A 58–year–old Caucasian male presented to the emergency department with a three–month history of worsening dyspnea, productive cough, low–grade fevers and chills. Past medical history was significant for 60 pack year smoking history, paranoid schizophrenia and end stage renal disease currently receiving hemodialysis. On physical exam, patient was afebrile, hypotensive with an oxygen saturation of 96%, frail with overall poor hygiene, in moderate distress with decreased breath sounds and dullness to percussion on the right side. Patient also had significant left upper extremity swelling. Chest x–ray revealed a massive right pleural effusion. Patient was admitted to the hospital and antibiotics were started for possible pneumonia. He then underwent thoracentesis, and the obtained pleural fluid showed an elevated triglyceride level of 693 mg/dl indicating chylothorax. Furthermore, a CT chest showed right pleural effusion, a small left pleural effusion, spiculated mass within the anterolateral aspect of the right lung, occlusion of the superior vena cava with collateralization, and extensive mediastinal and axillary adenopathy. However, video assisted thoracoscopy was performed which did not show any mass lesions. After a week into the admission, patient had continued respiratory distress and underwent bronchoscopy with transbronchial lung biopsy and lavage. No obstruction, lesions, or ulcerations were visualized in the bronchial segments. Bronchial wash was negative for gram stain, acid fast bacilli and Pneumocyctis Carinii organisms. The pathology of the bronchial wash showed bacteria with morphologic features of actinomyces, RBC’s and acute inflammation.
The patient presented with massive right–sided pleural effusion and adenopathy. Pleural fluid analysis was consistent with chylothorax, which is an indication of disruption of lymphatic flow usually due to malignancy, lymphoma or trauma. Diagnosis of thoracic actinomycosis in the patient was based on histologic examination. Actinomyces has propensity to extend across fissures and invade the chest wall. In this patient, actinomyces caused bronchopulmonary infection and chest wall disease by disruption of lymphatic flow resulting in chylothorax, and the SVC occlusion.
Awareness of this rare disease and its clinical presentation is important for hospitalist. It is usually unsuspected and under diagnosed due to lack of familiarity and failure to culture or culture appropriately this microaerophilic bacterium.
Figure 1Cell block with silver stain from a bronchial washing demonstrating morphologic features suggestive of actinomyces.
Figure 2CT chest with contrast demonstrating the pleural effusions and spiculated soft tissue mass within the anterior aspect of the right midlung.