Bronchopulmonary actinomycosis associated with hiatal hernia

Abstract

Objectives: To describe clinicoradiologic and histopathologic features of bronchopulmonary actinomycosis and to determine whether hiatal hernia (HH) is a potential predisposing factor for bronchopulmonary actinomycosis.

Patients and methods: We reviewed the medical charts of 10 patients who had bronchopulmonary actinomycosis between November 1, 2002, and January 31, 2008. Complete clinical data, radiologic studies (chest radiographs and computed tomographic scans), and histopathologic features were assessed to investigate clinical manifestations and predisposing factors related to bronchopulmonary actinomycosis.

Results: The series consisted of 6 men and 4 women, with a mean age of 63.5 years; 8 of the patients were smokers. Cough and fever were the most common symptoms. Chest imaging showed mass-like consolidation in 4 patients, bronchial thickening or lung atelectasis with pleural thickening in 2 patients each, and perihilar irregular mass or multiple bilateral nodules in 1 patient each. Primary or metastatic lung cancer was suspected clinically in 8 of the 10 patients. Foreign body-related endobronchial actinomycosis was diagnosed in 6 patients, 5 of whom had HH; only 1 had gastroesophageal reflux-related symptoms. Because of bronchial obstruction, rigid bronchoscopy was performed in 3 patients, lobectomy in 2, and atypical resection in 1. Antibiotic therapy with amoxicillin was given to all patients, with resolution of actinomycosis.

Conclusion: Bronchopulmonary actinomycosis is a rare condition that mimics pulmonary malignancy on clinical and radiologic grounds. Diagnosis relies on an accurate patient history and histopathologic examination. Although further confirmation is required, esophageal HH appears to be a potential predisposing factor.

FIGURE 1.

Chest computed tomograms. Right perihilar consolidation that is wrapping around the distal portion of the main and right upper bronchi, with mucoid impaction, enlargement of right hilar lymph nodes, and a peripheral “tree-in-bud” pattern (upper left) in patient with a severe hiatal hernia (upper middle). Complete resolution of the bronchopulmonary consolidation after antibiotics (upper right). Coronal reformation of contrast-enhanced chest computed tomogram showing a prominent hiatal hernia in patient 2 with endobronchial actinomycosis due to chicken bone aspiration (lower left). Pulmonary actinomycosis presenting as multiple bilateral nodules and ground-glass opacities in patient 4 with a history of breast and renal cancers (lower middle). Parenchymal actinomycosis appearing as a masslike consolidation with central cavity and associated with moderate esophageal ectasia in patient 5 (lower right).

FIGURE 2.

Histologic findings of endobronchial foreign body-associated actinomycosis showing sulfur granules around chicken bone (upper left) and digested vegetables (upper middle) (hematoxylin-eosin, original magnificatio×150). Pulmonary abscess centered by a sulfur granule in pulmonary actinomycosis (upper right, hematoxylin-eosin, original magnification ×100). Sulfur granules of Actinomyces stained with methenamine silver (lower left, histochemical stain Grocott-Gomori, original magnificatio×200) and Gram (lower middle, histochemical Gram stain, original magnificatio×200). Florid and reactive papillomatous changes of the bronchial mucosa with squamous cell metaplasia and mild cytologic atypia secondary to endobronchial actinomycosis (lower right, hematoxylin-eosin, original magnificatio×100).