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中华放射医志Chin J Radiol 2001; 26: 75-7975
Thoracic Actinomycosis on Radiologic Study:
Case Report
DA-CHUNGLIOUCHIH-SHUNWU
Department of Radiology, Military Tsoying Hospital
Actinomycotic disease is an uncommon
baterial infection. Primary actinomycosis of the
lung and chest wall has rarely been reported.
We here present the image findings in a case of
thoracic actinomycosis with lung infection, rib
and chest wall involvement.
It is a chronic infection with the ability to
spread to contiguous tissue. Major image
findings on the chest include pneumonia-like
consolidation of lung with pleural effusion or
pleural wall thickness, soft tissue mass on the
chest wall, and destruction of rib or vertebral
body. Medical treatment is the first
consideration, and it always has good prognosis
if clinical doctor made correct to diagnosis
early.
Key word: thorax actinomycosis, pneumonia-
like consolidation.
Thoracic actinomycosis is a chronic suppurative
infection with the ability to spread to contiguous
tissue without regard to normal anatomic barriers
[1,2,3]. The disease is found world-wide and has
no racial predisposition. Men are affected three to
four times more often than women [2].
The radiographic findings which are dependent
on the chronicity of the disease, include
pneumonia-like patchy consolidation with lower
lobe predominence, pleural effusion or thickness,
and chest wall extension by either a soft tissue
mass, wavy periostitis of rib or vertebral body
destruction [3,4,5].
We report a case of thoracic actinomycosis with
sonography, chest film and computor tomographic
(CT) findings.
CASE REPORT
A 47-year-old man was admitted to our hospital
due to a reddish mass with swelling and pain over
the right anterior chest wall for three days. He
also had a nonproductive cough and low-grade
fever for one week.
Physical examination showed a bulging mass
about 8x8cm over the right chest wall, and
decreased breath sounds over the right lower lobe.
Body temperature was 38.3 c, and WBC were
8300/uL. The patient had history of chronic
hepatitis B, but he denied other systemic disease.
Sonography showed soft tissue swelling over
the right anterior chest wall with central
hypoechoic abscess formation (Fig.1). The chest
film showed patchy infiltration over the right
lower lobe with pleural effusion or pleural wall
thickness (Fig. 2).The pattern was similar to
pneumonia. CT of the chest showed air-space
consolidation over the right lower lobe with a soft
tissue lesion on the pleural wall (Fig. 3), which
was contiguous to a soft tissue mass on the
CASE REPORT
Reprint requests to: Da-chung Liou
Department of Radiology, Military Tsoying Hospital. 553
Chun-Hsiao Road, Tsoying, 813, Kaohsiung, Taiwan.
R.O.C.
Thoracic actinomycosis76
anterior chest wall (Fig. 4). There was destruction
of the involved rib with loss of bone density (Fig.
3,4). Under the impression of actinomycosis with
chest wall involvement, a CT-guided biopsy of
the mass on the chest wall and consolidated areas
of the lung were performed. The pathology report
showed negative acid-fast stain with few mycelial
filaments, consistent with actinomycosis.
The patient received penicillin G 3000000 units
IV. q6h for months. He recovered and was
discharged in the thirty-two hospital days.
DISCUSSION
Actinomyces israelii, the most common human
pathogen is a slow-growing, filamentous, gram-
positive, non-acid-fast anaerobic bacteria with a
tendency to form mycelium-like colonies.
Morphologically and clinically, these agents
resemble fungi, but they have been established as
bacteria because of the composition of their cell
walls, their reproduction through bacillary fusion
and their sensitivity to antibiotics [1,6].
The organisms are not highly virulent and are
found normally in the crypts of the tonsils,
mouth, saliva, dental plaque, gingival sulci and
pyorrheal pockets [4,5,6], particularly in people
with poor oral hygiene, elderly people and
patients with cachexia. Tests of skin, saliva, and
serum have no value in diagnosis and even
bronchoscopic specimens may be contaminated
[7]. Disease can occur when these endogenous
organisms are able to invade normal tissue
because of infection, trauma or surgery [1,5].
Epidemiologically, there are two peak age
periods of actinomycotic infection: 11-20 year old
and 30-50 year old. Men are affected three times
as often as women. Only 27% of actinomycotic
infections occur in people under 20 years old
[1,2].
There are three major clinical forms of
actinomycosis-the cervicofacial, thoracic and
abdominopelvic. The thoracic form accounts for
about 15% of cases, the cervicofacial form for
about 55% and abdominal form for about 20%.
Infection of other organs including skin, brain,
pericardium and extremities accounts for 10% of
cases [4,6,7].
Pulmonary actinomycosis is most common in
patients with alcoholism and chronic obstructive
lung disease. The primary location involves the
peribronchial tissue, bronchioles and alveola, and
its organisms may spread from lung to pleura,
ribs, spine, heart, pericardium and chest wall
without regards for tissue plane and boundaries
[1,4,6,8]. The reason may relate to the proteolytic
activity of the bacteria [1,5].Thoracic disease
may occur by means of direct extension from the
cervicofacial and abdominopelvic regions [5].
The symptoms may be acute or chronic and
Figure 1.Sonogram of anterior chest wall showing. Soft
tissue swelling (small arrow) with central hypoechoic
abscess formation (large arrow).
Figure 2.Chest film. Patchy infiltration over the right
lower lobe with pleural effusion or pleural
thickness(arrow), similar to a pneumonia pattern.
Thoracic actinomycosis 77
vary depending on rib and chest wall
involvement. These include nonproductive cough,
low-grade fever, chills, hemoptysis, body weight
loss, pleuritic chest pain, and soft tissue swelling
of the chest wall. In advanced disease, it may
present as cutaneous fistulas, empyema,
periostitis or osteomyelitis of the ribs and spine,
vascular shunts, chronic sinus tract infection with
typical "sulfur granule" content, superior vena
cava syndrome or pericardial effusion [4,6].
Radiographic findings include nonsegmental
pneumonia-like infiltration (more frequently
occurring peripherally and over the lower lobe),
empyema, mass-like consolidation, cavitation,
pleural effusion or thickening, and chest wall
extension by either soft tissue mass, wavy
periostitis of rib, or destruction of vertebral body
[2,3].
The diagnosis may be difficult as the organism
is hard to recover even with percutaneous needle
biopsy, transbronchial biopsy and open lung
biopsy, so the final diagnosis is often made
histologically [3,5,6]. The lung abscess or
empyema typically are surrounded by granulation
tissue with a variable degree of fibrosis and
masses of polymorphonuclear cells which may
contain typical "sulfur granules". These granules
represent conglomerate masses of organisms that
have become mineralized [1].
With treatment, most patients are cured by
means of large doses of penicillin administered
over a period of weeks to months. Surgery may be
of help in draining empyemas, or in resecting
badly damaged lung tissue when lesions do not
respond to medical treatment [1,6,8]. The
differential diagnosis of pulmonary lesions should
include pneumonia with poor response to
treatment, nocardiosis, tuberculosis,
bronchogenic carcinoma, alveolar cell carcinoma,
lymphoma, and malignant mesothelioma, in
addition to some fungal diseases such as
histoplasmosis, cryptococcosis, blastomycosis
and coccidioidomycosis [4,5,6].
Actinomycosis, when it presents with the
classical triad of lung infection, empyema, and
rib or chest wall involvement, is not much of a
problem in diagnosis[6], but when it does not
present in the classical form, an aggressive
approach is needed for early diagnosis, and
institution of penicillin therapy to prevent serious
complications and avoid unnecessary surgery.
◆
REFERENCES
1. Kwong JS, Muller NL, Godwin JD, Aberle D,
Grymaloski MR. Thoracic actinomycosis: CT finding
in eight patients. Radiology 1992; 183: 189-192
2. Flynn MW, Felson B. The roentgen manifestations of
thoracic actinomycosis. AJR Am J Roentgenol 1970;
110: 707-716
3. Allen HA, Scatarige JC, Kim MH. Actinomycosis:
CT findings in six patients. AJR Am J Roentgenol
1987; 149: 1255-1258
4. Hsieh MJ, Liu HP, Chang CH. Thoracic
actinomycosis. Chest 1993;104: 366-370
5. Webb WR, Sagel SS. Actinomycosis involving the
Figure 3.CT film. Air-space consolidation over the right
lower lobe with A soft tissue lesion on the pleural wall
(large arrow), and loss of bone density with rib
destruction on the anterior chest wall (small arrow).
Figure 4.CT film. Soft tissue mass is contiguous to
anterior chest wall (large arrow). There is destruction of
the involved rib with loss of bone density (small arrow).
Thoracic actinomycosis78
chest wall: CT findings. AJR Am J Roentgenol 1982;
139: 1007-1009
6. Balikian JP, Cheng TH, Costello P, Herman PG.
Pulmonary actinomycosis. Radiology 1978; 128: 613-
616
7. Frank P, Strickland B. Pulmonary actinomycosis. Br J
Radiol 1974; 47: 373-378
8. Ng KK, Cheng YF, Ko SF, Ng SH, Pai SC, Tsai CC.
CT findings of pediatric thoracic actinomycosis:
report of four cases. J Formos Med Assoc 1992; 91:
346-350
Thoracic actinomycosis 79
胸部放线菌病在影像学上的研究:病例报告
刘大忠 吴志顺
国军左营医院 放射科
放线菌疾病是一种罕见的细菌性感染,在胸部和肺部的原发性放线菌病很少被报导.在这
理,我们提出一个有关放线菌病侵犯肺部,胸壁和肋骨的病例在影像上的发现,包括像肺炎般
的实质浸润,合并肋膜积水或肋膜增厚,胸壁上有肿块,肋骨或椎体的破坏.早期的发现可以
内科疗法治愈,因此提出来以作为放射科医师早期诊断上的依据与线索.
关键词:放线菌病,肺炎般实质浸润
Thoracic Actinomycosis on Radiologic Study:
Case Report
DA-CHUNGLIOUCHIH-SHUNWU
Department of Radiology, Military Tsoying Hospital
Actinomycotic disease is an uncommon
baterial infection. Primary actinomycosis of the
lung and chest wall has rarely been reported.
We here present the image findings in a case of
thoracic actinomycosis with lung infection, rib
and chest wall involvement.
It is a chronic infection with the ability to
spread to contiguous tissue. Major image
findings on the chest include pneumonia-like
consolidation of lung with pleural effusion or
pleural wall thickness, soft tissue mass on the
chest wall, and destruction of rib or vertebral
body. Medical treatment is the first
consideration, and it always has good prognosis
if clinical doctor made correct to diagnosis
early.
Key word: thorax actinomycosis, pneumonia-
like consolidation.
Thoracic actinomycosis is a chronic suppurative
infection with the ability to spread to contiguous
tissue without regard to normal anatomic barriers
[1,2,3]. The disease is found world-wide and has
no racial predisposition. Men are affected three to
four times more often than women [2].
The radiographic findings which are dependent
on the chronicity of the disease, include
pneumonia-like patchy consolidation with lower
lobe predominence, pleural effusion or thickness,
and chest wall extension by either a soft tissue
mass, wavy periostitis of rib or vertebral body
destruction [3,4,5].
We report a case of thoracic actinomycosis with
sonography, chest film and computor tomographic
(CT) findings.
CASE REPORT
A 47-year-old man was admitted to our hospital
due to a reddish mass with swelling and pain over
the right anterior chest wall for three days. He
also had a nonproductive cough and low-grade
fever for one week.
Physical examination showed a bulging mass
about 8x8cm over the right chest wall, and
decreased breath sounds over the right lower lobe.
Body temperature was 38.3 c, and WBC were
8300/uL. The patient had history of chronic
hepatitis B, but he denied other systemic disease.
Sonography showed soft tissue swelling over
the right anterior chest wall with central
hypoechoic abscess formation (Fig.1). The chest
film showed patchy infiltration over the right
lower lobe with pleural effusion or pleural wall
thickness (Fig. 2).The pattern was similar to
pneumonia. CT of the chest showed air-space
consolidation over the right lower lobe with a soft
tissue lesion on the pleural wall (Fig. 3), which
was contiguous to a soft tissue mass on the
CASE REPORT
Reprint requests to: Da-chung Liou
Department of Radiology, Military Tsoying Hospital. 553
Chun-Hsiao Road, Tsoying, 813, Kaohsiung, Taiwan.
R.O.C.
Thoracic actinomycosis76
anterior chest wall (Fig. 4). There was destruction
of the involved rib with loss of bone density (Fig.
3,4). Under the impression of actinomycosis with
chest wall involvement, a CT-guided biopsy of
the mass on the chest wall and consolidated areas
of the lung were performed. The pathology report
showed negative acid-fast stain with few mycelial
filaments, consistent with actinomycosis.
The patient received penicillin G 3000000 units
IV. q6h for months. He recovered and was
discharged in the thirty-two hospital days.
DISCUSSION
Actinomyces israelii, the most common human
pathogen is a slow-growing, filamentous, gram-
positive, non-acid-fast anaerobic bacteria with a
tendency to form mycelium-like colonies.
Morphologically and clinically, these agents
resemble fungi, but they have been established as
bacteria because of the composition of their cell
walls, their reproduction through bacillary fusion
and their sensitivity to antibiotics [1,6].
The organisms are not highly virulent and are
found normally in the crypts of the tonsils,
mouth, saliva, dental plaque, gingival sulci and
pyorrheal pockets [4,5,6], particularly in people
with poor oral hygiene, elderly people and
patients with cachexia. Tests of skin, saliva, and
serum have no value in diagnosis and even
bronchoscopic specimens may be contaminated
[7]. Disease can occur when these endogenous
organisms are able to invade normal tissue
because of infection, trauma or surgery [1,5].
Epidemiologically, there are two peak age
periods of actinomycotic infection: 11-20 year old
and 30-50 year old. Men are affected three times
as often as women. Only 27% of actinomycotic
infections occur in people under 20 years old
[1,2].
There are three major clinical forms of
actinomycosis-the cervicofacial, thoracic and
abdominopelvic. The thoracic form accounts for
about 15% of cases, the cervicofacial form for
about 55% and abdominal form for about 20%.
Infection of other organs including skin, brain,
pericardium and extremities accounts for 10% of
cases [4,6,7].
Pulmonary actinomycosis is most common in
patients with alcoholism and chronic obstructive
lung disease. The primary location involves the
peribronchial tissue, bronchioles and alveola, and
its organisms may spread from lung to pleura,
ribs, spine, heart, pericardium and chest wall
without regards for tissue plane and boundaries
[1,4,6,8]. The reason may relate to the proteolytic
activity of the bacteria [1,5].Thoracic disease
may occur by means of direct extension from the
cervicofacial and abdominopelvic regions [5].
The symptoms may be acute or chronic and
Figure 1.Sonogram of anterior chest wall showing. Soft
tissue swelling (small arrow) with central hypoechoic
abscess formation (large arrow).
Figure 2.Chest film. Patchy infiltration over the right
lower lobe with pleural effusion or pleural
thickness(arrow), similar to a pneumonia pattern.
Thoracic actinomycosis 77
vary depending on rib and chest wall
involvement. These include nonproductive cough,
low-grade fever, chills, hemoptysis, body weight
loss, pleuritic chest pain, and soft tissue swelling
of the chest wall. In advanced disease, it may
present as cutaneous fistulas, empyema,
periostitis or osteomyelitis of the ribs and spine,
vascular shunts, chronic sinus tract infection with
typical "sulfur granule" content, superior vena
cava syndrome or pericardial effusion [4,6].
Radiographic findings include nonsegmental
pneumonia-like infiltration (more frequently
occurring peripherally and over the lower lobe),
empyema, mass-like consolidation, cavitation,
pleural effusion or thickening, and chest wall
extension by either soft tissue mass, wavy
periostitis of rib, or destruction of vertebral body
[2,3].
The diagnosis may be difficult as the organism
is hard to recover even with percutaneous needle
biopsy, transbronchial biopsy and open lung
biopsy, so the final diagnosis is often made
histologically [3,5,6]. The lung abscess or
empyema typically are surrounded by granulation
tissue with a variable degree of fibrosis and
masses of polymorphonuclear cells which may
contain typical "sulfur granules". These granules
represent conglomerate masses of organisms that
have become mineralized [1].
With treatment, most patients are cured by
means of large doses of penicillin administered
over a period of weeks to months. Surgery may be
of help in draining empyemas, or in resecting
badly damaged lung tissue when lesions do not
respond to medical treatment [1,6,8]. The
differential diagnosis of pulmonary lesions should
include pneumonia with poor response to
treatment, nocardiosis, tuberculosis,
bronchogenic carcinoma, alveolar cell carcinoma,
lymphoma, and malignant mesothelioma, in
addition to some fungal diseases such as
histoplasmosis, cryptococcosis, blastomycosis
and coccidioidomycosis [4,5,6].
Actinomycosis, when it presents with the
classical triad of lung infection, empyema, and
rib or chest wall involvement, is not much of a
problem in diagnosis[6], but when it does not
present in the classical form, an aggressive
approach is needed for early diagnosis, and
institution of penicillin therapy to prevent serious
complications and avoid unnecessary surgery.
◆
REFERENCES
1. Kwong JS, Muller NL, Godwin JD, Aberle D,
Grymaloski MR. Thoracic actinomycosis: CT finding
in eight patients. Radiology 1992; 183: 189-192
2. Flynn MW, Felson B. The roentgen manifestations of
thoracic actinomycosis. AJR Am J Roentgenol 1970;
110: 707-716
3. Allen HA, Scatarige JC, Kim MH. Actinomycosis:
CT findings in six patients. AJR Am J Roentgenol
1987; 149: 1255-1258
4. Hsieh MJ, Liu HP, Chang CH. Thoracic
actinomycosis. Chest 1993;104: 366-370
5. Webb WR, Sagel SS. Actinomycosis involving the
Figure 3.CT film. Air-space consolidation over the right
lower lobe with A soft tissue lesion on the pleural wall
(large arrow), and loss of bone density with rib
destruction on the anterior chest wall (small arrow).
Figure 4.CT film. Soft tissue mass is contiguous to
anterior chest wall (large arrow). There is destruction of
the involved rib with loss of bone density (small arrow).
Thoracic actinomycosis78
chest wall: CT findings. AJR Am J Roentgenol 1982;
139: 1007-1009
6. Balikian JP, Cheng TH, Costello P, Herman PG.
Pulmonary actinomycosis. Radiology 1978; 128: 613-
616
7. Frank P, Strickland B. Pulmonary actinomycosis. Br J
Radiol 1974; 47: 373-378
8. Ng KK, Cheng YF, Ko SF, Ng SH, Pai SC, Tsai CC.
CT findings of pediatric thoracic actinomycosis:
report of four cases. J Formos Med Assoc 1992; 91:
346-350
Thoracic actinomycosis 79
胸部放线菌病在影像学上的研究:病例报告
刘大忠 吴志顺
国军左营医院 放射科
放线菌疾病是一种罕见的细菌性感染,在胸部和肺部的原发性放线菌病很少被报导.在这
理,我们提出一个有关放线菌病侵犯肺部,胸壁和肋骨的病例在影像上的发现,包括像肺炎般
的实质浸润,合并肋膜积水或肋膜增厚,胸壁上有肿块,肋骨或椎体的破坏.早期的发现可以
内科疗法治愈,因此提出来以作为放射科医师早期诊断上的依据与线索.
关键词:放线菌病,肺炎般实质浸润
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