Thoracic actinomycosis in an adolescent mimicking chest wall tumor or pulmonary tuberculosis

Actinomycosis is a rare disease in children and young adolescents and its thoracic manifestations accounted for a minority of all cases. We report a case of a 12-year-old boy who presented with a right anterior chest wall mass for one week together with weight loss and low grade fever for one month. His symptoms and signs as well as the results of the radiological investigations (i.e. chest X-ray and computed tomography (CT) of thorax with contrast) mimicked pulmonary tuberculosis or chest wall tumor. The definite diagnosis of actinomycosis relies on the Gram stain microscopy and culture of the chest wall lesion aspirates. An early and accurate diagnosis can prevent the patient from unnecessary invasive procedures such as open lung biopsy or thoracotomy. The mainstay of the treatment of actinomycosis remains to be a combination of abscess drainage as well as prolonged antibiotics such as penicillin. Follow-up CT scan of thorax with contrast is useful in monitoring the progress of disease recovery.     

Thoracic actinomycosis

Actinomycosis is an infectious disease distributed all over the world. Males are affected three times more than females; the incidence of the disease is higher in adults than in children. The main causative agent is Actinomyces israelii, which can be found in the oropharynx of healthy persons. Therefore actinomycosis represents always an endogenous infection, often in connection with other bacteriae. The thoracic manifestation amounts to approximately 15 percent of all cases. The main clinical symptoms are pain, fever, cough, fatigue, and weight loss. The blood picture shows an increased number of white blood cells with a left shift in the differential white blood cell count. Furthermore, there is a strongly raised erythrocyte sedimentation rate. Radiographs demonstrate no typical patterns of pulmonary abnormalities. For the diagnosis there is a need of anaerobic cultures, in second line histological examination of tissue specimens. Differential diagnosis of actinomycosis includes chronic pneumonias caused by other rare germs and neoplasms. After early onset antibiotic long term treatment a good prognosis may be expected. Penicillin represents the antibiotic of first choice.     

Post varicella hepatic actinomycosis in a 5-year-old girl mimicking acute abdomen

Actinomycosis is an indolent, slowly progressive infection caused by gram-positive, anaerobic or microaerophilic bacteria. Hepatic involvement is rare and generally secondary to abdominal or thoracic actinomycosis. Hepatic actinomycosis in children may mimic a wide variety of diseases and thus make the diagnosis much more challenging. Here, we report a 5-year-old girl with apparently primary hepatic actinomycosis mimicking acute abdomen 2 weeks after varicella. The diagnosis was made by ultrasonic guided fine needle aspiration biopsy of a hypoechoic lesion of 3.5 cm diameter in the liver showing sulfur granules surrounded by neutrophils. Hepatic actinomycosis should be taken into account when evaluating acute abdomen symptoms in children.     

儿童肺放线菌病一例并文献复习

目的总结儿童肺放线菌病的临床特征、影像学表现、诊治方法及预后。方法回顾性分析浙江大学医学院附属儿童医院呼吸科2019年12月收治的1例肺放线菌病患儿的临床资料。以“儿童”或“小儿”和“肺放线菌病”为关键词在万方数据库、中国期刊全文数据库、中国维普数据库,以“pulmonary”或“thoracic”和“actinomycosis”和“pediatric”或“children”或“child”为关键词在PubMed数据库检索1975年1月至2020年1月相关文献进行文献复习。结果患儿男,12岁6月龄,因“咳嗽伴胸痛20 d余”收入院,病初3 d有发热,外院胸部CT示“右肺中叶炎性病变,不除外空洞形成”,2次纤维支气管镜检查示“右中叶支气管黏膜充血水肿”,且1次灌洗液示结核杆菌DNA阳性,但结核菌素试验及结核感染T细胞检测均阴性。入院后患儿有咳嗽伴胸痛,体温正常,再次行纤维支气管镜检查,灌洗液送检病原微生物宏基因测序,检测出放线菌属(检出序列数222),格雷文尼放线菌(检出序列数185)。入院后予头孢哌酮舒巴坦针静脉滴注抗感染2周,出院后口服阿莫西林克拉维酸钾片6周,随访至2020年4月患儿无临床症状,且胸部影像学提示病变已明显吸收好转。共检索到符合条件的外文文献8篇,未检索到中文文献,共报道62例肺放线菌病患儿,文献报道最小年龄为27月龄。该病临床特征无特异性,主要表现为胸壁肿物(8例)、咳嗽(23例)、疼痛(胸部、背部、肩部、腋窝)(24例)、发热(25例)、体重下降(26例)等。结论儿童肺放线菌病的临床特征及影像学表现均不典型,临床上极易误诊,支气管肺泡灌洗液病原微生物宏基因测序有助于确诊,经抗菌药物治疗预后良好。     

Pulmonary actinomycosis in a child

Pulmonary actinomycosis is a rare bacteriological disease, characterized by local suppuration and an extensive fibro-inflammatory process, with a possible pseudotumoral outcome. We report on a case in a 15-year-old boy, admitted in our department for prolonged pleuropneumopathy. Clinical and radiological findings were not contributive. The diagnosis of actinomycosis was obtained by pathology after surgical resection. This disease can mimic on lung X-rays a number of disorders, such as pulmonary tuberculoma, invasive tuberculosis or lung carcinoma. Pleuropulmonary actinomycosis is a rare intrathoracic infection during childhood, of which poor outcome and tough diagnosis lead usually to a surgical attitude given a picture of recurrent pulmonary abnormality. When the diagnosis is established, the treatment is medical.     

Pulmonary actinomycosis

Pulmonary actinomycosis is rarely reported in pediatric age. An 11-year-old girl with history of two-month back pain was admitted to our hospital. On physical examination respiratory sounds were diminished on the left upper lung. Chest radiograph revealed a mass in the left upper lobe. Computed tomography showed solitary lesion (5.6 × 4.5 cm in size) in the left upper lobe. We could not rule out the possibility of malignant thoracic tumor. The patient underwent surgery. Histological examination of the resected tissue revealed, numerous sulfur granules, characteristic of Actinomyces, surrounded by purulent exudates, which are consistent with actinomycosis. She was treated with penicillin G. The patient responded well to penicillin therapy and the lesions regressed completely. She remained well throughout the three-year follow-up.     

Impact of Chest X-Ray Before Discharge in Asymptomatic Children After Cardiac Surgery—Prospective Evaluation

In many paediatric cardiac units chest radiographs are performed routinely before discharge after cardiac surgery. These radiographs contribute to radiation exposure. To evaluate the diagnostic impact of routine chest X-rays before discharge in children undergoing open heart surgery and to analyze certain risk factors predicting pathologic findings. This was a prospective (6 months) single-centre observational clinical study. One hundred twenty-eight consecutive children undergoing heart surgery underwent biplane chest X-ray at a mean of 13 days after surgery. Pathologic findings on chest X-rays were defined as infiltrate, atelectasis, pleural effusion, pneumothorax, or signs of fluid overload. One hundred nine asymptomatic children were included in the final analysis. Risk factors, such as age, corrective versus palliative surgery, reoperation, sternotomy versus lateral thoracotomy, and relevant pulmonary events during postoperative paediatric intensive care unit (PICU) stay, were analysed. In only 5.5 % (6 of 109) of these asymptomatic patients were pathologic findings on routine chest X-ray before discharge found. In only three of these cases (50 %), subsequent noninvasive medical intervention (increasing diuretics) was needed. All six patients had relevant pulmonary events during their PICU stay. Risk factor analysis showed only pulmonary complications during PICU stay to be significantly associated (p = 0.005) with pathologic X-ray findings. Routine chest radiographs before discharge after cardiac surgery can be omitted in asymptomatic children with an uneventful and straightforward perioperative course. Chest radiographs before discharge are warrantable if pulmonary complications did occur during their PICU stay, as this is a risk factor for pathologic findings in chest X-rays before discharge.     

Thoracic actinomycosis in childhood

A 14-year-old boy presenting with a chest wall mass, pulmonary infiltrate, and scoliosis was found to have thoracic actinomycosis with distal vertebral involvement. Review of the medical literature for the past 25 years revealed only 23 other pediatric cases of thoracic actinomycosis. Clinical, standard radiological, and microbiological findings can be nonspecific. The diagnosis is dependent on a high index of suspicion. A long course of penicillin is the treatment of choice. Body computed tomography is a useful diagnostic aid and is helpful also in evaluating response to therapy.     

Pulmonary actinomycosis in children

The radiological features of three cases of pulmonary actinomycosis in children are presented. Two of the cases had the classical roentgen features of chronic consolidation with overlying rib periostitis. The third had non specific consolidation but demonstrated extension through the diaphragm. Two of our cases were mentally subnormal children in institutional care. Their pulmonary pathology is almost certainly attributal to poor dental hygiene, a constant problem in this group of children. Hence, although pulmonary actinomycosis is rare in the general populus, we suggest it might be suspected more often in the subnormal group when chronic consolidation is present.     

Systemic air embolism after cardiopulmonary resuscitation in a preterm infant

We report a preterm infant with extensive systemic air embolism after cardiopulmonary resuscitation for cardiac arrest due to an occluding thrombus in the inferior vena cava. After excluding other potential causes (air infusion, necrotizing enterocolitis or pulmonary leakage syndrome), we postulate that the pressure gradient needed for air embolism to occur is related to the resuscitation procedure. An important clue of air embolism was noted on the chest X-ray taken before death showing intracardial air. CONCLUSION: Systemic air embolism may occur as a very rare complication after cardiopulmonary resuscitation.     

Multifocal thoracic actinomycosis simulating lymphoma

Thoracic actinomycosis is rare in the pediatric age group. We report the unusual case of a 10-year-old girl who presented with prolonged fever and weight loss with a neck mass and multiple pulmonary nodules resembling lymphoma. Open lung biopsy confirmed the diagnosis of actinomycosis and the symptoms and signs improved after treatment with cephalosporin. The pathogenesis and radiographic manifestations are briefly discussed.     

Streptococcus pneumoniae empyema necessitatis

Empyema necessitatis is a rare complication of empyema characterized by extension of suppuration from the pleural space through the chest wall. The most common etiologies are tuberculosis and actinomycosis. We describe a 1-year-old boy with Streptococcus pneumoniae empyema necessitatis and review previously reported cases.     

CFTR pharmacological modulators: A great advance in cystic fibrosis management

Cystic fibrosis is a severe monogenic disease that affects around 7400 patients in France. More than 2100 mutations in the cystic fibrosis conductance transmembrane regulator (CFTR), the gene encoding for an epithelial ion channel that normally transports chloride and bicarbonate, lead to mucus dehydration and impaired bronchial clearance. Systematic neonatal screening in France since 2002 has enabled early diagnosis of cystic fibrosis. Although highly demanding, supportive treatments including daily chest physiotherapy, inhaled aerosol therapy, frequent antibiotic courses, nutritional and pancreatic extracts have improved the prognosis. Median age at death is now beyond 30 years. Ivacaftor was the first CFTR modulator found to both reduce sweat chloride concentration and improve pulmonary function in the rare CFTR gating mutations. Combinations of modulators such as lumacaftor + ivacaftor or tezacaftor + ivacaftor were found to improve pulmonary function both in patients homozygous for the F508del mutation characterized by the lack of CFTR protein and those heterozygous for F508del with minimal CFTR activity. The triple combination of ivacaftor + tezacaftor + elexacaftor was recently shown to significantly improve pulmonary function and quality of life, to normalize sweat chloride concentration, and to reduce the need for antibiotic therapy in patients with at least one F508del mutation (83% in France). These impressive data, however, need to be confirmed in the long term. Nevertheless, it is encouraging to hear treated patients testify about their markedly improved quality of life and to observe that the number of lung transplants for cystic fibrosis decreased dramatically in France after 2020, despite the COVID pandemic, with no increase in deaths without lung transplant.     

An unusual cause of thoracic mass.

A previously well 10 year old boy presented with scoliosis, a mass in the chest wall, and a pleural effusion. Chest radiography showed the triad of chronic consolidation, pleural effusion, and rib periostitis. Investigations confirmed thoracic actinomycosis. Tissue spread was evaluated by computed tomography. It was successfully treated with benzylpenicillin, which was later replaced by clindamycin.     

Differential diagnosis of congenital heart disease in the first 3 months of life: Significance of a superior (left) QRS axis

The ECGs of 473 infants under the age of 3 months who were referred to a paediatric cardiological unit were analysed; 47 (10%) of the ECGs showed a superior axis (dominantly negative deflection S wave, in lead aVF). Of these, the majority of noncyanosed patients with plethora on chest x-ray proved to have either an atrioventricular canal defect or a large ventricular septal defect. When cyanosis and pulmonary plethora on x-ray were present, tricuspid atresia with increased pulmonary flow (types Ic or IIc) or d-transposition with ventricular septal defect accounted for most cases. With cyanosis and pulmonary oligaemia on x-ray, tricuspid atresia (types Ia and b) or pulmonary atresia with ventricular septal defect accounted for all cases. Finally, 2 patients with superior axis presenting in a shocked condition were found to exhibit the hypoplastic left heart syndrome.Recognition of superior axis in the ECG provides a useful diagnostic aid in congenital heart disease in early infancy.     

Actinomycotic osteomyelitis of the skull and atlas with late dissemination

Actinomycosis of the skull and/or the vertebral colum is extremely rare in previously healthy children and its diagnosis is difficult. A case is reported here involving the occipital bone and the atlas. The disease had started 4 years before diagnosis and presented as a neurosurgical affection in a 13-year-oldgirl. The disease spread towards the retropharyngeal space and probably disseminated to the liver and the lung. Actinomyces israeli grew from cultures. Antibiotic treatment was successful.     

Pulmonary emboli following therapeutic embolization of cerebral arteriovenous malformations in children

Background. Reports of the complicating side effect of pulmonary embolism (PE) following endovascular therapy of cerebral arteriovenous malformations (AVM) in children have been limited in number. Details of its occurrence are yet to be fully elucidated.¶Objective. The hypothesis is that inadvertent pulmonary migration of embolic material is common and may go unrecognized.¶Materials and methods. Forty-seven patients (ages 1 day to 16 years and 11 months) underwent embolization of a cerebral AVM with at least one material (cyanoacrylate, platinum coils, detachable balloons, polyvinyl alcohol particles). The medical records and chest radiographs were reviewed retrospectively. Chest radiographs were available in 34 patients. The radiographs were analyzed for the presence or absence of foreign material in the lungs.¶Results. The chest radiographs in 12 patients (35 %) showed pulmonary deposits of embolic material; cyanoacrylate in 10 patients and platinum coils in 2. Two of the patients with cyanoacrylate deposits in the lungs developed respiratory distress that required endotracheal intubation. The patients gradually improved after a time period of 7–10 days with conservative treatment.¶Conclusion. PE is not an uncommon complication in children undergoing embolization of brain AVM. Although usually asymptomatic, PE may cause severe symptoms.     

Pulmonary nodular opacities in children with hereditary hemorrhagic telangiectasia

Background Hereditary hemorrhagic telangiectasia (HHT) is a rare inherited disorder of vascular endothelium that can result in the formation of pulmonary arteriovenous malformations (pAVMs). We observed that small pulmonary nodules, possibly representing early vascular malformations, are more common in these children than in the general population. Objective To describe and characterize the small pulmonary nodules seen on chest CT examination in the lungs of children with HHT. Materials and methods We followed 19 children who had undergone chest CT as part of their initial diagnostic evaluation in the HHT clinic of a pediatric hospital. Chest CT scans were reviewed independently by two radiologists blinded to clinical data. Pulmonary nodules were analyzed according to lobar distribution, anatomic position in the lung (outer, mid, inner third), shape (round, linear, V- or Y-shaped, ill-defined), presence of overt AVMs, and nodule size (≤ or >5 mm). We also reviewed a control group of chest CT scans performed on 25 age-matched children. Results A total of 35 pulmonary nodules were identified on the CT scans in 15 of the 19 children. Multiple nodules were seen in eight children (42%), solitary nodules were seen in seven children (37%) and no nodules were seen in the remaining four children (21%). The nodules were found to be nonspecific with regard to multiple factors other than their anatomic position within the lung. The chest CT scans of 2 of the 25 age-matched controls revealed a total of only four nodules, a significantly lower total (P = 0.0001 vs. children with HHT). Conclusion Nonspecific nodules are commonly seen in children with HHT.     

Diagnostic accuracy of chest radiography in detecting mediastinal lymphadenopathy in suspected pulmonary tuberculosis

Objective: To estimate the diagnostic accuracy of chest radiography in the detection of chest lymphadenopathy in children with clinically suspected pulmonary tuberculosis. Methods: Design: Prospective cross sectional study. Setting: A short stay ward in a children''s hospital in South Africa. Patients: Consecutive children under 14 years of age admitted with suspected pulmonary tuberculosis. Diagnostic test: Antero-posterior and/or lateral chest x rays interpreted independently and blind to the reference standard by three primary care clinicians and three paediatricians, all with a special interest in tuberculosis. Reference standard: Spiral chest computed tomography (CT) with contrast injection. Results: One hundred children (median age 21.5 months) were enrolled. Lymphadenopathy was present in 46 of 100 reference CT scans and judged to be present in 47.1% of x ray assessments. Overall sensitivity was 67% and specificity 59%. Primary care clinicians were more sensitive (71.5% v 63.3%, p = 0.047) and less specific (49.8% v 68.9%, p<0.001) than paediatricians. Overall accuracy was higher for the paediatricians (diagnostic odds ratio 3.83 v 2.49, p = 0.008). The addition of a lateral to an antero-posterior view did not significantly increase accuracy (diagnostic odds ratio 3.09 v 3.73, p = 0.16). Chance adjusted inter-observer agreement (κ) varied widely between viewer pairs, but was around 30%. Conclusions: Detection of mediastinal lymphadenopathy on chest x ray to diagnose pulmonary tuberculosis in children must be interpreted with caution. Diagnostic accuracy might be improved by refining radiological criteria for lymphadenopathy.