A RARE CASE OF CONCURRENT PULMONARY ACTINOMYCOSIS AND ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS IN A PARTICIPANT OF NATIVE AMERICAN SWEAT LODGE CEREMONIES

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pulmonary actinomycosis is a rare manifestation, typically seen in patients with poor oral hygiene at risk for aspiration. Whether underlying pulmonary disease predisposes risk of thoracic infection has not been well elucidated due to the disease rarity. CASE PRESENTATION: A 32-year-old male with childhood asthma was referred to our Interventional Pulmonologist for evaluation of a lung mass incidentally discovered on spine radiograph during back pain workup. He reported 3-month history of dyspnea, nonproductive cough, constitutional symptoms, and scant hemoptysis. The patient had participated in multiple local Native American tribal sweat lodge ceremonies where members sit around hot stones doused with water to produce steam in huts made of sticks covered with animal skins and blankets that have been stored in the woods. CT showed an 8x9 cm RLL finger-like mass extending across the fissure to the RUL with background multifocal bronchiectasis. Bronchoscopy revealed diffuse mucopurulent secretions with a large yellow-black broncholith at the os of the superior segment of RUL enclosing an area of post-obstructive pus and multiple sulfur granules. Antibiotics, voriconazole, and corticosteroids were initiated for presumed ABPA and post-obstructive pneumonia. Serum aspergillus IgE was strongly positive (29.2 kU/L), aspergillus IgG elevated at 91.9 mg/L, total IgE initially 1424 IU/mL and increased to 5291 IU/mL, confirming ABPA. BAL cultures speciated Actinomyces odontolyticus. Maxillofacial CT revealed a right periodontal abscess, suggesting cervicofacial actinomycosis as the potential source of thoracic disease. He was discharged on a prolonged course of ampicillin/sulbactam, subsequently transitioned to amoxicillin, corticosteroids, and voriconazole with significant improvement of respiratory status, imaging, and IgE levels on outpatient follow-up. DISCUSSION: To our knowledge, this is the first case of pulmonary actinomycosis reported in a patient with ABPA. Thoracic involvement typically results from aspiration of orogastric contents, supported by radiographic predilection for peripheral and lower lobes. Our case strengthens the limited body of evidence suggesting underlying respiratory disease as potential risk factor for pulmonary involvement. The presence of sulfur granule broncholithiasis and endobronchial disease involvement adds to the unique presentation, as does the potential link between sweat lodge exposure and ABPA. While lodge-related deaths from heat overexposure, smoke inhalation, dehydration, and improper construction causing suffocation have been reported, this is the first case to our knowledge of a potential link to aspergillus-associated lung disease. CONCLUSIONS: Pulmonary actinomycosis is a rare cause of airway obstruction and may be more prevalent in patients with underlying respiratory disorders such as ABPA, which may arise following sweat lodge exposure. REFERENCE #1: Pulmonary actinomycosis G.F. Mabeza, J. Macfarlane European Respiratory Journal Mar 2003, 21 (3) 545-551; DOI: 10.1183/09031936.03.00089103 REFERENCE #2: Byard, RW; Riches, KJ (September 2005). "Dehydration and heat-related death: sweat lodge syndrome". Am J Forensic Med Pathol. 26 (3): 236–9. REFERENCE #3: Herel, Suzanne (2002-06-27). "2 seeking spiritual enlightenment die in new-age sweat lodge". San Francisco Chronicle. Hearst Communications. Retrieved 2006-09-26. DISCLOSURES: No relevant relationships by Shaheen Lashani, source=Web Response No relevant relationships by Justin Thomas, source=Web Response No relevant relationships by Shawnt Tosonian, source=Web Response