Scandinavian Journal of Infectious Diseases

ISSN: 0036-5548 (Print) 1651-1980 (Online) Journal homepage: http://www.tandfonline.com/loi/infd19

Aggregatibacter actinomycetemcomitans infection mimicking lung cancer: A case report Melissa Matzumura-Kuan & Jeffrey Jennings To cite this article: Melissa Matzumura-Kuan & Jeffrey Jennings (2014) Aggregatibacter actinomycetemcomitans infection mimicking lung cancer: A case report, Scandinavian Journal of Infectious Diseases, 46:9, 669-672 To link to this article: http://dx.doi.org/10.3109/00365548.2014.920104

Published online: 09 Jun 2014.

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Date: 12 November 2015, At: 01:40

Scandinavian Journal of Infectious Diseases, 2014; 46: 669–672

CASE REPORT

Aggregatibacter actinomycetemcomitans infection mimicking lung cancer: A case report

MELISSA MATZUMURA-KUAN1 & JEFFREY JENNINGS2

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From the 1Department of Internal Medicine, and 2Department of Pulmonary and Critical Care, Henry Ford Hospital, Detroit, Michigan, USA

Abstract Pulmonary infections can mimic a pulmonary neoplasm. Multiple organisms, including bacteria, viruses, and fungi, can present with similar clinical, radiographic, and surgical findings as neoplastic processes. Because treatment and the prognosis are completely different, an accurate diagnosis is crucial, and lung biopsy is usually required. Aggregatibacter actinomycetemcomitans is part of the normal oral flora and is a rare cause of invasive infection due to hematogenous dissemination or aspiration, particularly infective endocarditis. We present a case of A. actinomycetemcomitans and Actinomyces co-infection that presented as a mediastinal mass, with surgical findings similar to lung malignancy but with biopsy and culture showing an infectious origin. After antibiotic treatment, follow-up images showed resolution of the mass.

Keywords: Aggregatibacter actinomycetemcomitans, lung, infection, mimic, cancer

Introduction Pulmonary infections, especially those that are chronic, can occasionally be difficult to differentiate from cancer. Both entities can present with nonspecific symptoms such as cough and chest pain. In addition, radiographic findings of infectious processes occasionally present as a mass. Aggregatibacter (formerly Actinobacillus) actinomycetemcomitans is a common oral commensal organism, but can also become pathogenic, causing chronic periodontitis, soft tissue abscesses, and endocarditis. Pulmonary involvement is a less frequent complication and may become a diagnostic challenge, as atypical presentations may mimic a neoplastic process [1]. We present a case of A. actinomycetemcomitans and Actinomyces co-infection masquerading as a lung cancer.

Case report A 47-y-old African American male with a 20 pack-y smoking history and no other pertinent medical or surgical history, presented with 5 days of produc-

tive cough, subjective fever, non-radiating sharp chest pain, and moderate dyspnea on exertion. Physical examination revealed a temperature of 36.8°C, a heart rate of 99 beats/min, a respiratory rate of 20 breaths/min, and a blood pressure of 145/80 mmHg. He was noted to have poor dentition with multiple pieces of teeth missing. The remainder of the examination was unremarkable, including normal lung auscultation and absence of cervical lymphadenopathy. Laboratory studies showed a white blood cell count of 17.1 ⫻ 109, hemoglobin 12.4 g/l, C-reactive protein of 11.4 mg/dl, and erythrocyte sedimentation rate of 105 mm/h. The rest of the studies were within normal limits, including a non-reactive HIV test. Chest X-ray was normal; however, chest computed tomography showed a right anterior mediastinal mass without lymphadenopathy (Figure 1). The patient underwent fine needle aspiration of the mass, but the sample was insufficient for tissue diagnosis (small fragments of fibrocollagenous tissue with mixed inflammatory infiltrate rich in plasma cells, lymphocytes, and few eosinophils) and the culture was pending.

Correspondence: M. Matzumura-Kuan, Department of Internal Medicine, Henry Ford Hospital, 2799 West Grand Blvd, CFP 1, Detroit, MI 48202, USA. Tel: ⫹ 1 313 916 1888. E-mail: [email protected] (Received 6 April 2014 ; accepted 23 April 2014 ) ISSN 0036-5548 print/ISSN 1651-1980 online © 2014 Informa Healthcare DOI: 10.3109/00365548.2014.920104

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Figure 1. Contrast-enhanced thoracic computed tomography. (A) Right anterior speculated mediastinal mass without lymphadenopathy suspicious for malignancy. (B) Follow-up contrast-enhanced thoracic computed tomography showing resolution of the anterior mediastinal mass after 2 months of antibiotic treatment.

He subsequently underwent a right thoracoscopy. Surgical findings showed dense adhesion of the medial aspect of the right upper lobe to the posterior sternum and mediastinum in the apex and clear infiltration of the right upper lobe into the mediastinum. The frozen biopsy of the mediastinal mass was interpreted as being positive for adenocarcinoma. Because of the mediastinal invasion, the intra-surgical diagnosis was a T4 tumor that was eroding well into the mediastinum. However, final pathology showed a Gram-positive filamentous Actinomyces species (sulfur granules) and associated reactive changes. Malignancy was not seen on extensive histological evaluation of the mass-like area. Subsequently, the initial fine needle aspiration culture became positive for A. actinomycetemcomitans. The patient was discharged on penicillin G 24 million units for 6 weeks of treatment, followed by 6 months of oral penicillin. A follow-up computed tomography 2 months after treatment showed complete resolution of the right anterior consolidation. Discussion To our knowledge, only 1 published case report exists of A. actinomycetemcomitans–Actinomyces-associated lymphadenopathy mimicking lymphoma [1]. This is the first report of pulmonary co-infection with A. actinomycetemcomitans and Actinomyces presenting as an invasive lung cancer. Thoracic actinomycosis is uncommon and typically presents as a slow-growing pulmonary or mediastinal mass-like lesion [2], oftentimes with pleural and chest wall involvement. The organism commonly resides in gingival and subgingival crevices, and progression of the disease can involve both lymphatic and blood spread [1,3]. Patients usually have poor dentition with infectious progression secondary to aspiration of oral saphrophytes. The diagnosis can be

difficult, as these patients oftentimes also have risk factors for lung cancer. Mediastinal involvement is probably the result of direct extension from the lung [2,4]. The typical radiographic features are chronic airspace disease, cavitation, and fibrosis associated with mediastinal or hilar adenopathy, which can also be seen with lung cancer [2,3]. Amrikachi et al. [1] reported 2 cases of extensive reactive lymphadenopathy secondary to Actinomyces infection, 1 of them associated with A. actinomycetemcomitans. Similar to our case, both patients had a significant tobacco history and poor dentition. Although the specific pathophysiology is unknown, it is thought that invasive A. actinomycetemcomitans is acquired by translocation from oral mucosa to blood and increases the low invasive property of Actinomyces. The patient reported by Amrikachi et al. had respiratory symptoms for 6 months and the lymphadenopathy involvement was more extensive, which is in contrast to our patient who presented with acute symptoms and only mediastinum involvement. The antibiotic of choice in both cases was penicillin, with resolution of the symptoms. The isolation of A. actinomycetemcomitans can be difficult because of its slow growth, and culture is often discarded before bacteria are isolated [5–8]. A. actinomycetemcomitans shares similar characteristics with other members of HACEK (Haemophilus aphrophilus, Haemophilus paraphrophilus, Haemophilus parainfluenzae, A. actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae) [7,8]. It usually grows in trypticase soy–serum–bacitracin–vancomycin agar. Differentiation of A. actinomycetemcomitans and Haemophilus species can be done by fermentation of sucrose and lactose; however this process is time-consuming and sometimes inaccurate. The best method to identify this species is the arbitrarily primed polymerase chain reaction (AP-PCR);

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Pulmonary infection mimicking lung cancer alternatively Rapid NH and API ZYM systems can be used. Of the latter 2 systems, the first detects bacterial enzymes and has poor capacity to identify A. actinomycetemcomitans, and the second detects enzymatic reactions and cannot differentiate A. actinomycetemcomitans serotypes [9]. Similar to our case, the patient reported by Amrikachi et al. had a positive clinical response to penicillin [1]. However, in vitro susceptibility is extremely important because there is no standard optimal antibiotic treatment recommendation for A. actinomycetemcomitans due to different in vitro and in vivo susceptibility [1]. A. actinomycetemcomitans is usually susceptible to cephalosporin, rifampicin, chloramphenicol, aminoglycosides, fluoroquinolones, and tetracycline. Susceptibility to ampicillin and penicillin is variable, but it is often resistant to vancomycin, erythromycin, and clindamycin [1,10–12]. The duration of treatment depends on clinical response. Clinical and radiographic characteristics of pulmonary malignancies are usually such that distinguishing between cancer and infection is straightforward. Nevertheless, infectious processes can present in a manner that mimics malignancy. In both processes the patient may present similarly, with cough, hemoptysis, weight loss, and fever [1,3,4,10,11]. Although an infectious process can present as a solitary nodule rather than the typical consolidation [10], there are radiological features that are highly suggestive of a neoplastic process (spiculated margins, thick-walled cavity, and chest wall invasion). Despite such findings, a definitive diagnosis ultimately requires tissue sampling. The infrequency of infection as the cause of a presumed lung malignancy was further illustrated in a retrospective study by Rolston et al. Of the patients referred to their center to rule out presumed lung cancer, only 1.3% ultimately had an infectious process [10]. Of these, over two-thirds were either fungal or mycobacterial. Typical bacterial infections are even less likely to mimic a typical lung cancer lesion. Wu et al. [4] reported a high percentage of viridans streptococci and Neisseria spp. in their specimens, but these patients had presented with masses that had characteristics of organizing pneumonia. Round pneumonia, specifically attributed to Streptococcus pneumoniae, can also be confused with cancer when present in adults with risk factors for it [12]. Other infections that can be easily confused with cancer include tuberculosis [3,13], cytomegalovirus [14], cryptococcosis [15], histoplasmosis [16], and aspergillosis [17]. Symptoms and images of infectious and neoplastic lung processes can overlap, and both processes can even co-exist. Taking a good history and looking

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for risk factors for these processes may help in the differential diagnosis process; however, patients may not have particular risk factors, and signs and symptoms can be unspecific. Thus, in the setting of lung masses, a malignancy process is the top of the differential diagnosis because of its outcome; however, an infectious process, including atypical organisms, must be part of the differential workup, despite the immune state or imaging findings. An appropriate diagnosis is fundamental for prognosis and treatment. This differentiation could be challenging, and biopsy is oftentimes required for a definitive diagnosis. The results of fine needle aspiration biopsy are frequently inconclusive and patients undergo surgical biopsy, which can be diagnostic and also curative. However, before unnecessary surgical procedures, it is important to complete the work-up for typical and atypical infectious processes, because these usually do not need surgery. For example, in our patient, because of poor dental hygiene and lymphadenopathy, A. actinomycetemcomitans should have been part of the differential diagnosis. Declaration of interest: The authors declare that there are no conflicts of interest. There were no sources of funding for this work. There are no financial disclosures.

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Aggregatibacter actinomycetemcomitans infection mimicking lung cancer: a case report.

Pulmonary infections can mimic a pulmonary neoplasm. Multiple organisms, including bacteria, viruses, and fungi, can present with similar clinical, ra...
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