DISSEMINATED ACTINOMYCOSIS PRESENTING AS PNEUMONIA WITH MULTIPLE PULMONARY NODULES AND PELVIC OSTEOMYELITIS

Abstract

TOPIC: Chest Infections TYPE: Fellow Case Reports INTRODUCTION: Actinomycosis is a chronic granulomatous infectious disease caused by filamentous gram-positive anaerobic bacteria. Due to better oral hygiene and susceptibility to multiple oral antibiotics, it is rare. It occurs predominantly in males due to inapt oral hygiene and increased oral trauma [1]. A case of disseminated actinomycosis manifesting as pneumonia with multiple pulmonary nodules and pelvic osteomyelitis is presented here. CASE PRESENTATION: A 53-year-old healthy male was admitted to our medical center for five weeks of right hip & low back pain (LBP), fevers, productive cough with white phlegm, generalized malaise, weight loss, and progressively worsening dyspnea. He was an active smoker with 30 pack-years of smoking, sexually active with his girlfriend, and worked at a farm. He was treated two weeks prior by the emergency department for LBP with muscle relaxants and steroids. He returned in five days with no improvement and was diagnosed with right upper lobe (RUL) pneumonia requiring admission and treatment with antibiotics. Workup showed leukocytosis of 22,600/mL, C reactive protein of 16 mg/dl, procalcitonin of 4.63 ng/mL, and a negative human immunodeficiency virus test. Computed tomography (CT) of the chest, abdomen, and pelvis revealed RUL consolidation with multiple bilateral noncalcified nodules and a 17 x 11.8 x 10.5 cm multilevel lobulated cystic mass centered around the right diffusely permeative iliac bone with lateral extension into adjacent gluteal musculature (Figure A-B). On arrival, clinical examination revealed an ill, thin male with warm, tender right hip able to only raise the leg up to 20 degrees. A right gluteal abscess aspirate revealed 20 ml purulent fluid, and the right iliac biopsy was positive for osteomyelitis with acute & chronic granulomatous inflammation. Surgical debridement of the pelvic lesion was followed by bronchoscopy (RUL bronchioalveolar lavage {BAL}, lymph node biopsies). Aspiration cytology revealed Splendore-Hoeppli phenomenon, sulfur granules, and Actinomyces bacterial colonies (Figure C). BAL culture grew Actinomyces odontolyticus (>100,000 colonies/mL). His poor dentition was the source of this disseminated infection. His recovery was successful with tooth extraction, six weeks of ceftriaxone followed by 42 weeks of oral amoxicillin. DISCUSSION: Actinomycosis is the most misdiagnosed disease even by experienced clinicians. Disseminated actinomycosis is exceedingly rare, especially from the hematogenous spread as in our patient [1]. The source can be a disease at any location. Lungs are a common site, whereas musculoskeletal involvement is infrequent [2]. CONCLUSIONS: Clinicians should be aware of this indolent presentation with the extent of the disease appreciated. It should be considered in a patient with bad oral hygiene, pneumonia, and pelvic osteomyelitis. REFERENCE #1: Wong VK, Turmezei TD, Weston VC. Actinomycosis. BMJ. 2011;343:d6099. REFERENCE #2: Apothéloz C, Regamey C. Disseminated infection due to Actinomyces meyeri: case report and review. Clin Infect Dis. 1996;22(4):621-5. DISCLOSURES: No relevant relationships by Jonathan Ross Ang, source=Web Response No relevant relationships by Phillip Beck, source=Web Response No relevant relationships by Andres Bran, source=Web Response No relevant relationships by Michael Hunter, source=Web Response No relevant relationships by SACHIN PATIL, source=Web Response