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THORACIC ACTINOMYCOSIS MIMICKING PRIMARY TUBERCULOSIS

Goussard, Pierre M.Med.Ped.; Gie, Robert F.C.P.Ped.; Kling, Sharon F.C.P.Ped.; Beyers, Nulda Ph.D.

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The Pediatric Infectious Disease Journal: May 1999 - Volume 18 - Issue 5 - p 473-475
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Thoracic actinomycosis is an unusual disease in childhood. The diagnosis is rarely made initially because the clinical picture can vary greatly. Classically it involves the cervicofacial (55%), abdominopelvic (20%) and thoracic organs (15%) as well as the skin, brain and pericardium.1, 2 The incidence is said to be waning because of improvement in dental hygiene. The incidence in the developing world is unknown. We present a case of thoracic actinomycosis in a child who was initially incorrectly diagnosed as primary tuberculosis as many of the clinical and radiologic features overlapped.

Case report. A 5-year-old boy presented to his local health care clinic complaining of cough, weight loss and excessive sweating at night. A clinical diagnosis of pneumonia was made and the boy was treated with oral amoxicillin. When he failed to improve after 10 days, a tuberculin skin test (tine test) was performed and was strongly positive (Grade 4 positive). The chest radiograph had an area of consolidation in the right upper lobe. He was treated with isoniazid (10 mg/kg/day), rifampin (10 mg/kg/day) and pyrazinamide (20 mg/kg/day). This was evidently the child's second episode of tuberculosis; he had been treated at 9 months of age for primary tuberculosis. On the current regimen he failed to improve and was referred to the tertiary care hospital for further investigation.

On examination he was febrile (temperature, 39°C) and looked chronically ill. His length and head circumference were on the 25th percentile but his weight was below the 3rd percentile, indicating recent weight loss. He had no lymph-adenopathy. There was dullness to percussion and decreased breath sounds over the right upper lobe. The rest of the clinical examination was normal.

The white blood cell count was 11 × 109/l with absolute neutrophil and lymphocyte counts of 6.5 × 109/l and 2.9 × 109/l, respectively. The C-reactive protein was 197 mg/ml. The chest radiograph revealed a densely opacified right upper lobe without air bronchograms which was thought to be the result of endobronchial tuberculosis (Fig. 1). A Mantoux tuberculin skin test had 11 mm induration. At bronchoscopy the right upper lobe bronchus was 75% occluded and the bronchus intermedius was 50% narrowed. A biopsy was performed of a granuloma at the opening to the right upper lobe. The histology was nonspecific and not indicative of tuberculosis. The computerized tomogram of the chest confirmed the dense opacification of the right upper lobe and apex of the right lower lobe with a small pleural effusion. In addition calcified right paratracheal and subcarinal glands were visible. These findings were interpreted as being compatible with extensive endobronchial tuberculosis. The serum immunoglobulin concentrations were nonspecifically raised and T lymphocyte function was normal. The serologic test for HIV infection was negative and the nitroblue-tetrazolium test was normal.

F1-18
Fig. 1:
Chest radiograph at the time of initial presentation. There is dense opacification of the right upper lobe without an air bronchogram being visible.

The diagnosis of reactivated tuberculosis was made and treatment was continued with isoniazid, rifampin and pyrazinamide. To this therapy prednisone (2 mg/kg/day) was added to relieve the bronchial compression. After 1 month of therapy the child developed an abscess on the back which was surgically drained and treated with penicillin and flucloxacillin for 10 days. The etiology of the abscess was not defined and actinomycosis was not considered. After 3 months he was readmitted with a recurrence of the abscess on the back and abscesses in the right axilla. He looked chronically ill and was febrile. Reevaluation of his respiratory system now showed deviation of the trachea to the right and decreased chest wall movement on the right, with bronchial breathing audible over the right upper lobe. The chest radiograph showed extension of the consolidation of the right upper lobe and apex of the right lower lobe. Osteitis of the ribs on the right side was visible. At bronchoscopy pus was seen coming from the right upper lobe bronchus; cultures of the pus were sterile. Biopsy of the axillary glands showed histologic changes consistent with actinomycosis, but the organism was never successfully cultured. The boy was treated with penicillin. He responded rapidly and was given amoxicillin (50 mg/kg/day) for 4 months. The abscess in the axilla cleared rapidly and the patient became asymptomatic.

At follow-up 4 months later his chest radiograph revealed a round shadow in the left upper lobe with an enlarged left hilum. An open lung biopsy was performed and the histology was typical of actinomycosis with several aggregates of filamentous organisms visible. The culture was again negative.

The boy was treated with amoxicillin, with a good clinical response. The chest radiograph cleared. Nine months later he developed large cervical glands which were tender with areas of fluctuation. The biopsy of the glands was again indicative of actinomycosis and from the pus Actinomyces israelii was cultured. The patient was treated with intravenous penicillin and clindamycin. Because of a presumed allergy to the penicillin he was treated only with clindamycin. The enlarged cervical glands resolved and the boy is asymptomatic and thriving. The clindamycin therapy will be continued for 15 months.

Discussion. We have shown that thoracic actinomycosis can present with the features that resemble endobronchial tuberculosis. This boy resided in an area with a reported tuberculosis incidence of 1505 new cases per 100 000 in 1991.3 The initial bronchoscopic findings were incorrectly interpreted as being consistent with tuberculous glandular compression of the airways. The endoscopic appearance of actinomycosis has been reported in a child and an adult4, 5 as a hard yellowish endobronchial mass with inflamed and edematous mucosa.

From none of our bronchoscopic or other specimens was Actinomyces cultured, even after we became aware of the diagnosis. This is not unusual; it is reported that the organism is recovered from culture in only 24 to 50% of cases because of overgrowth of synergistic bacteria, improper anaerobic culturing or prior antibiotics.6, 7 Sulfur granules occasionally can be confused with infection caused by Nocardia, pigment-producing fungi or Staphylococcus aureus.8

Below the age of 5 years actinomycosis infections are rare. Golden et al.9 in 1985 found only 23 cases during the previous 25 years; of these only a single case was 5 years or younger. The clinical picture of thoracic actinomycosis is varied but is classically described to have the following triad: chronic lower lobe pneumonia, empyema and wavy periostitis of the ribs. Other clinical pictures described include pulmonary masses, endobronchial obstruction with lobar collapse, mediastinal masses and chest wall sinuses. Clinically actinomycosis may resemble pneumonia that responds poorly to therapy, tuberculosis, lung tumor, cryptococcosis, histoplasmosis or lung infarction.1

The drug of choice for treatment of actinomycosis remains penicillin combined with clindamycin, tetracycline, erythromycin and amoxicillin/clavulanic acid for children who do not respond to single drug treatment. The duration of treatment is unclear with reported periods of between 3 and 15 months. A consensus seems to be to continue treatment for 12 months in thoracic actinomycosis, considering the difficulty in drug penetration into areas of dense fibrosis.5 Surgical intervention in children should be limited mainly to diagnostic procedures and the drainage of empyema. Rarely elective resection is indicated if a patient fails to respond to treatment or has a chronically infected lung.

With medical management the prognosis is good with 85 to 100% of children being cured.9 Relapses have been reported and occur when short courses of therapy are used.

Acknowledgments. Supported by Glaxo-Wellcome International Action TB Initiative.

Pierre Goussard, M.Med.Ped.

Robert Gie, F.C.P.Ped.

Sharon Kling, F.C.P.Ped.

Nulda Beyers, Ph.D.

Department of Paediatrics and Child Health; University of Stellenbosch and Tygerberg Hospital; Tygerberg, South Africa

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Keywords:

Actinomycosis; tuberculosis; childhood

© 1999 Lippincott Williams & Wilkins, Inc.