pulmonary actinomycosis
Description
● Introduction:
➣ Definition: Actinomyces species, which are native to the human oral cavity, gastrointestinal tract, and female vaginal tract, are the source of the uncommon bacterial infection known as pulmonary actinomycosis.
➣ Pathogenesis: When the mucosal barrier is disrupted, an endogenous infection results, which can impact several organs.
➣ Epidemiology
Cervicofacial and abdominopelvic actinomycosis are the most prevalent types, although pulmonary form accounts for around 15% of all actinomycosis cases. Aspiration of gastrointestinal or oropharyngeal secretions frequently leads to pulmonary infection.
➣ Medical appearance:
• General symptoms include fever, haemoptysis, coughing, and weight loss.
• Imaging: varied, frequently non-specific, and capable of mimicking aspergillosis, pneumonia, TB, or lung cancer.
➣ Diagnostic challenge: Non-specific clinical and radiological findings sometimes result in delayed or incorrect diagnoses.
● Case Presentation:
➣ Patient: 68-year-old male with comorbidities: hypertension, type II diabetes, and 35 pack-years of smoking. Symptoms include fever (38.3°C), widespread weakness, and a productive cough with purulent sputum for two weeks. Initial treatment: 95% oxygen saturation; 3 days of clarithromycin without improvement.
➣ Investigations
• Chest X-ray: Left lower lobe has a little opacity.
•Laboratory: CRP 7 mg/dL, WBC 12,700/mL.
• CT thorax: Obstructive pneumonia due to patchy air-space consolidation in the posterior section of the left lower lobe.
• Bronchoscopy: 60% blockage from an endobronchial white necrotised lesion in the left lower lobe's B6 that mimics cancer.
➣ Microbiology:
• Gram-positive bacteria after cleaning the bronchi; cultures are negative (probably because of previous antibiotics).
• Biopsy: eosinophils, neutrophils, and plasma cells; no cancer.
•PAS stain: Actinomyces-like radiating filamentous colonies.
● Discussion:
➣Risk Factors
• Diabetes, alcoholism, haematologic disorders, immunosuppression, and chronic lung illnesses (COPD, bronchiectasis).
• Broncholithiasis and endobronchial actinomycosis: foreign bodies.
•In this instance, the patient is immunocompetent, diabetic, and free of foreign bodies and pulmonary diseases.
➣Difficulties in Diagnosis
•Clinical: Symptoms resemble cancer, TB, or pneumonia.
• Imaging: CT results are non-specific and may reveal ground-glass opacities, pleural thickening, necrotic mass, air-space consolidation, and lobar consolidation.
• Bronchoscopy: Endobronchial lesions can resemble lung cancer by showing up as partial or complete blockage, granular thickening, or necrotic mass.
➣Microbiology:
•Anaerobic growth needs (5–20 days) and previous antibiotics make culture challenging.
•Microscopy of Gram-positive filamentous bacteria aids in diagnosis.
➣Histopathology
•includes fibroblasts, plasma cells, and polymorphonuclear infiltration.
•Sulphur granules and radiating filamentous colonies are seen with PAS staining.
•Molecular techniques that can verify species include PCR, 16S rRNA sequencing, and FISH.
Protocol
➣ Administration
•First line of treatment: intravenous penicillin G 24 million units per day; after a week, symptoms and test results improve.
•Transition: The patient declined to continue receiving IV treatment, therefore 100 mg of oral doxycycline twice a day was given instead.
➣A follow-up
• Two months later, a bronchoscopy and CT scan revealed full resolution.
• Doxycycline was used continuously for four months with no recurrence.
● Difficulties in Nursing Case Management
➣ Ambiguity of Roles and Regulations: Nurses frequently face ambiguous boundaries concerning their duties, particularly with regard to direct care and legal restrictions, including writing prescriptions for drugs or administering specific treatments.
➣High Caseloads: In order to guarantee that every client receives enough care, nurse case managers usually oversee a large number of patients at once, taking on various responsibilities and putting in long hours.
➣ Lack of Training: Nurse case managers often lack a standardised or adequate ongoing education model, which leads to variations in case management quality and capacity to manage difficult situations.
➣Managing Compassion and Professionalism: When resources are scarce, nurses find it difficult to draw a line between upholding professional norms and their own empathy.
● Nursing interventions and management:
➣ Structured Care Process: Nurses employ a methodical approach that includes assessment, issue analysis, care planning, execution, and evaluation. In order to preserve continuity of care, this involves creating customised care plans that are no longer task-oriented but rather person-centred, frequently incorporating families.
➣ Personalised Health Promotion: Nurse case managers provide preventative care and education based on the individual health of each patient. This empowers patients and promotes healthy behaviours.
➣ Holistic Support: By bridging the divide between communities and healthcare systems, nurses support patients' rights and make resources and services more accessible, guaranteeing inclusive and thorough treatment.
➣ Teamwork and Communication: Case managers help multidisciplinary teams communicate with one another, which guarantees that all healthcare providers work together to get the greatest results.
Notes
For more details visit 10.1016/j.rmcr.2019.100930
