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.