In April 2000, a 69-year-old man was admitted to Inha General Hospital due to productive cough with dark, brown-colored sputum. He complained of night sweat and weight loss of more than 9 killograms for 2 months. Nine years before entry, the patient experienced a cerebrovascular accident which left a sequelae of left side weakness, mild dysphagia and dysarthria. Because of poor oral hygiene, plaque and calculus, the patient had frequent visits to the dentist but no dental care was given within the previous 5 years. The patient had no past medical history of pulmonary tuberculosis, chronic lung disease or any other condition.
On physical examination, the patient's blood pressure was 130/90 mmHg, pulse rate 80/min and body temperature 36.7 C. His mental status was alert but dysarthric feature and left side hemiparesis was shown. Oral examination by a dentist revealed gingivitis, dental decay, very poor hygienic state and moderate amount of plaque and calculus. On chest examination, abnormal breathing sounds, such as crackle and expiratory wheezing, were not audible. There were no other physical abnormalities noted.
Laboratory examination showed the hemoglobin was 13.8 g/dL, hematocrit 40.4%, white blood cell 6,700/muL, platelet 177,000/muL. Erythrocyte sedimentation rate was 14 mm/h. C-reactive protein was 0.5 mg/dL. Cytologic examination of sputum was negative. Bacteriologic examination of sputum showed no evidence of mycobacterial tuberculosis or fungal infection. Chest radiographs revealed increased opacity and atelectatic change in the anterior segment of the left upper lobe, suggestive of obstructive pneumonitis or pulmonary tuberculosis (Figure 1A). A computed tomographic scan (CT) of the thorax showed consolidation and air bronchogram in the left upper lobe with partial atelectasis, but significant enlargement of mediastinal or hilar lymph node was not observed (Figure 1B). Bronchoscopic examination showed a pink and soft protruding mass obstructing the left upper lobar bronchus was suggestive of bronchogenic carcinoma (Figure 2A). The presumptive diagnosis by bronchoscopy was bronchogenic carcinoma. However, biopsy of the lung tissue obtained by bronchoscopy showed gram-positive sulfur granules and hyphe-like components within a granulomatous formation, which showed squamous metaplasia of bronchial mucosa with mixed inflammatory cellular infiltration and some colonies of actinomycosis (Figure 3). The final diagnosis was endobronchial actinomycosis.
The patient was given 10 million units of intravenous penicillin-G daily for two weeks. The opacities and infiltration on chest radiographs gradually decreased. After two weeks of penicillin therapy, he was switched to 2 g amoxicillin daily. At discharge, more than 80% of his pulmonary infiltration had resolved and the remainder was markedly reduced in size. After discharge, oral antibiotics were administered for 4 weeks. Follow-up bronchoscopic examination revealed a complete resolution of the endobronchial mass lesion and, in place, a foreign body was exposed (Figure 2B). The removed foreign body was proven to be a very small-sized fish bone. This unfortunate accident is the first case of a foreign body-induced pulmonary actinomycosis in Korea. The patient was completely cured with no remaining symptoms.
A chest CT scan obtained at the level of the aortic arch reveals consolidation with airbronchogram (arrow) in the left upper lobe. Fish bone was not identified in the CT scan.