
==== Front
Turk Patoloji Derg
Turk Patoloji Derg
Turk Patoloji Derg
Turkish Journal of Pathology
1018-5615
1309-5730
1018-5615
Federation of Turkish Pathology Societies Ankara, Turkey

38801125
10.5146/tjpath.2024.13407
Case Report
Bronchiectatic Actinomycosis with Osseous Metaplasia Masquerading as Lung Cancer
Bhat Archana *
J Manjunath
Mascarenhas Don
Department of Pathology, Father Muller Medical College, Mangalore, India
* E-mail: archibhat3@fathermuller.in
Concept: AB, MJ, DM, Design: AB, MJ, DM, Supervision: AB, MJ, DM, Materials: AB, MJ, DM, Data collection and/or processing: AB, MJ, DM, Analysis and/or interpretation: AB, MJ, DM, Literature search: AB, MJ, Writing: AB, MJ, Approval: AB, MJ, DM.

2024
02 9 2024
40 3 202204
07 3 2024
22 4 2024
Copyright © 2024 The Author(s).
2024
The Author(s)
https://creativecommons.org/licenses/by/4.0/ This is an open-access article published by Federation of Turkish Pathology Societies under the terms of the Creative Commons Attribution License which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is properly cited. No use, distribution or reproduction is permitted which does not comply with these terms.
Bronchial involvement in pulmonary actinomycosis is rare and has been reported in the literature rarely. However, these reports describe endobronchial actinomycosis secondary to foreign body aspiration (for example, a fish bone). Our case did not have any history or clinical evidence suggesting foreign body aspiration, which makes it even more rare.

A 55-year-old woman presented with complaints of on and off haemoptysis and cough for three weeks. In view of the haemoptysis and consolidation seen on imaging, a bronchoalveolar lavage was done and sent for cytological assessment. Few atypical cells with nuclear hyperchromasia and prominent nucleoli were noted. In view of the persistent haemoptysis, worsening symptoms, and non-resolution of the consolidation despite antibiotics, and the finding of atypical cells, segmental resection was done. A final diagnosis of bronchiectatic actinomycosis with osseous metaplasia was given. The patient was started on prolonged antibiotics with good response and recovery.

Other risk factors associated with pulmonary actinomycosis include alcoholism, diabetes, haematological diseases, human immunodeficiency viral infection, use of immunosuppressants, and rarely chronic lung diseases, such as bronchiectasis. Our case had this rare association of bronchiectasis with bronchial actinomycosis.

Bronchiectatic actinomycosis is a rare infection and it can mimic several lung disorders like unresolving pneumonia, pulmonary tuberculosis, foreign body, and even lung tumours. The pathologists and clinicians should be aware of this entity and thus help in the early diagnosis and better management of patients with this disease.

Diagnostics
Infection
Pneumonia
Haemoptysis
Consolidation
==== Body
pmcINTRODUCTION

Actinomycosis is a chronic and rare granulomatous disease caused by the filamentous anaerobic Gram-positive bacteria of the family Actinomycetaceae (genus Actinomyces) (1). Actinomycosis can affect any organ in the body. Pulmonary actinomycosis constitutes 15% of the total disease burden and is the third most common form of disease after cervicofacial and abdominopelvic forms (2). The pulmonary form is associated with concomitant respiratory disorders like emphysema, chronic bronchitis, bronchiectasis, and suppurative infections. Alcoholism, poor oral hygiene, dental disease, and facial or dental trauma are important risk factors (3). It is a rare infection with an occurrence of 1 in 3,00,000 people per year (3). Primary endobronchial actinomycosis is rare, and often associated with foreign body aspiration. It can mimic malignancy, tuberculosis, or nocardiosis, due to its continuous spread and progression, and tendency to form a cold abscess (4). A high level of clinical suspicion is needed for its diagnosis. We present a case of bronchiectatic actinomycosis without any evidence of foreign body aspiration, which closely mimicked malignancy.

CASE REPORT

A 55-year-old woman presented with complaints of on-and-off haemoptysis and cough for three weeks. There was no history of fever, vomiting, weight loss, or breathing difficulties. There was no history of any trauma. She had no known comorbidities. Her history revealed that she had undergone total abdominal hysterectomy with bilateral salphingo-oophrectomy with pelvic lymph node dissection for endometrial carcinoma twelve years ago. Her respiratory examination findings revealed bilateral air entry with coarse crepitations on the right side. The abdomen was soft and non-tender, and no abnormality was detected. Cardiovascular and central nervous system examination were within normal limits. In view of hemoptysis and consolidation on imaging, a bronchoalveolar lavage was done and sent for cytological assessment. Few atypical cells with nuclear hyperchromasia and prominent nucleoli were noted. Tuberculosis was ruled out. In view of the persistent hemoptysis, worsening symptoms, and non-resolution of consolidation despite antibiotics, and the finding of atypical cells, a segmental resection was done. The gross pathology revealed dilated bronchi and areas of congestion. No growth or necrosis was seen. Microscopy revealed dilated bronchi with inflammation and osseous metaplasia (Figure 1). Intraluminal radiating filamentous bacterial colonies were seen, which stained positive with the Gomori methenamine silver stain (Figure 2) and gram stain, and were negative with the modified acid-fast stain. A final diagnosis of bronchiectatic actinomycosis with osseous metaplasia was given. The patient was started on prolonged antibiotics with good response and recovery.

Figure 1 Haematoxylin and eosin stain, 10X, showing dilated bronchi lined by respiratory epithelium. Dense inflammation is seen in the wall along with osseous metaplasia.

Figure 2 Gomori methenamine silver stain, 40X, showing silverpositive intraluminal radiating filamentous bacterial colonies.

DISCUSSION

Bronchial involvement in pulmonary actinomycosis is rare and has been reported in the literature rarely. However, these reports describe endobronchial actinomycosis secondary to foreign body aspiration (for example, a fish bone) (5). Our case did not have any history or clinical evidence suggesting foreign body aspiration, which makes it even more rare.

Other risk factors associated with pulmonary actinomycosis include alcoholism, diabetes, hematological diseases, human deficiency viral infection, use of immunosuppressants, and rarely chronic lung diseases, such as bronchiectasis (6). Our case had this rare association of bronchiectasis with bronchial actinomycosis.

The suspicion of pulmonary actinomycosis is commonly raised by radiological findings like interstitial or pleural thickening, endobronchial mass causing atelectasis, lobar or air-space consolidation, ground glass opacities, pleural effusion, hilar lymphadenopathy, or necrotic mass. However, the diagnosis remains challenging due to the absence of any radiological features that are specific to the disease (7).

The bronchoscopic features of endobronchial actinomycosis are non-specific and include wall thickening with partial or complete occlusion of bronchi or an exophytic mass or a submucosal mass lesion, at times with necrosis, mimicking tuberculosis, or lung cancer (8). Thus a wide range of differentials enter the list including tumours - both benign and malignant, infective causes, and miscellaneous causes. The benign tumours include namely pulmonary hamartoma, lipoma, carcinoid, and fibroepithelial polyp. The malignant tumours include neuroendocrine carcinoma, bronchogenic tumours, endobronchial metastasis, and mucoepidermoid carcinoma. The infective endobronchial lesions include endobronchial tuberculosis or nocardiosis, and miscellaneous causes include mucus plug or foreign body (9). Pulmonary actinomycosis can be easily confused with other diseases. This may lead to unnecessary surgeries (10).

The reactive pneumocytes or reactive bronchial epithelial cells can masquerade as malignant cells on bronchoalveolar lavage or bronchial brush smears, as it happened in our case. Histopathological examination and microbiological evaluation will help in arriving at a definitive diagnosis. Early diagnosis and treatment will help in preventing dangerous complications like rib fractures, cardiac involvement, or fatal pericarditis (9).

CONCLUSION

Bronchiectatic actinomycosis is a rare infection and it can mimic several lung disorders like unresolving pneumonia, pulmonary tuberculosis, foreign body, and even lung tumours. Pathologists and clinicians should be aware of this entity and thus help in the early diagnosis and better management of patients with this disease.

Conflict of Interest

The authors declare that they have no conflict of interest.
==== Refs
Russo TA Principles and Practice of Infectious Diseases Agents of Actinomycosis Mandell DL , Bennett JE , Dolin R Elsevier Churchill Livingstone 2010
3209 3219 10.1016/B978-0-443-06839-3.00255-1
Mabeza G. F. , Macfarlane J. Eur Respir J Pulmonary actinomycosis 03 2003
21 545 551 10.1183/09031936.03.00089103 12662015
Yildiz Orhan , Doganay Mehmet Curr Opin Pulm Med Actinomycoses and Nocardia pulmonary infections 05 2006
12 228 234 10.1097/01.mcp.0000219273.57933.48 16582679
Wong V. K. , Turmezei T. D. , Weston V. C. BMJ Actinomycosis 10 2011
343 d6099 d6099 10.1136/bmj.d6099
Maki Kanako , Shinagawa Naofumi , Nasuhara Yasuyuki , Oizumi Satoshi , Domen Hiromitsu , Haga Hironori , Nishimura Masaharu Intern Med Endobronchial actinomycosis associated with a foreign body--successful short-term treatment with antibiotics-- 2010
49 1293 1296 10.2169/internalmedicine.49.3475 20606362
Valour Florent , Sénéchal Agathe , Dupieux Céline , Karsenty Judith , Lustig Sébastien , Breton Pierre , Gleizal Arnaud , Boussel Loïc , Laurent Frédéric , Braun Evelyne , Chidiac Christian , Ader Florence , Ferry Tristan Infect Drug Resist Actinomycosis: etiology, clinical features, diagnosis, treatment, and management 2014
7 183 197 10.2147/IDR.S39601 25045274
Kim Tae Sung , Han Joungho , Koh Won-Jung , Choi Jae Chol , Chung Myung Jin , Lee Ju Hyun , Shim Sung Shine , Chong Semin AJR Am J Roentgenol Thoracic actinomycosis: CT features with histopathologic correlation 01 2006
186 225 231 10.2214/AJR.04.1749
Farrokh Donya , Rezaitalab Fariba , Bakhshoudeh Banafsheh Tanaffos Pulmonary actinomycosis with endobronchial involvement: a case report and literature review 2014
13 52 56
Golfi Nicoletta , Mastriforti Roberta , Guidelli Luca , Scala Raffaele BMC Infect Dis A case of endobronchial actinomycosis as a challenging cause of lung atelectasis 05 2021
21 433 433 10.1186/s12879-021-06126-3 33964874
Khoshbayan Amin , Amirmozafari Nour , Mirkalantari Shiva Front Med (Lausanne) An overview of case reports and case series of pulmonary actinomycosis mimicking lung cancer: a scoping review 2024
11 1356390 1356390 10.3389/fmed.2024.1356390 38523909
