogenic Actinomyces. Some authors6
have suggested that
in a small crushed bronchial biopsy, the morphologic appearance of the
sulfur granule may get distorted, making diagnosis difficult. The Wang
needle aspirate obtained a submucosal tissue sample unlike the mucosal
biopsies and was diagnostic of Actinomycosis. A literature review of
the past 25 years uncovered no reported case of endobronchial
actinomycosis diagnosed using Wang needle aspiration. Dissemination by
biopsy is a theoretical possibility, but no reference could be found in
the literature regarding it. In our case, the history of a tooth
abscess preceding the patient’s initial pneumonia may be relevant. A
diagnosis delayed up to 44 months from the beginning of symptoms is
reported by all authors,3
as was the case in our patient.
The hallmark of actinomycosis is the formation of yellow sulfur
granules. Although they may be abundant, only a single granule was
identified in 26% of specimens in one series.7
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Conclusion
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Endobronchial actinomycosis is rare and should be considered in a
patient with recurrent pneumonia and an endobronchial mass. Fiberoptic
bronchoscopy could help avoid a surgical procedure and aid in making a
diagnosis. Wang needle aspirate by bronchoscopy may be used to obtain
clinical material for diagnosis.
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Footnotes
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Abbreviation: RBI = right bronchus intermedius
Received for publication August 8, 2000.
Accepted for publication December 12, 2000.
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References
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Russo, TA (1995) Agents of actinomycosis: part III; Infectious diseases and their etiologic agents. Mandell, GL eds. Mandell, Douglas and Bennett’s principles and practice of infectious diseases 4th ed. ,2280-2281 Churchill Livingstone New York, NY.
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Weese, WC, Smith, M (1975) A study of 57 cases of actinomycosis over a 36-year period. Arch Intern Med 135,1562-1568[Abstract]
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Jensen, BM, Kruse-Anderson, S, Anderson, K (1989) Thoracic actinomycosis. Scand Thorac Cardiovasc Surg 23,181-184[ISI][Medline]
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Kinnear, WJM, MacFarlane, JT (1990) A survey of thoracic actinomycosis. Respir Med 84,57-59[ISI][Medline]
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Dalhoff, K, Wallner, S, Finck, C, et al (1994) Endobronchial actinomycosis. Eur Respir J 7,1189-1191[Abstract]
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Ariel, I, Breuer, R, Kamal, NS, et al (1991) Endobronchial actinomycosis simulating bronchogenic carcinoma. Chest 99,493-495[Abstract/Free Full Text]
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Hsieh, MJ, Liu, HP, Chang, JP (1993) Thoracic actinomycosis. Chest 104,366-370[Abstract/Free Full Text]
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Abstract
Introduction
