Pulmonary actinomycosis is a rare bacterial lung infection caused by Actinomyces israelii that is acquired by aspirating oropharyngeal material. It presents with chronic cough, chest pain, and sometimes hemoptysis or weight loss. Diagnosis relies on culture, biopsy showing sulfur granules, or PCR of infected tissue. Imaging often shows consolidation, nodules, or cavitary lesions confined to one lobe. Treatment is prolonged intravenous and oral penicillin, sometimes requiring surgery for complications like abscesses.

1. Pulmonary Actinomycosis
D R . M D . S H A F I Q U L I S L A M D E WA N
R E S I D E N T ( P U L M O N O L O G Y )
D E PA RT M E N T O F R E S P I R ATO RY M E D I C I N E
D H A K A M E D I C A L C O L L E G E H O S P I TA L

2. Actinomyces
Actinomyces are gram-positive, non–spore-forming, anaerobic, branching
filamentous bacilli.
A. israelii is the commonest cause of actinomycosis.
Actinomyces are commensals in the oropharynx, gastrointestinal, and genital
tracts.
Actinomycosis most commonly affects the face and neck. The infection can
sometimes occur in the chest (pulmonary actinomycosis), abdomen, pelvis, or
other areas of the body.
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 2

3. Pulmonary Actinomycosis
Pulmonary actinomycosis is a rare bacterial lung infection caused by A. israelii.
It’s also known as thoracic actinomycosis. It’s not contagious.
Mode of transmission: Aspiration of oropharyngeal material.
Risk factors include_
 Poor dental hygiene
 Smoking
 Alcohol abuse
 Chronic lung disease
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 3

4. Clinical features
•History of chronic productive cough and chest pain.
•Haemoptysis has been reported in 30% of patients.
•Weight loss and malaise are common.
•Fever and night sweats are observed in only 20–30%.
•Chest wall lesions and draining sinuses are now uncommon.
•Presentation with a radiologic abnormality with some of the above features is
now more usual.
•Physical signs are nonspecific.
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 4

5. Differential Diagnosis
•Lung abscess
•Malignancy
•Tuberculosis
•Other causes of chronic pneumonia.
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 5

6. Investigation
Imaging: Chest x-ray, CT chest
Culture (Pus or tissue)
Biopsy & Histopathology (Transbronchial biopsies are usually not helpful, and
CT-guided needle biopsies are more often diagnostic)
PCR (Tissue)
Definitive diagnosis depends on demonstrating the characteristic
histopathology and culture from a sterile site or tissue biopsy.
Cultures are frequently negative or contain other organisms.
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 6

7. Imaging
•Classic finding for actinomycosis is direct extension of a cavity or mass through
an interlobar fissure.
•Commonly, changes are confined to a single lobe with consolidation, nodules,
one or more small cavitary lesions.
•Pleural thickening or effusions are also encountered.
•Advanced cases, the findings may be more distinctive, with penetration
through the chest wall and/or destruction of adjacent bone tissue.
•CT imaging may reveal bone erosion.
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 7

8. Histopathologic features
Supportive histopathologic features include identification of filamentous forms
on Gomori methenamine silver stain or modified Gram stain.
Identification of basophilic “sulfur granules” containing a mass of mycelial
elements in a protein and polysaccharide matrix, and granulomatous-like
reactions, although classic granulomata are rare.
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 8

9. DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 9

10. DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 10

11. DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 11

12. Complications
•Empyema
•Cutaneous thoracic sinuses
•Mediastinitis
•Pericarditis
•Vertebral or rib osteomyelitis.
•Metastatic infection, including brain, skin, and bone, is now rare.
•With adequate therapy, death from actinomycosis is rare.
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 12

13. Treatment
Treatment of choice: Penicillin G, IV
Doses & Duration: 18 to 24 million units/day IV in divided doses every 4 to 6
hours for 2 to 6 weeks
Followed by at least 6 to 12 months of oral penicillin V or ampicillin.
Doxycycline is the most often prescribed alternative as oral therapy.
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 13

14. Shorter durations of therapy
•Shorter durations of therapy have been reported in selected patients without
abscesses or chest wall involvement.
•These patients had at least 3 months of total therapy, including 1 to 2 months
after clinical and radiologic resolution.
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 14

15. Surgical treatment
•Rarely, surgical resection is required for cure.
•May be indicated to manage_
• Hemoptysis
• Fistulae
• Abscesses
• Empyema
•In cases where the diagnosis remains in doubt, to obtain surgical specimens.
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 15

16. DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 16
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