FIRST REPORT OF BRONCHOPLEURAL FISTULA DUE TO ACTINOMYCES ODONTOLYTICUS EMPYEMA IN A PATIENT WITH AN OBSTRUCTIVE ENDOBRONCHIAL TUMOR

SESSION TITLE: Many Roads Lead to the Pleural Space SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/09/2023 09:40 am - 10:25 am INTRODUCTION: In 4 decades of following the isolation of Actinomyces odontolyticus, about 20 cases of invasive infection have been reported across the world, including bacteremia, descending mediastinitis, hepatic abscess, peritonitis, tubo-ovarian abscess, purulent pericarditis, recurrent acute cholecystitis, and only 3 cases of lung abscess or empyema.[1-3] We report a unique case of a bronchopleural fistula and empyema due to Actinomyces odontolyticus in a patient with endobronchial squamous cell carcinoma (SqCC). CASE PRESENTATION: A 59-year-old man was referred for mediastinal staging to the interventional pulmonary clinic in March 2023 after a new diagnosis of SqCC with endobronchial tumor involvement in right lower lobe (RLL) and mediastinal adenopathy on PET scan (station 7). The patient underwent bronchoscopy, Argon plasma coagulation in the RLL anterior and lateral segmental branches for tumor destruction, and biopsy of lymph node stations 11 L, 4L, 4R, 7 and 11Rs (day 1, Figure 1). Complete occlusion of RLL subsegmental airways was noted on bronchoscopy. Pathology was negative for metastatic disease. Patient was admitted to an outside hospital on day 13 with respiratory failure, postobstructive pneumonia, and empyema treated with high flow oxygen and meropenem. After stabilization, he was transferred to our facility on day 24. Bedside ultrasound revealed right loculated pleural effusion, and pleural fluid studies showed 535000/μL nucleated cells, 100% polymorphs, glucose 22 mg/dL, LDH 90382 Units/L, protein 2 gm/dL and culture grew Actinomyces odontolyticus. Blood culture on admission was sterile. Patient was started on vancomycin and meropenem. Chest tube was inserted with 100-150 cc/day drainage of purulent material; a one-time dose of intrapleural tissue plasminogen activator and deoxyribonuclease was given. Intermittent air leak from the chest tube was noted. Imaging demonstrated improvement of empyema, moderate right hydropneumothorax, and bronchopleural fistula to RLL bronchus (Figure 2). Patient is currently hospitalized, and is awaiting repair of bronchopleural fistula with thoracic surgery. DISCUSSION: Of the 3 reported cases of empyema due to Actinomyces odontolyticus, the first patient from Iran died in a week due to rapid disease progression and respiratory failure. The second patient from Korea was on mechanical ventilation for 6 days and eventually recovered with oral amoxicillin/clavulanate. The third patient from Mexico was transferred to the USA, and also recovered by day 10. CONCLUSIONS: Actinomyces odontolyticus can result in bronchopleural fistula; our patient is clinically stable on penicillin and metronidazole and is awaiting surgical repair. A prolonged duration of therapy (6-12 months) is recommended in actinomycosis due to the high frequency of recurrence. REFERENCE #1: Ruan, Hang; Yi-ming, Tao; Shu-sheng, Li. Actinomyces odontolyticus lung abscess and pleural empyema. Archives of Iranian Medicine; Tehran Vol. 25, Iss. 6, (Jun 2022): 402-404. DOI:10.34172/aim.2022.65 REFERENCE #2: Yun SS, Cho HS, Heo M, Jeong JH, Lee HR, Ju S, Kim JY, You JW, Cho YJ, Jeong YY, Kim HC, Lee JD, Lee SJ. Lung abscess by Actinomyces odontolyticus and Parvimonas micra co-infection presenting as acute respiratory failure: A case report. Medicine (Baltimore). 2019 Aug;98(35):e16911. doi: 10.1097/MD.0000000000016911. PMID: 31464925; PMCID: PMC6736456. REFERENCE #3: Peralta DP, Najjar H. A Case of Empyema Due to Actinomyces odontolyticus and Streptococcus Species Co-infection in an Immunocompetent Woman. Cureus. 2022 Dec 19;14(12):e32700. doi: 10.7759/cureus.32700. PMID: 36686073; PMCID: PMC9853470. DISCLOSURES: No relevant relationships by Muhammad Arif No relevant relationships by Abid Khokar No relevant relationships by Deepika Razia No relevant relationships by Ali Saeed