Download Actinomycosis of the Trachea with Acute Tracheal Obstruction

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Brief Reports
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cause of genitourinary infections in adults. J Clin Microbiol 1989;
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Actinomycosis of the Trachea with Acute Tracheal
Obstruction
Actinomycosis is a chronic suppurative infection that often involves the lower face and neck and, less often, the chest and
abdomen. Only eight previous cases oftracheal or laryngeal actinomycosis have been reported in the literature [1]. Lesions in the
larynx are often preliminarily diagnosed as malignancy on the
basis oftheir gross appearance [1]. We describe a case oflaryngeal
actinomycosis that is also the first recorded incidence of acute
tracheal obstruction due to laryngeal infection with Actinomyces
naeslundii.
A 64-year-old man presented to another hospital with a 6-month
history of worsening throat pain and difficulty swallowing. He had
seen his local physician who noted that the pharynx appeared
normal; cultures of pharyngeal specimens did not yield any pathogens. He was treated with severaI2-to-3-week courses of antibiotics without noticeable improvement in his condition. His medical
history was significant for smoking (>45 packs per year), mild
chronic obstructive pulmonary disease, and moderately severe
rheumatoid arthritis that required treatment with prednisone (5 mg
daily).
He was evaluated by an otolaryngologist for persistent throat
pain. An indirect mirror examination revealed marked swelling of
the larynx in the area of the posterior arytenoid cartilage. The
patient was scheduled to undergo a biopsy at another hospital. On
arrival at the hospital he was wheezing, and shortly thereafter he
went into respiratory arrest. Intubation was not possible because
of complete tracheal obstruction, and an emergency tracheostomy
was performed.
Direct laryngoscopy revealed a large circumferential tracheal
ulcer just distal to the larynx with marked swelling and areas of
purulent drainage. Examination of a biopsy specimen of the ulcer
edge demonstrated a fibrinopurulent exudate with aggregates of
filamentous bacteria. Cultures were negative for aerobic bacteria,
viruses, and fungi. The biopsy specimen was not cultured anaerobically. The bacteria observed in the biopsy specimen were interpreted as contaminants. The patient was thought to have a laryngeal
Reprints or correspondence: Dr. Stephen A. Klotz, Department of Medicine,
Veterans Affairs Medical Center, 4801 Linwood Boulevard, Kansas City, Missouri 64128.
Clinitllllnfectious Diseases 1996; 22:1126-7
This article is in the public domain.
em
1996;22 (June)
unusual members of the family Pasteurellaceae isolated from human
sources-phenotypic features and genomic relationships. Int J Med
Microbioll991;275:143-55.
8. King EO. The identification of unusual pathogenic gram negative bacteria.
Atlanta: Centers for Disease Control, 1964.
9. Sakazaki R, Yoshizaki E, Tamura K, Kuramochi S. Increased frequency
of isolation of Pasteurella and Actinobacillus species and related organisms. Eur J Clin MicrobioI1984;3:244-8.
10. Salopatek A. Infected Bartholin abscess caused by HB-5. Can J Moo
Technoll975;37:86-7.
malignancy and began treatment with steroids; the tracheostomy
remained in place.
The patient continued to have throat pain and was referred to
our hospital 2 months later. Examination of a specimen obtained
by a second biopsy demonstrated acute and chronic inflammation
with a fibrinopurulent exudate. Sulfur granules were present in the
inflammatory tissue (figure 1). Gram-positive filamentous bacteria
were also present and had invaded the adjacent cartilage. The
microorganisms also stained well with Grocott-Gomori methenamine-silver nitrate stain. These features are all typical of disease
due to Actinomyces species [2]. Aerobic cultures of the biopsy
tissue did not yield any microorganisms, but the anaerobic culture
yielded A. naeslundii.
The patient was treated with intravenous penicillin G (12 million
units daily) for 3 months followed by another 3 months of therapy
with oral penicillin V (2 g daily). Repeated laryngoscopy demonstrated complete resolution of the lesion, and the tracheostomy
was removed.
Actinomycosis of the larynx or trachea is uncommon, and few
cases have been reported in the literature [1, 3, 4]. Several patients
previously described have developed laryngeal actinomycosis following radiation therapy for carcinoma [3]; the other patients de-
Figure 1. Acute and chronic inflammation with a central sulfur
granule seen in a specimen obtained from the second tracheal biopsy
performed for a patient who had laryngeal actinomycosis with acute
tracheal obstruction. The epithelial lining of the trachea has been
destroyed, and there is destruction of the underlying cartilage. Filamentous structures line the tracheal lumen side ofthe biopsy specimen
(stain, hematoxylin-eosin; original magnification, x 400).
em
1996; 22 (June)
Brief Reports
scribed have presumably been healthy hosts. Our patient had several debilitating diseases and was receiving chronic steroid therapy,
but there was no known local insult to the larynx, history of dental
work, or periodontal disease that would have predisposed him to
actinomycosis.
The results of the first biopsy of our patient's larynx were incorrectly interpreted, possibly because of the rarity of this entity, i.e.,
laryngeal actinomycosis coupled with the presentation of acute
tracheal obstruction. On review of the initial biopsy tissue, it was
apparent that what was believed to be contaminant bacteria at the
other hospital were, in fact, filamentous, gram-positive microorganisms that were compatible with actinomycetes.
A. naeslundii is the third most common cause of actinomycosis.
It is said to form sulfur granules less readily than Actinomyces
israelii, but free filaments of the microorganism are seen in tissue
specimens more often than in specimens from patients infected
with A. israelii [5]. Since actinomycetes are strict anaerobes, the
failure to culture the patient's earlier biopsy specimens for anaerobic bacteria most likely accounted for the failure to isolate the
microorganism.
Intravenous treatment for actinomycosis was continued for 3
months because of the severity of the clinical presentation, the
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presence of a tracheostomy for most of the therapeutic period, and
the concurrent use of prednisone therapy for rheumatoid arthritis
(the effect of this therapy on healing and cure is unknown).
Margaret E. Hagan, Stephen A. Klotz, William
Bartholomew, Rachel Cherian, and Douglas McGregor
Department of Medicine, Veterans Affairs Medical Center, Kansas City,
Missouri, and the Departments of Medicine and Pathology, University
of Kansas School of Medicine, Kansas City. Kansas
References
1. Nelson EG, Tybor AG. Actinomycosis of the larynx. Ear Nose Throat J
1992;71:356-8.
2. Brown JR. Human actinomycosis: a study of 181 subjects. Hum Pathol
1973;4:319-30.
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of the larynx. Auris Nasus Larynx 1991; 18:79-85.
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of the vallecula: report of a case and review of the literature. J Laryngol
Otoll995; 109:154-6.
5. Georg LK. The agents of human actinomycosis. In: Balows A, ed. Anaerobic
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