2 | CASE PRESENTATION
A 63-year-old man presented with a 2-week history of right-sided pleuritic chest pain with shortness of breath. He also experienced a high-grade fever with a productive cough. He denied hemoptysis, night sweats, and weight loss. His past medical history was significant for chronic obstructive pulmonary disease (COPD). He used to be a heavy cigarette smoker with 3–4 packs per day for at least 27 years, but he quit recently. He admitted being a heavy alcohol drinker but denied any drug use. He reported no history of trauma or surgery and no history of recent travel.
His vital signs were as follows: a body temperature of 38.6°C, a heart rate of 100 beats/min, a respiratory rate of 24 breaths per minute, and an oxygen saturation of 90% in room air. On physical examination, he looks thin and wasted, but he isn’t jaundiced or cyanosed. On examination of the chest, there was reduced chest expansion on the right side. The percussion note was stony dull at the right base. Auscultation revealed diminished breathing sounds with a few crackles and wheezes. Examination of the mouth was notable for poor dentition. Cardiac examination was normal with no murmurs. Abdominal examination was normal with no tenderness, masses, or organomegaly. There are no palpable lymph nodes.
Laboratory studies were significant for a white blood cell count (WBC) of (17,400/mm3), with neutrophilia of 90%, a haemoglobin concentration of (11.5 g/dL), and an increased C-reactive protein (CRP) of (30.7 mg/dL). Renal function test (RFT) and electrolytes were normal. The liver function test (LFT) was also normal. Chest X-ray revealed a right-sided pleural effusion, and chest computed tomography was done to rule out any masses (Figure 1). A pleural fluid sample was aspirated, and analysis revealed a straw-coloured exudative effusion with elevated protein and lactate dehydrogenase (LDH). Also, pleural fluid revealed a high white blood cell count of (2930/μL), with 61.5% neutrophils and 37% lymphocytes. The pleural fluid adenosine deaminase (ADA) level was 36.7 IU/L. Cytologic analysis of the pleural fluid revealed inflammatory cells, but no microorganisms were isolated. Additionally, no malignant cells were found in the pleural fluid. Ultrasound-guided percutaneous pleural biopsy was performed, and both histological examination and microbiological assessment revealed a background of inflammatory cell infiltrates with yellow sulfur granules and gram-positive branching filamentous rods, which is consistent with a diagnosis of pulmonary actinomycosis. Importantly, the patient was investigated for human immunodeficiency virus (HIV), but the test result was negative.
The patient was treated with intravenous amoxicillin/sulbactam (3 g/ 8hrs) for two weeks, then switched to oral amoxicillin for six months. Additionally, a drainage chest tube was inserted, and all fluid was removed till dryness. The dentist was consulted to evaluate the patient’s oral cavity and to discuss the optimum routine for better dental hygiene. Finally, follow-up at 8 months after discharge showed significant improvement in the patient’s symptoms and resolution of the radiological changes.