Presentation
Adult male with three week history of cough and weight loss.
Patient Data
Right lower zone opacity obscuring the right heart border and medial right hemidiaphragm.
Consolidation within the right lower lobe with loculated right sided pleural effusion.
Multiple enhancing pleural-based lesions infiltrate the adjacent fat and involve the right hemidiaphragm.
Abnormal paravertebral soft tissue mass T11-L2 with moth-eaten appearance of T12 vertebral body and associated T12 fracture; abnormal soft tissue narrows the spinal canal at T12.
Appearances are concerning for malignancy. MRI spine and biopsy of pleura advised.
Extensive infiltration of T12 with associated vertebral body collapse.
Pathological soft tissue extends posteriorly to narrow the spinal canal and indents but does not compress the cord.
The infiltrated vertebrae are surrounded by abnormal soft tissue which is contiguous with the right pleural mass, suggesting all related to the same disease process.
Small cystic/necrotic regions in the paraspinal soft tissues without drainable abscess.
Summary:
Pathology / Microbiology Investigations
The patient underwent ultrasound assisted biopsy of the right pleural mass and a chest drain was inserted into the right sided pleural collection.
Microscopy:
Sections show multiple core biopsies which consist largely of fibrous connective tissue. There is an infiltrate of mixed inflammatory cells which are predominantly plasma cells but with aggregates of neutrophil polymorphs and scattered lymphocytes. In one core biopsy there is a cluster of actinomyces-like organisms. The overall appearances appear inflammatory in nature and raise the possibility of an infective etiology.
Further info: ISH for Kappa and Lambda show the plasma cell population to be polyclonal. Special stains for organisms highlight Gram positive PAS positive bacterial colonies.
Pleural Fluid:
CULTURE RESULT:
a) Fusobacterium nucleatum - Isolated
b) Actinomyces meyeri - Isolated
Case Discussion
Management:
The patient was managed with intravenous antibiotics, right-sided chest drain, underwent fixation of the spinal fracture and was prescribed 18 months of oral antibiotics.
Learning Points:
Differential for invasive pleural processes in young patients includes atypical infection. A clear trigger for actinomycosis (such as intra-uterine contraceptive device or poor dentition) is not always evident.
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