Archivos de Bronconeumología (English Edition) Archivos de Bronconeumología (English Edition)
Arch Bronconeumol 2017;53:274-6 - Vol. 53 Num.5 DOI: 10.1016/j.arbr.2017.03.014
Scientific Letter
Actinomyces Meyeri Empyema
Empiema por Actinomyces meyeri
Lucía Ferreiroa,b,, , María Luisa Pérez del Molinoc, Carlos Rábadea, Luis Valdésa,b
a Servicio de Neumología, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
b Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, Spain
c Servicio de Microbiología, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
To the Editor,

Actinomycosis is a chronic infection caused by gram-positive anaerobic bacteria of the Actinomyces genus that are normally saprophytic colonizers of the oral cavity and gastrointestinal and urogenital tracts. Dissemination is generally hematogenous.1 Unlike other Actinomyces species, Actinomyces meyeri (A. meyeri) can cause lung infections, although empyema caused by this strain is very rare. Actinomycosis is characterized by the development of fistulae in affected tissues and suppuration containing sulfur granules, and it is technically difficult to culture.

We report a case of empyema caused by A. meyeri recently treated in our hospital. Our patient was a 62-year-old man, smoker of 40 pack-years and alcohol consumption of 18 units/day, with severe neurosensory hypoacusia resulting from meningitis in his adolescence. He presented in the emergency department of our hospital with a 3-week history of left pleuritic pain, non-productive cough, a sensation of dysthermia, and unexplained weight loss. He was hemodynamically stable and afebrile, with normal breathing in room air. Physical examination revealed halitosis due to septic mouth with several missing teeth, reduced vocal fremitus throughout the left hemithorax and dullness on percussion, and hepatomegaly of 2 finger breadths.

Clinical laboratory tests showed: red blood cells 3.77×106/μL, hemoglobin 11.5g/dl, hematocrit 33.9%, MCV 100, leucocytes 8.87×103/μL (85% neutrophils), sedimentation rate 120, total bilirubin 2.4mg/dl (direct 1.9mg/dl), GOT 114IU/l, GPT 129IU/l, GGT 280UI/l and alkaline phosphatase 245IU/l. Arterial blood gases (room air): pH 7.51, pCO2 33.1mmHg, pO2 69.5mmHg. Chest radiograph showed an apparently homogeneous increase in density occupying most of the left hemithorax, with a well-defined, convex upper border, that did not move when the patient was placed in lateral decubitus. Abundant left hyperechogenic pleural effusion with internal septa was observed on chest ultrasonography. Purulent fluid was obtained by thoracocentesis, showing pH 6.80, leukocytes 173×103/μL (75% neutrophils), glucose 15mg/dl, LDH 20,000UI/l, proteins 4.7g/dl, C-reactive protein 9.88mg/dl, procalcitonin <0.020ng/mL, interleukin-6 152,525pg/ml and adenosine deaminase 227U/l. A diagnosis of empyema was reached, and empirical antibiotic treatment began with i.v. amoxicillin/clavulanic acid 2g every 8h, chest tube (16F; 9 days), and intrapleural urokinase (100,000IU/day, 3 days). Progress was favorable. Blood cultures were negative. Culture of pleural fluid for mycobacteria was negative, and anaerobic culture for A. meyeri was positive.

Two months later, the patient remains asymptomatic, and continues to receive oral amoxicillin (500mg/8h). Chest computed tomography shows pleural thickening throughout the lateral and posterior region of the left hemithorax with a minimum amount of associated pleural fluid.

Pleural infection with A. meyeri is very rare, and to date, only 12 cases have been published in the literature (Table 1).2–12 Poor oral hygiene and alcoholism, as presented by our patient, are predisposing factors, since the bacteria reaches the pulmonary parenchyma via aspiration from the oral cavity. The pleura becomes involved either from contiguity or hematogenous dissemination.1,13 Patients are usually men (11/13 cases; 84.6%), over 40 years of age (12/13; 92.3%), other organs in addition to the pleura may be involved (generally the lung), and fistulization may occur. Pleural fluid shows typical features of empyema: high LDH and leukocyte values (generally neutrophils), and low pH and glucose. Some cases may also involve high levels of adenosine deaminase and low proteins.14

Table 1.

Cases of Pleural Empyema Caused by Actinomyces Meyeri Described in the Literature.

Author (ref.)  Sex/Age (Years)  Risk Factor  Clinical Presentation  AB therapy  AB duration (Months)  CT  UK  Leuk. PF (cell)/seg (%)  pH  Glucose (mg/dl)  LDH (IU/l)  ADA (U/l)  Prot. (g/dl)  Progress 
Rose et al.2  M/49  Alcoholism, poor oral hygiene  Empyema
Pneumonia
Bronchopleural fistula
Osteomyelitis (sternum) 
Penicillin G/clindamycin/tetracycline  6 months (until death)  Yes                Death 
  M/62  Alcoholism, poor oral hygiene  Empyema
Pneumonia
Subcutaneous abscess left hip 
Penicillin G/amoxicillin  12 months  Yes                NS 
Lentino et al.3  M/16  NS  Empyema
Bone marrow 
Clindamycin  6 months  Yes/thoracotomy (decortication)    141×103/83            Favorable 
Alemanni et al.4  M/58  Alcoholism, poor oral hygiene  Empyema
Muscle abscess 
Penicillin G  NS  NS                Probably favorable 
Del Castillo et al.5  M/61  Poor oral hygiene  Empyema  Penicillin G/amoxicillin  4 months  No    1×106/100  6.34  14  1367  74  5.1  Favorable
Pleural thickening 
Vallet et al.6  F/64  Alcoholism  Empyema
Pleural-subcutaneous fistula 
Penicillin  6 months  Yes/thoracotomy (decortication)                Favorable
Pleural thickening 
Fazili et al.7  M/45  Poor oral hygiene  Empyema
Pneumonia 
Penicillin G  12 months  Yes/thoracotomy (decortication)                Lost-to-follow-up 
Porcel et al.8  M/49  Alcoholism  Empyema
Pneumonia 
Clindamycin/doxycycline  6 months  Yes  Yes  160×109/neutroph  6.82  17,700  0.3  2.4  Favorable 
Attaway et al.9  M/61  Alcoholism, poor oral hygiene  Empyema
Pneumonia
Lumpy jaw 
Ampicillin/penicillin G/doxycycline  6 months  Thoracotomy (decortication)                NS 
Alonso et al.,10a  F/83  Dental abscess  Empyema  Imipenem/doxycycline  6 months  Yes    649×103/neutroph  16,300    1.2   
Jung et al.11  M/49  Alcoholism  Empyema
Pneumonia 
Penicillin G/amoxicillin  4 months  Yes    56×103/89      20,530    Favorable 
Sander et al.12  M/84    Empyema
Pneumonia 
Amoxicillin/clavulanic acid  3 months  Yes  Yes  9.6×103/36  6.80  5560  117    Favorable 
Our case  M/62  Alcoholism, poor oral hygiene  Empyema  Amoxicillin/clavulanic acid  2 monthsb  Yes  Yes  173×103/75  6.80  15  20,000  227  4.7  Favorableb
Pleural thickening 

AB: antibiotic; ADA: adenosine deaminase; CT: chest tube; M: male; LDH: lactate dehydrogenase; Leuk.: leukocytes; PF: pleural fluid; F: female; NS: not specified; Prot.: proteins; ref: reference; UK: urokinase.

a

Actinomyces spp.

b

Treatment ongoing.

The disease may coexist with lung cancer, since A. meyeri tends to colonize the necrotic tissue that often occurs with malignancy.15 In the absence of characteristic sulfur granules in pus from the infected tissue, isolation in sputum can be a sign of simple colonization. In such cases, isolation of A. meyeri is of little diagnostic interest. In contrast, A. meyeri cultured in pleural fluid is the basis for the diagnosis of infection, and care should be taken to use appropriate anaerobic media. Treatment of choice is amoxicillin/clavulanic acid or penicillin G sodium (administered intravenously for 2–6 weeks, followed by oral amoxicillin for 6–12 months), depending on clinical and radiological progress. Other alternatives are clindamycin, doxycycline or erythromycin, if the patient has penicillin allergy or intolerance.7 A chest tube and intrapleural fibrinolytics are generally required, and occasionally pleural decortication can be a last resort.14 Progress is usually favorable, although one case of death has been reported.2 Residual diffuse pleural fibrosis is a possible sequela. Our patient has only been receiving treatment for 2 months, but his clinical response appears to be favorable, pending evaluation of the possible sequela of his residual left pleural thickening with lung function testing.

The take-home message from this case is that when faced with slow-progressing pleural effusion that does not respond to standard antibiotics in a patient with known risk factors, cultures in the appropriate media should be performed to rule out empyema caused by A. meyeri.

Authors’ contribution

Lucía Ferreiro: author and writer. Concept and design. Final approval of the manuscript.

María Luisa Pérez del Molino: co-author. Final approval of the manuscript.

Carlos Rábade: co-author. Final approval of the manuscript.

Luis Valdés: author and writer. Concept and design. Final approval of the manuscript.

References
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Please cite this article as: Ferreiro L, Pérez del Molino ML, Rábade C, Valdés L. Empiema por Actinomyces meyeri. Arch Bronconeumol. 2017;53:274–276.

Corresponding author. (Lucía Ferreiro lferfer7@gmail.com)
Copyright © 2016. SEPAR
Arch Bronconeumol 2017;53:274-6 - Vol. 53 Num.5 DOI: 10.1016/j.arbr.2017.03.014