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Images of Memorable Cases: Case 78

Module by: Herbert L. Fred, MD, Hendrik A. van Dijk

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Case_78-pres1-1.jpg Case_78-pres1-2.jpg

This 50-year-old woman presented with a one-year history of dyspnea on exertion and a two-week history of a painful, swollen right breast. On examination, she had a tender, warm right breast and several draining sinuses in and near her sternum (left image). Chest radiograph showed miliary lesions throughout both lungs. Contrast material injected into a sinus opening demonstrated irregular tracts and cavities in the right breast and chest wall (right image).

78. Actinomycosis of the right breast, chest wall, and lungs

The clinical findings suggested tuberculosis versus actinomycosis. Incision and drainage of the right breast abscess showed pockets of pus, but acid fast and fungal stains were negative and cultures grew no organisms. Open lung biopsy, however, showed microabscesses containing sulfur granules. Cultures again were sterile and stains showed no pathogens. Nevertheless, the combination of sulfur granules and draining sinuses pointed strongly to actinomycosis. Accordingly, the patient received high doses of penicillin intravenously for six weeks, after which time her sinuses had closed, the breast abscess had healed, and the lung lesions had all but disappeared.

This case may be only the second reported example of miliary lung lesions caused by actinomycosis. It also joins only a handful of reported cases of actinomycotic breast abscess.

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