Empyema necessitans caused by actinomycosis: A case report

Empyema necessitans as a rare manifestation of Staphylococcus aureus

Empyema necessitans (EN) is a rare complication of empyema, in which pus accumulates within the pleural space and spreads through the chest wall, leading to the formation of a subcutaneous abscess. This condition presents significant diagnostic and therapeutic challenges due to its rarity and potential for serious complications. Here, we present the case of an 8-year-old boy with a history of parapneumonic effusion that was incompletely treated due to a lack of fibrinolytic agent injection. He presented with fever, chills, a productive cough, and left-sided chest pain with yellowish purulent secretions from the left chest wall. The patient was diagnosed with EN caused by Staphylococcus aureus, which has occurred due to inadequate treatment and the lack of administration of a fibrinolytic agent injection for the patient. He was treated with broad-spectrum antibiotics, video-assisted thoracic surgery, and a chest tube for complete drainage. The patient showed a smooth and uneventful recovery, highlighting the importance of early diagnosis and prompt treatment of EN to avoid further complications. This case report aims to increase awareness among clinicians about the importance of early recognition and appropriate management of EN to improve patient outcomes.

An overview of case reports and case series of pulmonary actinomycosis mimicking lung cancer: a scoping review

Background

Pulmonary actinomycosis (PA) is a rare type of Actinomyces infection that can be challenging to diagnose since it often mimics lung cancer.

Methods

Published case reports and case series of PA in patients with suspicion of lung cancer were considered, and data were extracted by a structured search through PubMed/Medline.

Results

After analyzing Medline, 31 studies were reviewed, from which 48 cases were extracted. Europe had the highest prevalence of reported cases with 45.1%, followed by Asia (32.2%), America (19.3%), and Africa (3.2%). The average age of patients was 58.9 years, and 75% of all patients were above 50 years old. Male patients (70%) were predominantly affected by PA. The overall mortality rate was 6.25%. In only eight cases, the causative agent was reported, and Actinomyces odontolyticus was the most common isolated pathogen with three cases. Based on histopathological examination, 75% of the cases were diagnosed, and the lobectomy was performed in 10 cases, the most common surgical intervention. In 50% of the cases, the selective antibiotics were intravenous and oral penicillin, followed by amoxicillin (29.1%), amoxicillin-clavulanic acid, ampicillin, levofloxacin, and doxycycline.

Conclusion

The non-specific symptoms resemble lung cancer, leading to confusion between PA and cancer in imaging scans. Radiological techniques are helpful but have limitations that can lead to unnecessary surgeries when confusing PA with lung cancer. Therefore, it is important to raise awareness about the signs and symptoms of PA and lung cancer to prevent undesirable complications and ensure appropriate treatment measures are taken.

Pulmonary actinomycosis mimicking lung malignancy: About two cases

Pulmonary actinomycosis is a rare anaerobic infection with non specific clinical and radiographic presentations that delay diagnosis. Throughout literature, a significant number of misdiagnosed cases have been reported. The diagnosis is substantially based on histopathological pattern. We describe the cases of two patients evaluated and treated in pulmonary department 1 of Abderrahmane Mami hospital of Tunisia with a diagnosis of pulmonary actinomycosis. There are two men. The first patient had hypertension and chronic obstructive pulmonary disease and the second one underwent surgery for bronchiectasis. Clinical presentation was consistent with productive cough, hemoptysis, and deterioration of general status. The medical examination was non-specific. The chest X-ray revealed an apical opacity, excavated in the first case and retractable in the second one. Biology showed an inflammatory syndrome. Bronchoscopy was performed in the two cases and showed lesions mimicking lung malignancy. Diagnosis is confirmed by histopathological examinations of surgical specimens in the two cases. Both patients were received antibiotic therapy. The results were excellent with a favorable clinical course and no deaths. This study highlights the misleading patterns of actinomycosis to prompt accurate diagnosis and earlier treatment, thus improving the outcome. Given either its low culture yield or the limited use of new molecular diagnostic tools in routine clinical practice, histological examination of lung tissue specimens is crucial to get the correct diagnosis.

Actinomycosis with Fusobacterium empyema

Actinomyces, are gram-positive, non-spore forming anaerobic or microaerophilic species. Empyema due to actinomycosis is relatively rare and can be difficult to diagnose as the presenting symptoms may be indolent and the micro-organism may be difficult to culture. This case report describes a patient presenting with dyspnoea, weight loss and lethargy. The chest radiograph, CT and thoracic ultrasound revealed a left-sided pleural effusion. A chest drain was inserted under ultrasound guidance. The pleural fluid was macroscopically consistent with pus and microbiology showed growth of gram-positive bacilli, Actinomyces meyeri as well as the Fusobacterium species. The patient was treated with a drainage of the pleural fluid, a prolonged course of antibiotics and made a good recovery. The awareness that the Actinomyces species and the Fusobacterium species through their synergistic interaction may cause empyema, may lead to a timely diagnosis and treatment.

Necrotizing fasciitis of the chest wall caused by empyema necessitans following tuberculosis: Case report and literature review

INTRODUCTION AND IMPORTANCE

Empyema is a serious complication characterized by pus and bacteria in the pleural space which may progress to necrosis, cavitation, or fistulas in the thoracic cavity. Infection and trauma are the commonest causes in the developed countries while tuberculosis is the commonest cause of empyema in developing countries. Empyema necessitans is a rare complication of pleural space infections.

CASE PRESENTATION

A 50 years old male patient presented to our hospital with right side chest pain and shortness of breath of 3-week duration. He had completed treatment of pulmonary tuberculosis 6 months ago. The patient was apparently healthy for the last six months after the treatment. The patient was acutely sick looking and has tachycardia with pulse rate of 115, respiratory rate was 36 and arterial oxygen saturation of 80 % with atmospheric air but becomes 96 % with facemask humidified oxygen. Tube thoracostomy and chest wall debridement was done for empyema necessitans with chest wall necrotizing fasciitis.

CLINICAL DISCUSSION

Empyematous collection with time may lead to a more complicated scenario called empyema necessitans. Empyema necessitans is the dissection of puss thru the pleural space and collection in the torso/ free rupture with or without collection of air. The most common cause of empyema globally is untreated parapneumonic effusion. Tuberculosis constitutes for most of the cases of empyema necessitans in third world countries. Debridement and wound care are monumental for the management of necrotizing fasciitis in addition to broad spectrum antibiotics.

CONCLUSION

Timely treatment/drug adherence to pneumonia and tuberculosis decreases the rate of having empyema and subsequent complication. Chest wall necrotizing fasciitis is extremely rare and judicious management with debridement and wound care is appropriate whenever it happens. Broad spectrum antibiotics with drainage are the norm of management of empyema/empyema necessitans.

The diagnosis and management of pulmonary actinomycosis

Pulmonary actinomycosis is a rare infection caused by the bacterial species actinomyces. This paper aims to provide a comprehensive review of pulmonary actinomycosis to improve awareness and knowledge. The literature was analysed using databases including Pubmed, Medline and Embase from 1974 to 2021. After inclusion and exclusion, a total of 142 papers were reviewed. Pulmonary actinomycosis is a rare disease occurring in approximately 1 per 3,000,000 people annually. Historically, pulmonary actinomycosis was a common infection with high mortality; however, the infection has become rarer since the widespread use of penicillins. Actinomycosis is known as "the great masquerade"; however, it can be differentiated from other diseases with acid-fast negative ray-like bacilli and sulphur granules being pathognomonic. Complications of the infection include empyema, endocarditis, pericarditis, pericardial effusion, and sepsis. The mainstay of treatment is prolonged antibiotic therapy, with adjuvant surgery in severe cases. Future research should focus on multiple areas, including the potential risk secondary to immunosuppression from newer immunotherapies, the utility of newer diagnostic techniques and ongoing surveillance post-therapy.

Aggregatibacter actinomycetemcomitans Causing Empyema Necessitans and Pyomyositis in an Immunocompetent Patient

Empyema necessitans is a relatively rare clinical entity in which the empyema extends through the parietal pleura into the adjacent soft tissue and musculature of the chest wall. It usually occurs due to inadequate treatment of a primary lung infection. Aggregatibacter (formerly Actinobacillus) actinomycetemcomitans is a facultative anaerobic gram-negative coccobacillus that is part of the normal oral flora. Infections due to this organism usually result from aspiration in conjunction with dental disease or trauma to the oral mucosa resulting in pneumonia or empyema. It often coinfects with Actinomyces and is known to cause empyema necessitans. Cases of monomicrobial empyema necessitans due to Aggregatibacter actinomycetemcomitans in adults have rarely been reported with four such publications found on review of the literature. We present a patient with severe periodontitis who developed empyema necessitans due to Aggregatibacter actinomycetemcomitans likely from aspiration complicated by pyomyositis of the right triceps brachii and a left posterior thigh abscess.

Pulmonary actinomycosis diagnosed by transbronchoscopic lung biopsy: A case report and literature review

Pulmonary actinomycosis is a chronic, suppurative, granulomatous disease caused by Actinomyces israelii, an obligate anaerobe. The clinical manifestations and imaging characteristics of pulmonary actinomycosis lack specificity and can lead to confusion with tuberculosis and lung cancer. The present study reported a case of pulmonary actinomycosis diagnosed by transbronchoscopic lung biopsy and reviewed the literature on the disease. The clinical characteristics, signs, laboratory findings as well as progression, diagnosis and treatment in the case of pulmonary actinomycosis were analyzed. The patient was diagnosed by transbronchoscopic lung biopsy. After two weeks of antibiotic therapy, the cough was significantly improved and the patient's temperature returned to normal. Moreover, the lesion in the left lower lung was significantly smaller. Pulmonary actinomycosis is usually confused for tuberculosis and lung cancer. The present findings indicated that transbronchoscopic lung biopsy is a useful tool for diagnosing the disease. To conclude, doctors should have a clear enough understanding of the disease to prescribe empirical antibiotics and avoid unnecessary surgery.