Case Report: Fatal massive hemoptysis secondary to pulmonary actinomycosis: a diagnostic and therapeutic challenge in a multidisciplinary approach

TL;DR

A 74-year-old man with a rare lung infection called pulmonary actinomycosis experienced severe and fatal hemoptysis, requiring multiple treatments and surgery for diagnosis and management.

Contribution

This case report highlights the diagnostic and therapeutic challenges of fatal hemoptysis caused by pulmonary actinomycosis and emphasizes the role of surgical resection in life-threatening cases.

Findings

Pulmonary actinomycosis can present with recurrent hemoptysis and imaging features similar to tuberculosis or tumors.

Surgical resection may be necessary to control life-threatening hemoptysis in pulmonary actinomycosis.

Emergency bronchoscopic balloon occlusion and lobectomy improved prognosis in this fatal case.

Abstract

Actinomyces infections tend to involve the head and neck, while lung infections are relatively rare, and fatal hemoptysis due to pulmonary actinomycosis is even rarer.

A 74-year-old male patient who presented with a cough with intermittent hemoptysis for 17 months was admitted to the hospital for the fourth time on June 24, 2024. At the first visit (15 months ago), a computed tomography (CT) scan of the chest revealed a high-density shadow in the right middle bronchus (suggesting a foreign body to be drained) and an infected lesion in the lower lobe of the right lung. Hemoptysis was temporarily relieved after bronchoscopic removal of the foreign body and anti-infective treatment. Four months later, the patient was readmitted to the hospital due to a recurrence of hemoptysis. CT showed a lesion in the right lower lobe of the lung with cavitation, and bronchoscopy showed no abnormality. The pathology of percutaneous lung puncture biopsy suggested acute and chronic inflammation, and the patient was discharged under oral treatment with moxifloxacin. Four months later, the patient was admitted to the hospital for the third time because the hemoptysis volume had increased to 50 ml/day. Digital subtraction angiography-guided bronchial artery embolization was performed, and hemoptysis was controlled after the operation. Six months later, the patient was re-admitted to the hospital because of sudden hemoptysis as an emergency. Various medications were ineffective in stopping the hemoptysis, and the hemoptysis recurred; the volume was about 150 ml, with a sudden drop in blood oxygen saturation level to 82%. Due to the possibility of asphyxiation by blood clot, emergency bronchoscopic balloon occlusion was performed to stop bleeding, and right lower lobectomy was performed after multidisciplinary consultation. Post-operative pathology showed that the lung tissue was accompanied by tracheal dilatation, pus accumulation, and inflammatory granulomatous changes, with positive periodic acid Schiff staining, supporting actinomycetes infection. The patient continued anti-actinomycosis treatment for 1 month after surgery, and his condition stabilized after 8 months of follow-up.

Imaging of pulmonary actinomycosis is easily confused with tuberculosis and tumors and is difficult to diagnose. Pulmonary actinomycosis should be considered in patients with a lung mass shadow and recurrent hemoptysis. When life-threatening hemoptysis complicates pulmonary actinomycosis, surgical resection may effectively control the condition and improve the prognosis.

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