Case Presentation: A 36yo M with PMH of alcohol abuse presented with intermittent atypical chest pain, worsening exertional shortness of breath, chills, and right (R) upper quadrant abdominal pain for the past three weeks. On physical exam, he was noted to be tachycardic and tachypneic; respiratory exam was significant for decreased breath sounds in R upper lobe and absent sounds in middle and lower lobes. Chest X-Ray (CXR) showed a large R-sided pleural effusion, further imaging with CT and bedside ultrasound revealed a large, multi-loculated fluid collection complicated by R lung collapse. R upper quadrant ultrasound was performed and showed findings consistent with hepatic cirrhosis as well as moderate ascites. The patient was initiated on broad spectrum antibiotics and a chest tube was inserted into largest fluid pocket, which drained two liters of a dark yellow, purulent, foul-smelling fluid. Pleural fluid cultures were sent which grew Actinomyces meyeri; blood and sputum cultures were negative. Two subsequent chest tubes were inserted on the R side in fluid pockets as identified on ultrasound. Patient’s antibiotic regimen was narrowed to IV penicillin. With continued drainage, his symptoms improved and follow-up imaging done 10 days after chest tube placement showed significant interval decrease in fluid. The chest tubes were subsequently removed. He was discharged with Augmentin to complete 6 months of therapy.
Discussion: Actinomyces meyeri is an anaerobic gram-positive bacillus and can be found in normal oral flora. Rarely, it can cause pneumonia and empyemas, notably in patients with structural lung disease, aspiration risks, and alcohol abuse. This pathogen is difficult to differentiate with clinical symptoms or imaging, thus histologic and microbiologic testing is very important for diagnosis. Treatment is similar to other pathogens which include drainage of purulent fluid via chest tube and possible decortication and antibiotics. Standard treatment for actinomyces is IV penicillin followed by PO amoxicillin or augmentin for six to twelve months.
Conclusions: There should be a high index of suspicion for empyemas in patients who present with symptoms suggestive of pneumonia. It is important to rule out complications of simple infections to determine length of antibiotic therapy. This case demonstrates an interesting etiology for a common hospital condition, emphasizing the importance of prompt diagnosis.