Postgraduate Education Corner

CHEST IMAGING AND PATHOLOGY FOR CLINICIANS

CHEST
1158 Postgraduate Education Corner
CHEST 2014; 145 ( 5 ): 1158 1161
A
50-year-old man presented with a 1-week history
of a painful hard lump above his right nipple. He
attended the Accident and Emergency Department
when the lump suddenly grew bigger and more pain-
ful. He had been unwell for 4 weeks, with a produc-
tive cough, loss of appetite, and weight loss. He was
normally well, and there was no relevant medical his-
tory. He smoked 50 cigarettes a day and drank exces-
sive quantities of alcohol each week. He worked in a
warehouse and had not traveled outside the United
Kingdom. On examination, he was comfortable at
rest and did not look unwell. He was apyrexial, and
oxygen saturations were 98% on room air. His BP was
110/70 mm Hg, and pulse rate was 90 beats/min.
There was a large, hard, tender mass above his right
nipple associated with some bruis ing of the skin. On
auscultation of his chest, a few crackles were audible.
His dentition was poor. The remainder of his physical
examination was normal.
Case Report
Laboratory workup showed a hemoglobin concen-
tration of 9.7 g/dL, WBC count of 21,000 cells/ m L,
neutrophils count of 19,000 cells/ m L, platelet count of
438,000 cells/ m L, sodium concentration of 127 mmol/L,
potassium concentration of 3.6 mmol/L, creatinine
concentration of 56 m mol/L, and C-reactive protein
level of . 150 mg/L. An HIV test result was negative.
The patient underwent a chest radiograph ( Fig 1 )
and a contrast-enhanced CT chest scan ( Figs 2 - 4 ). The
chest radiograph showed multifocal, bilateral consoli-
dation and diffuse, poorly marginated, increased opacity
A 50-Year-Old Man With a Cough and
Painful Chest Wall Mass
Quentin Jones , MBBS ; Rachel Benamore , MBBChir ; Eve Fryer , BMBCh ;
and Anny Sykes , PhD
Manuscript received September 3 , 2013 ; revision accepted
December 28 , 2013 .
Afliations: From the Oxford Centre for Respiratory Medi-
cine (Drs Jones and Sykes) and the Department of Radiology
(Dr Benamore), Churchill Hospital; and the Department of His-
topathology (Dr Fryer), John Radcliffe Hospital, Oxford, England.
Correspondence to: Quentin Jones, MBBS, Oxford Centre for
Respiratory Medicine, Churchill Hospital, Oxford, OXE 7L3,
England; e-mail: quentinjones7@hotmail.com
2014 American College of Chest Physicians. Reproduction
of this article is prohibited without written permission from the
American College of Chest Physicians. See online for more details.
DOI: 10.1378/chest.13-2039

Figure 1. Chest radiograph showing multifocal bilateral consoli-
dation. There is a diffuse, poorly marginated, increased opacity in
the right midzone and enlargement and increased density of the
soft tissues, suggestive of a chest wall mass.

Figure 2. The CT scan shows multifocal, bilateral, nodular, and
mass-like consolidation.
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in the right midzone and enlargement and increased
density of the adjacent soft tissues, suggestive of a
chest wall mass. The CT scan showed multifocal bilat-
eral nodular and mass-like consolidation, which con-
tained areas of low attenuation in keeping with necrosis
( Figs 2 , 3 ). The mass-like consolidation in the middle
lobe was causing rib erosion and extended directly
into the anterior chest wall, deep to the pectoralis
major muscle, where there was a multiseptated
low-density collection ( Figs 3 , 4 ).
An ultrasound of the right anterior chest wall was
performed, which conrmed that the swelling was
caused by a localized uid collection. Image-guided
aspiration yielded frank pus. Gram stain showed
gram-positive lamentous rods.

Figure 3. CT scan showing the mass-like consolidation in the
middle lobe contains areas of low attenuation in keeping with
necrosis and is causing rib and costal cartilage erosion; it extends
directly into the anterior chest wall, deep to the pectoralis major
muscle, where there is a multiseptated low-density collection.

Figure 4. CT scan sagittal view showing rib erosion.
What is the diagnosis?
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1160 Postgraduate Education Corner
Diagnosis: Actinomycosis with empyema necessitans
Discussion
Clinical Discussion
Actinomycoses are commensals in the human oro-
pharynx, GI tract, and female genitalia. Rarely, they
cause chronic suppurative granulomatous inamma-
tion with abscess and sinus tract formation. The most
common sites of infection are the face, jaw, abdomen,
pelvis, and lungs.
1
Pulmonary actinomycosis accounts
for 15% to 20% of cases
1 , 2
and is associated with
chronic respiratory disorders, alcoholism, and poor
oral hygiene.
3 , 4
Aspiration of secretions containing
actinomycosis is thought to be the mechanism of
infection.
5
The disease is more common in men
2
; it
has been suggested that this may be because of poorer
oral hygiene in men and higher rates of trauma from
st ghts.
5
A clue to the diagnosis in this patient was
the history of poor dentition and increased alcohol
intake. On taking a more detailed history, it transpired
that he had recently removed a rotten tooth himself
with a pair of pliers.
Like pneumonia, pulmonary actinomycosis fre-
quently presents with a low-grade fever, cough, and
shortness of breath. However, unlike in pneumonia,
the history is often longer, and weight loss and chest
pain may be prominent features (as in this patient).
6

There are usually pulmonary inltrates, which may
invade surrounding structures including the ribs,
mediastinum, and soft tissue of the chest wall, causing
pain. This patient developed empyema necessitans
caused by invasion of the pleural space followed by
invasion of the chest wall. It is likely that the history
of sudden chest pain and the increasing size of the
chest wall mass were caused by rupture of the abscess
though the chest wall.
The mainstay of treatment of actinomycosis is pro-
longed antibiotics. In vitro studies indicate that the
organism is sensitive to a wide range of antibiotics,
including penicillin.
7
Historically, treatment consisted
of high-dose IV penicillin for a long duration (generally
6 weeks) followed by oral antibiotics for up to 6 to
12 months.
8
The risk of developing penicillin resis-
tance is thought to be low. More recently, successful
outcomes with a shorter duration of antibiotics have
been reported.
9
In a series of 16 patients, cure was
achieved after a median duration of 2 weeks of IV anti-
biotics and 3 months of oral penicillin.
10
Erythromycin,
clindamycin, and doxycycline are alternative antibiotics
for patients allergic to penicillin.
11 , 12

Surgery may be needed in the treatment of large
abscesses and empyema, especially if sinus tracts, s-
tulas, or extensive necrotic tissue are present.
13
Surgery
should also be considered in patients who respond
poorly to antibiotics. A retrospective review identied
ve patients who had responded poorly to initial anti-
biotics and went on to have successful surgical treat-
ment.
14
Prolonged antibiotic treatment is also necessary
after surgery, because surgery alone is not curative.
Prognosis in actinomycosis is generally excellent.
9

Radiologic Discussion
Pulmonary actinomycosis may mimic other chronic
suppurative lung diseases such as TB, nocardiosis, fun-
gal disease, lung abscess, and thoracic malignancies.
Radiographic ndings in actinomycosis are often non-
specic, particularly in the early stages of infection.
Various CT scan ndings have been described, includ-
ing multifocal or mass-like consolidation, which may
involve the chest wall and pleura and may cavitate
and form abscesses and sinus tracts. There is often a
peripheral and lower-lobe predominance of disease.
15

Unlike in most infections, regional lymphadenopathy
is rare.
The differential diagnoses of the radiologic ndings
in actinomycosis include infection (TB, fungal dis-
ease, invasive pulmonary aspergillosis, botryomyco-
sis, nocardiosis, and other subacute bacterial necrotizing
pneumonias), malignancy (multifocal adenocarcinoma,
necrotic bronchogenic carcinoma, and lymphoma), and
vasculitis (granulomatosis with polyangiitis [Wegener]
and atypical granulomatosis with polyangiitis). In this
patient, infection was most likely caused by the pre-
sumed abscess formation in the chest wall.
The diagnosis of pulmonary actinomycosis can be
difcult. Up to one-quarter of cases may be misdiag-
nosed initially as malignancy, leading to delay in treat-
ment and unnecessary surgical procedures.
16
An added
diagnostic difculty is that actinomycosis may colo-
nize necrotic tissues and coexist with malignancy.
2
The
presence of air bronchograms within mass-like, pleural-
based densities may help distinguish actinomycosis
from malignancy; however, imaging alone is insuf-
cient to make the diagnosis. Pathologic conrmation
by culturing actinomycosis is vital.
Pathologic Discussion
Actinomycosis is a slow-growing, gram-positive rod
that frequently branches. The organism was rst iso-
lated in the nineteenth century from jaw abscesses
in cattle. The name actinomycosis derives from the
Greek term akino, which refers to the radiating
appearance of sulfur granules and mykos, meaning
fungus (a misnomer because the organism is actually
a bacterium). Sulfur granules are colonies of organisms
arranged in round basophilic masses with eosinophilic
terminal clubs on staining with hematoxylin-eosin.
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However, they are often best seen when stained with
periodic acid shift diastase, which highlights their
structure ( Fig 5 ). Sulfur granules can be distinguished
from the Bollinger granules found in Botryomycosis
(a rare granulomatous bacterial infection, usually
caused by Staphylococcus aureus , which mimics acti-
nomycosis). Bollinger granules are rings of bacteria
surrounded by eosinophilic matrix but, unlike sulfur
granules, they lack lamentous structures.
Actinomycosis is a fastidious organism that may be
difcult to isolate. Failure to culture the organism
can be caused by antibiotic therapy, overgrowth by a
contaminant, or inadequate culture technique. Less
than 30 min of exposure to air may result in inhibition
of actinomycosis. Protected specimen brushing with
expedient transport of specimens and taking a sample
prior to administering antibiotics may improve the
yield. Bronchoscopy is usually not useful in making
the diagnosis.
Demonstration of a gram-positive lamentous branch-
ing organism and sulfur granules on histologic examina-
tion supports the diagnosis of actinomycosis. However,
sulfur granules are not always present and can occur
in other conditions, such as nocardiosis. If actino-
mycosis is suspected, the microbiology laboratory
should be asked specically for actinomycosis cul-
tures. In general, the organism is identied by colony
morphology and biochemical profiling. Molecular
genetic techniques using polymerase chain reaction,
16s ribosomal RNA sequencing, and comparison with
a database, or uorescence in situ hybridization can
rapidly confirm the diagnosis. Direct staining with
uorescent-conjugated monoclonal antibody may also
allow rapid identication.
Conclusions
In this patient, cultures of pus aspirated from the
chest wall grew Actinomyces meyeri. The chest wall
abscess was incised and drained. A 32F chest drain
was inserted into the pleural cavity, with a corregated
drain into the subpectoral abscess cavity. The patient
received 6 weeks of IV benzyl penicillin followed by
6 months of oral penicillin and made a good recovery.
Acknowledgments
Financial/nonnancial disclosures: The authors have reported
to CHEST that no potential conicts of interest exist with any
companies/organizations whose products or services may be dis-
cussed in this article .
Other contributions: CHEST worked with the authors to ensure
that the Journal policies on patient consent to report information
were met.
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Figure 5. Actinomycosis forming sulfur granules (periodic acid
shift diastase, original magnication 3 100).
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