Hemoptysis secondary to actinomycosis: A rare presentation
A 70-year-old female patient presented to us in the early morning of January 1, 2011 with massive haemoptysis. The patient was a known case of hypothyroidism and hypertension and on regular treatment. She had been complaining of cough with expectoration and mild streaking of blood in sputum for about 3 days. On examination the pulse rate was 96/min, BP 134/76 mm Hg, RR 25/min, and SPO2 94% on 2 l of O2. Chest examination revealed bilateral vesicular breath sounds with crepts in right infrascapular and infra-axillary regions. There was no history of dental manipulation, facial lesions or trauma to mouth, aspiration, or alcoholism. Her cardiovascular, GIT, and central nervous system examinations revealed no abnormality. She was admitted in the intensive care unit and her initial investigations including ECG, ABG, CBC, KFT, LFT, and RBS were within the normal range. Her sputum was sent for AFB, gram's stain, and fungal stain along with culture and sensitivity for pyogenic organisms. Her chest X-ray revealed right mid zone homogenous opacity along with the obliteration of both right costophrenic and cardiophrenic angles []. She was started on piperacillin + tazobactum along with IV haemostatics, IV fluids, and cough suppressants. Once stabilized, she was taken for diagnostic fibreoptic bronchoscopy that revealed a cauliflower-like growth in RUL bronchus [] raising a high suspicion of malignancy. BAL was taken and bronchial biopsy for histopathology was obtained from the lesion and sent for histopathological examination. She was continued on conservative treatment and the haemoptysis stopped. BAL was negative for AFB; no organisms were seen on gram's stain and fungal stain. Pyogenic culture also did not grow any organisms. Her chest X-ray after the antibiotics showed an increase in the size of the homogenous opacity abutting the heart []. CECT thorax revealed a large heterogenous soft tissue mass measuring 7 × 5.9 × 6 cm with surrounding parenchymal infiltrates in anterior segment of upper-right lobe and medial segment of middle-right lobe. The mass was abutting the anterior segmental bronchus of upper-right lobe, medial segmental bronchus of the middle-right lobe, costal and mediastinal pleura; the patchy area of consolidation was seen in lower-right lobe limited by oblique fissure with bilateral pleural effusions, which were more on the right side []. Diagnostic pleural aspiration was done. Pleural fluid did not show any organisms on gram stain, AFB stain, and fungal stain. Pyogenic culture was sterile and malignant cells were not seen. The ADA level was 4.76 IU, thus almost ruling out TB. Bronchial biopsy showed markedly inflamed bronchial mucosa with granulation tissue and sheets of inflammatory cells, predominantly neutrophils. Bronchial biopsy was also sent for culture where occasional colonies of gram positive filamentous bacteria surrounded by neutrophils were seen. CT-guided FNAC and Trucut biopsy were done for better understanding of the lesion. On performing FNAC thick pus was aspirated out. FNAC showed sheets of neutrophils and occasional branches of filamentous bacteria with impression of suppurative pathology. Trucut biopsy showed sheets of neutrophils with colonies of filamentous bacteria and sulphur granules [] consistent with actinomycotic infection. She was started on Benzyl penicillin 20 lac units IV 6 hourly and had a dramatic response. Her symptoms disappeared and chest X-ray almost cleared []. Finally, she was discharged in a stable condition on oral amoxicillin + clavulanic acid combination. She is under regular follow up and has continued to be in a stable condition for more than a year.