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Pulmonary Actinomycosis


Presentation

PA follows a chronic course. Patients may present with constitutive symptoms like fatigue, fever, night sweats, loss of appetite and weight. While dyspnea, non-productive cough, and chest pain may indicate a thoracic pathology, these symptoms are neither specific for PA. On the other hand, affected individuals may claim purulent expectoration or hemoptysis. Pus may also be discharged through sinus tracts and typically contains sulphur granules. The most common symptoms are cough, expectoration and chest pain, which are experienced by 71, 55, and 41% of affected individuals, respectively [3].

In recent decades, a general trend towards a less dramatic, even subclinical course of the disease has been observed [4]. Nowadays, the incidental observation of pulmonary shadowing is often the first indicator of lung diseases like PA. Due to limited awareness and because of the disease' epidemiology, physicians frequently misdiagnose PA as malignancy, lung abscess, or tuberculosis [5] [6].

Fever
  • The fever subsided after intravenous augmentin was given, followed by 6 months of oral amoxicillin. The patient is doing well and has had no recurrent hemoptysis.[ncbi.nlm.nih.gov]
  • We report a case of a 47-year-old man with AIDS who presented with fever, cough and a lingular infiltrate.[ncbi.nlm.nih.gov]
  • We report the case of an HIV-seropositive patient with a two-week history of fever, a productive cough, and pleuritic chest pain. Chest x-ray revealed bilateral patchy alveolar infiltrates.[ncbi.nlm.nih.gov]
  • Main symptoms were cough (87.6%), expectoration (40%), blood-stained sputum (37.2%), fever (26.9%), chest pain (24.8%) and haemoptysis (16.6%). Eighty-eight (60.7%) patients had no underlying disease.[ncbi.nlm.nih.gov]
  • ( A78 ) rheumatic fever ( I00 ) schistosomiasis ( B65.0- B65.9 ) Type 1 Excludes candidial pneumonia ( B37.1 ) chlamydial pneumonia ( J16.0 ) gonorrheal pneumonia ( A54.84 ) histoplasmosis pneumonia ( B39.0- B39.2 ) measles pneumonia ( B05.2 ) nocardiosis[icd10data.com]
Sulfur Granules
  • Actinomycosis is a chronic suppurative infection caused by filamentous Gram-positive bacilli, leading to a purulent discharge due to sulfur granule formation.[ncbi.nlm.nih.gov]
  • The nodules included sulfur granules containing Gram-positive branching filamentous organisms consistent with Actinomyces.[ncbi.nlm.nih.gov]
  • The diagnosis was made by skin biopsy, which showed sulfur granules with actinomyces colonies. She was successfully treated with intravenous ceftriaxone and penicillin G for 6 weeks, followed by oral amoxicillin for 6 months.[ncbi.nlm.nih.gov]
  • In addition, biopsies demonstrating branching filamentous forms and "sulfur granules" were found in exudates from the lungs, submandibular region and left quadrants of the oral cavity.[ncbi.nlm.nih.gov]
  • 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.[ncbi.nlm.nih.gov]
Sulfur Granules
  • Actinomycosis is a chronic suppurative infection caused by filamentous Gram-positive bacilli, leading to a purulent discharge due to sulfur granule formation.[ncbi.nlm.nih.gov]
  • The nodules included sulfur granules containing Gram-positive branching filamentous organisms consistent with Actinomyces.[ncbi.nlm.nih.gov]
  • The diagnosis was made by skin biopsy, which showed sulfur granules with actinomyces colonies. She was successfully treated with intravenous ceftriaxone and penicillin G for 6 weeks, followed by oral amoxicillin for 6 months.[ncbi.nlm.nih.gov]
  • In addition, biopsies demonstrating branching filamentous forms and "sulfur granules" were found in exudates from the lungs, submandibular region and left quadrants of the oral cavity.[ncbi.nlm.nih.gov]
  • 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.[ncbi.nlm.nih.gov]
Weight Loss
  • A 64-year-old male patient presented with a productive cough, bloody sputum, and weight loss. Thoracic computed tomography (CT) showed a 5-cm mass in the upper lobe of the right lung, and a 2-cm mass in the lower lobe of the left lung.[ncbi.nlm.nih.gov]
  • Systemic symptoms such as fever and weight loss are suggestive of an infective lesion rather than malignancy. Our patient had suffered from hemoptysis as well as fever but she denied any weight loss or anorexia.[lungindia.com]
  • It usually presents with a history of prolonged use ( 2 years) and symptoms of fever, vaginal discharge, pelvic or abdominal pain, and weight loss.[patient.info]
  • Clinical symptoms at presentation were cough (6), haemoptysis (2), weight loss (2) and septic disease (2). Chest wall infiltration (2) and fistulisation through the chest wall (1) caused severe thoracic pain.[myeventflo.com]
  • loss 18 (36.7) night sweats 12 (24.5) dyspnoea 7 (14.3) haemoptysis 6 (12.2) swelling of chest wall 4 (8.2) no symptoms 3 (6.1) broncholithiasis 1 (2.0) Duration of symptoms (months) 2 [1.25–6] Suspected diagnosis for hospitalization malignancy 24 (49[academic.oup.com]
Malaise
  • Malaise, weight loss, pleuritic chest pain and productive cough: What is your call? CMAJ 2008;178:1289-91. 3. Kim SR, Jung LY, Oh IJ, Kim YC, Shin KC, Lee MK, et al.[lungindia.com]
  • 2000 to 2014 of 28 cases of actinomycosis, the most common symptoms observed were fever in 57%, weight loss and anorexia in 43% and 50% of the cases (73%), expectoration (74%), chest pain (68%), dyspnea (47%), hemoptysis (31%), night sweats (32%) and Malaise[ejbio.imedpub.com]
  • Advanced or disseminated disease can be associated with weight loss, malaise, high fever, and draining sinuses. Actinomycosis can be found in the flora of the oropharynx, especially in dental plaque, and in the GI tract.[ctsnet.org]
  • In a patient known to have pulmonary actinomycocis, marked weight loss, malaise and high fever may be more suggestive of disseminated disease 10 , 11 .[erj.ersjournals.com]
Cough
  • The condition occurred most frequently in middle-aged males, the most common symptom being haemoptysis, followed by cough and sputum.[ncbi.nlm.nih.gov]
  • We report a case of a 47-year-old man with AIDS who presented with fever, cough and a lingular infiltrate.[ncbi.nlm.nih.gov]
  • We report the case of an HIV-seropositive patient with a two-week history of fever, a productive cough, and pleuritic chest pain. Chest x-ray revealed bilateral patchy alveolar infiltrates.[ncbi.nlm.nih.gov]
  • The most common symptoms are cough, expectoration and chest pain, which are experienced by 71, 55, and 41% of affected individuals, respectively.[symptoma.com]
  • The patient was a 56-year-old Japanese woman who aspirated decorative cedar leaves contained in a lunch box while eating a meal, and coughing and bloody phlegm occurred thereafter.[ncbi.nlm.nih.gov]
Hemoptysis
  • The patient is doing well and has had no recurrent hemoptysis.[ncbi.nlm.nih.gov]
  • Surgical intervention may be necessary when frequent hemoptysis has no resolution or lung neoplasm cannot be ruled out.[ncbi.nlm.nih.gov]
  • RESULTS: The data of the study showed that pulmonary actinomycosis occurs frequently in middle to old-aged males (mean age; 57.7 years old) and that the most common symptoms are cough, hemoptysis, and sputum production.[ncbi.nlm.nih.gov]
  • We describe a 53-yr-old male who presented with a hemoptysis and have a lung mass at the left upper lobe on chest radiograph.[ncbi.nlm.nih.gov]
  • Abstract A 51-year-old woman visited our hospital with massive hemoptysis. She had suffered from recurrent hemoptysis for five years and had undergone bronchial artery embolization many times.[e-sciencecentral.org]
Pleural Effusion
  • Accordingly, pleurodesis with minocyclin was undertaken, which was fortunately effective for controlling the pleural effusion.[ncbi.nlm.nih.gov]
  • However, aspiration of pleural effusion revealed that the pulmonary lesion was actinomycosis. We present a case of pulmonary actinomycosis mimicking a lung metastasis from esophageal cancer.[ncbi.nlm.nih.gov]
  • The initial plain chest radiograph and CT scan showed pleural effusion. Gross pus was observed during the thoracentesis and laboratory test of pleural effusion revealed empyema.[kjccm.org]
  • Chest radiograph showed a large right pleural effusion. White blood cell count was 13,800/μL. She was intubated for respiratory failure, and piperacillin/tazobactam and vancomycin were started.[journals.lww.com]
  • A chest radiograph (Figure 2) was obtained and showed hyperinflation with right lung consolidation and pleural effusion.[alliedacademies.org]
Productive Cough
  • We report the case of an HIV-seropositive patient with a two-week history of fever, a productive cough, and pleuritic chest pain. Chest x-ray revealed bilateral patchy alveolar infiltrates.[ncbi.nlm.nih.gov]
  • A 64-year-old male patient presented with a productive cough, bloody sputum, and weight loss. Thoracic computed tomography (CT) showed a 5-cm mass in the upper lobe of the right lung, and a 2-cm mass in the lower lobe of the left lung.[ncbi.nlm.nih.gov]
  • He had productive cough for 40 days. Bronchoscopy was normal. Cmputed tomography revealed a solid large mass in the upper lobe of his left lung with mimicking malignant leisions. He was referred for surgery and underwent left upper lobectomy.[ijms.sums.ac.ir]
  • While dyspnea, non-productive cough, and chest pain may indicate a thoracic pathology, these symptoms are neither specific for PA. On the other hand, affected individuals may claim purulent expectoration or hemoptysis.[symptoma.com]
  • Eleven years prior to presentation she developed a chronic productive cough.[rc.rcjournal.com]
Sputum Production
  • RESULTS: The data of the study showed that pulmonary actinomycosis occurs frequently in middle to old-aged males (mean age; 57.7 years old) and that the most common symptoms are cough, hemoptysis, and sputum production.[ncbi.nlm.nih.gov]
  • The infection presents with slowly progressive non-specific symptoms such as cough, sputum production, breathing difficulties, and chest pain.[dermnetnz.org]
  • Case Report A 61-year-old white female presented to the emergency department with weakness, fatigue, increased sputum production, and a 4-month history of hemoptysis.[rc.rcjournal.com]
  • The most common symptoms were cough (n   62), followed by sputum production (n   54) and hemoptysis (n   40). Massive hemoptysis defined as   200 mL/day occurred in 9 (13.2%) patients.[bmcinfectdis.biomedcentral.com]
Chest Pain
  • We report the case of an HIV-seropositive patient with a two-week history of fever, a productive cough, and pleuritic chest pain. Chest x-ray revealed bilateral patchy alveolar infiltrates.[ncbi.nlm.nih.gov]
  • The most common symptoms are cough, expectoration and chest pain, which are experienced by 71, 55, and 41% of affected individuals, respectively.[symptoma.com]
  • Main symptoms were cough (87.6%), expectoration (40%), blood-stained sputum (37.2%), fever (26.9%), chest pain (24.8%) and haemoptysis (16.6%). Eighty-eight (60.7%) patients had no underlying disease.[ncbi.nlm.nih.gov]
  • The most common symptoms are chest pain, productive cough, and dyspnea.[cjhr.org]
  • Case : A 22-year old woman reported left anterior chest pain and fever since February 1999. Chest X-ray and chest computed tomography (CT) scan showed an infiltrative shadow and pleural effusion due to pneumonia with pleuritis.[jstage.jst.go.jp]
Night Sweats
  • Patients may present with constitutive symptoms like fatigue, fever, night sweats, loss of appetite and weight. While dyspnea, non-productive cough, and chest pain may indicate a thoracic pathology, these symptoms are neither specific for PA.[symptoma.com]
  • sweats 12 (24.5) dyspnoea 7 (14.3) haemoptysis 6 (12.2) swelling of chest wall 4 (8.2) no symptoms 3 (6.1) broncholithiasis 1 (2.0) Duration of symptoms (months) 2 [1.25–6] Suspected diagnosis for hospitalization malignancy 24 (49) tuberculosis 7 (14.3[academic.oup.com]
  • Symptoms may include any of the following: Chest pain when taking a deep breath Cough with phlegm (sputum) Fever Lethargy Night sweats Shortness of breath Unintentional weight loss The goal of treatment is to cure the infection.[medlineplus.gov]
  • Common signs include: fever fatigue shortness of breath weight loss chest pain when inhaling deeply night sweats appetite loss a cough with phlegm that might contain blood Without treatment, pulmonary actinomycosis can permanently injure parts of your[healthline.com]
  • These may include: Chest pain, which increases on taking deep breaths Cough, which may be associated with phlegm (phlegm may contain blood) Dry cough possibly with blood Fever and night sweats Loss of appetite; loss of weight Breathlessness Fatigue How[dovemed.com]
Altered Mental Status
  • An 84-year-old woman was admitted for respiratory distress and altered mental status. She had a history of hypertension and diabetes mellitus for 30 years.[journals.lww.com]

Workup

As has been implied above, thoracic imaging often reveals first evidence of a pulmonary mass consistent with PA. Both plain radiography and computed tomography scans may allow to assess the extension of the disease. Images most commonly comprise hyperdense regions corresponding to areas of air-space consolidation [7]. The detection of central cavitation and satellite nodules as well as peripheral enhancement due to fibrotic demarcation may aid to distinguish PA from lung cancer [8]. Additional, yet non-specific findings comprise hilar or mediastinal lymphadenopathy, bronchiectasis within the consolidated area, pleural thickening and pleural effusion. Although further clarification may be achieved performing bronchoscopy, only the isolation of Actinomyces spp. from otherwise sterile sites is diagnostic of actinomycosis. In order to do so, tissue samples have to be obtained by means of lung biopsy. This procedure is generally performed percutaneously under ultrasound or computed-tomography guidance, but may also be realized during open surgery. There is little consensus regarding the usability of transbroncheal biopsy samples for bacteriological testing [4] [1]. Obtained specimens should not only be subjected to bacteriological analysis, but also be evaluated histopathologically to rule out neoplasms. Of note, the bacteriological examination of sputum is a poorly sensitive measure since positive results may result from the mere colonization of mucous membranes by Actinomyces spp. [9].

Laboratory analyses of blood samples should be carried out to evaluate the overall condition of the patient. PA is generally associated with mild leukocytosis and anemia as well as mild to moderate enhancement of acute phase parameters [10].

Atelectasis
  • 2 (4.1) abscess 2 (4.1) bronchiectasis 2 (4.1) other 6 (12.2) actinomycosis 1 (2.0) Findings of imaging peripheral mass/infiltrate 26 (53.1) abscess/infected cavity 12 (24.5) endobronchial manifestation 4 (8.2) central mass with atelectasis 3 (6.1) multilocular[academic.oup.com]
  • Chest computed tomography shows a thickened bronchial wall, dense pulmonary alveolar opacity, atelectasis, pleural effusion, bronchiectasis, lymphadenopathy, or a radiopaque foreign body.[e-sciencecentral.org]
  • MRI: infiltration of pericardium, intercostal and pectoral muscles, atelectasis. 33 Yeung VH 25/M/12 - - X-ray consolidation, collapse.[alliedacademies.org]
  • […] lymphadenopathy ( Fig. 1 ), near-complete consolidation of the right lower lobe, with cavitation and necrosis, tubular bronchiectasis in the right lower lobe ( Fig. 2 ), an enlarged (short axis 14 mm) lymph node anterior to the superior vena cava, and atelectasis[rc.rcjournal.com]
  • ., is aspirated into a minor bronchus, causing atelectasis and a pneumonitis.[erj.ersjournals.com]
Pericardial Effusion
  • Culture of the bloody pericardial effusion resulted in positive growth of Actinomyces israeli. He was successfully treated with penicillin G, ampicillin, and minocyclin. However, right pleural effusion appeared two months later.[ncbi.nlm.nih.gov]
  • Very occasionally, pericardial effusion results from pericardial involvement or pericarditis 52 , 53 .[erj.ersjournals.com]
Pericardial Effusion
  • Culture of the bloody pericardial effusion resulted in positive growth of Actinomyces israeli. He was successfully treated with penicillin G, ampicillin, and minocyclin. However, right pleural effusion appeared two months later.[ncbi.nlm.nih.gov]
  • Very occasionally, pericardial effusion results from pericardial involvement or pericarditis 52 , 53 .[erj.ersjournals.com]
Cavitary Lesion
  • Three cases of primary pulmonary actinomycosis are presented showing three different pulmonary forms of the disease and comprising (a) subacute patchy pulmonary infiltrates, (b) a cavitary lesion simulating tuberculosis, and (c) a central mass lesion[ncbi.nlm.nih.gov]
  • Three cases of primary pulmonary actinomycosis are presented showing three different pulmonary forms of the disease and comprising ( a ) subacute patchy pulmonary infiltrates, ( b ) a cavitary lesion simulating'tuberculosis, and ( c ) a central mass lesion[pubs.rsna.org]
Cavitary Lesion
  • Three cases of primary pulmonary actinomycosis are presented showing three different pulmonary forms of the disease and comprising (a) subacute patchy pulmonary infiltrates, (b) a cavitary lesion simulating tuberculosis, and (c) a central mass lesion[ncbi.nlm.nih.gov]
  • Three cases of primary pulmonary actinomycosis are presented showing three different pulmonary forms of the disease and comprising ( a ) subacute patchy pulmonary infiltrates, ( b ) a cavitary lesion simulating'tuberculosis, and ( c ) a central mass lesion[pubs.rsna.org]
Pleural Effusion
  • Accordingly, pleurodesis with minocyclin was undertaken, which was fortunately effective for controlling the pleural effusion.[ncbi.nlm.nih.gov]
  • However, aspiration of pleural effusion revealed that the pulmonary lesion was actinomycosis. We present a case of pulmonary actinomycosis mimicking a lung metastasis from esophageal cancer.[ncbi.nlm.nih.gov]
  • The initial plain chest radiograph and CT scan showed pleural effusion. Gross pus was observed during the thoracentesis and laboratory test of pleural effusion revealed empyema.[kjccm.org]
  • Chest radiograph showed a large right pleural effusion. White blood cell count was 13,800/μL. She was intubated for respiratory failure, and piperacillin/tazobactam and vancomycin were started.[journals.lww.com]
  • A chest radiograph (Figure 2) was obtained and showed hyperinflation with right lung consolidation and pleural effusion.[alliedacademies.org]

Treatment

  • CONCLUSIONS: Antibiotic treatment with or without surgery was effective for treatment of pulmonary actinomycosis.[ncbi.nlm.nih.gov]
  • Seven patients showed a very good clinical and radiographic response as well as bronchoscopically-documented treatment success. Treatment failed in one patient.[ncbi.nlm.nih.gov]
  • As a consequence, the infection may progress to stages which will not respond to medical treatment alone. Surgery then provides the best method to achieve diagnosis and ultimate treatment.[ncbi.nlm.nih.gov]
  • Penicillin G is the standard treatment. The optimal duration of antibiotic treatment merits further investigation.[ncbi.nlm.nih.gov]
  • Here, surgery in combination with medical treatment offered reliably excellent results.[ncbi.nlm.nih.gov]

Prognosis

  • Consequently, the optimal therapeutic regimen, appropriate duration of treatment, long-term prognosis, and factors predicting prognosis are not well established.[ncbi.nlm.nih.gov]
  • This will expedite the diagnosis of an otherwise highly treatable condition with an excellent prognosis if picked up early.[ncbi.nlm.nih.gov]
  • Overall, 110 (75.9%) patients were fully cured, 4 died, 1 was lost to follow-up, and a record of the prognosis was not available for 30 patients. Mean duration of follow-up was 26 months ( 32).[ncbi.nlm.nih.gov]
  • […] characteristics, clinical symptoms, underlying diseases, diagnostic methods, pulmonary function test results, chest computed tomography (CT) tests, fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) tests, initial diagnosis, treatment and prognosis[ncbi.nlm.nih.gov]

Etiology

  • Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology.[icd10coded.com]
  • The finding of Actinomyces throughout the broncholith is strong evidence that the etiology of the broncholithiasis was a primary pulmonary Actinomyces infection.[ncbi.nlm.nih.gov]
  • Although the etiology of PCG is still controversial, many findings have lent support to the lesion being a reactive inflammatory process rather than a neoplastic one.[ncbi.nlm.nih.gov]
  • Pulmonary actinomycosis (PA) is a rare infectious disease whose etiological agents pertain to the genus Actinomyces.[symptoma.com]
  • Actinomycosis: etiology, clinical features, diagnosis, treatment, and management. Infect Drug Resist. 2014; 5, 7: 183–97. .... 2. Kim SR, Jung LY, Oh IJ, Kim YC, Shin KC, Lee MK, et al.[aaem.pl]

Epidemiology

  • Due to limited awareness and because of the disease' epidemiology, physicians frequently misdiagnose PA as malignancy, lung abscess, or tuberculosis.[symptoma.com]
  • […] and pathogenesis No data are available on the epidemiology of extrafacial bone and joint actinomycosis.[dovepress.com]
  • Epidemiology [ 1 ] Actinomycosis is rare.[patient.info]
  • Epidemiology Frequency United States Actinomycosis is rare. During the 1970s, the reported annual incidence of actinomycosis in the Cleveland area was 1 case per 300,000 persons.[emedicine.medscape.com]
  • The epidemiological, clinical, diagnostic and therapeutic characteristics of the disease are reviewed here.[erj.ersjournals.com]
Sex distribution
Age distribution

Pathophysiology

  • Pathophysiology Actinomycetes are prominent among the normal flora of the oral cavity but less prominent in the lower gastrointestinal tract and female genital tract.[emedicine.medscape.com]
  • Consequently, actinomycosis is mainly considered an endogenous infection that is triggered by a mucosal lesion. 1 – 3 The pathophysiology of invasive disease following oral mucosal breach is unknown, but the invariably co-isolated commensals, such as[dovepress.com]

Prevention

  • An early, accurate diagnosis will prevent the considerable psychological and physical morbidity, including unwarranted surgery, associated with delayed diagnosis.[ncbi.nlm.nih.gov]
  • To prevent instrumentation failure, an external immobilization (halo fixation) was applied until complete fusion was documented in CT during the postoperative course.[ncbi.nlm.nih.gov]
  • […] or swelling in your tummy, pus leaking from small holes in your skin Pelvis: leaving an IUD contraceptive coil in for too long pain low down in your tummy, vaginal bleeding or unusual discharge, a lump or swelling in your lower tummy You can't always prevent[nhs.uk]
  • This helps prevent bacteria from overgrowing and spreading to other parts of your body. To do this: Brush and floss your teeth twice a day. Get regular dental cleanings and exams. Eat fewer sugary foods.[healthline.com]

Summary

Pulmonary actinomycosis (PA) is a rare infectious disease whose etiological agents pertain to the genus Actinomyces. The most common species to cause the disease is Actinomyces israelii [1], but a variety of other representatives of this genus have also been associated with the disease. Actinomyces spp. form part of the commensal flora of the oropharynx, gastrointestinal and urogenital tract, and causative pathogens reach the respiratory tract upon the aspiration of oropharyngeal or gastrointestinal secretions [2]. Tobacco consumption, alcohol abuse, a poor oral hygiene as well as underlying respiratory disorders predispose for PA [3].

Affected individuals may present non-specific respiratory and general symptoms that may mimic more severe diseases like cancer and tuberculosis. However, PA patients respond well to treatment with penicillin. The antibiotic is generally given over the course of two weeks and causes a rapid improvement of the patient's condition.

References

Article

  1. Kim SR, Jung LY, Oh IJ, et al. Pulmonary actinomycosis during the first decade of 21st century: cases of 94 patients. BMC Infect Dis. 2013; 13:216.
  2. Valour F, Senechal A, Dupieux C, et al. Actinomycosis: etiology, clinical features, diagnosis, treatment, and management. Infect Drug Resist. 2014; 7:183-197.
  3. Kolditz M, Bickhardt J, Matthiessen W, Holotiuk O, Hoffken G, Koschel D. Medical management of pulmonary actinomycosis: data from 49 consecutive cases. J Antimicrob Chemother. 2009; 63(4):839-841.
  4. Mabeza GF, Macfarlane J. Pulmonary actinomycosis. Eur Respir J. 2003; 21(3):545-551.
  5. Elkambergy H, Irani F, Okoli K, Jamal R. Pulmonary actinomycosis: the great masquerader. BMJ Case Rep. 2009; 2009.
  6. Varshney MK, Trikha V, Khan SA. Actinomycosis or tuberculosis? A diagnostic dilemma. Scand J Infect Dis. 2006; 38(5):378-381.
  7. Farrokh D, Rezaitalab F, Bakhshoudeh B. Pulmonary actinomycosis with endobronchial involvement: a case report and literature review. Tanaffos. 2014; 13(1):52-56.
  8. Lee IJ, Henschke CI. Diagnostic differences between pulmonary actinomycosis and lung adenocarcinoma. Onkologie. 2012; 35(10):553-554.
  9. Katsenos S, Galinos I, Styliara P, Galanopoulou N, Psathakis K. Primary Bronchopulmonary Actinomycosis Masquerading as Lung Cancer: Apropos of Two Cases and Literature Review. Case Rep Infect Dis. 2015; 2015:609637.
  10. Ferreira HP, Araujo CA, Cavalcanti JF, Miranda RL, Ramalho Rde A. Pulmonary actinomycosis as a pseudotumor: a rare presentation. J Bras Pneumol. 2011; 37(5):689-693.

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Last updated: 2019-07-11 20:43