LAUSR

Pulmonary actinomycosis, a chronic infectious disease, caused by anaerobic bacteria, Actinomyces sp, is extremely rare. It is associated with poor oral hygiene, respiratory disease and immunodeficiency. It usually manifests as nonresolving pneumonia. A 69year old male had a nonproductive cough for 6 months. A chest Xray revealed haziness in the right middle lobe of the lung. On computed tomography (CT), lobar collapse with pleural thickening and bronchial narrowing, calcified nodule and cavitation were noted. Bronchoscopy revealed endobronchial mucosal oedema, stenosis and purulent secretions. Clinically, tuberculosis and fungal infection were suspected. A transbronchial lung biopsy showed nonspecific inflammation. Bronchoalveolar lavage (BAL) was negative for acid fast bacilli and fungal infection on smear and culture. GeneXpert was negative for Mycobacterium tuberculosis . In our laboratory, MayGrünwald–Giemsa and Papanicolaoustained smears were prepared. Microscopically, Grampositive, dense cottonballlike colonies of thin filamentous bacteria were noted with necrotising inflammation conforming to the morphology of Actinomyces sp (Figure 1 ). He received intravenous amoxicillin for 1 month followed by oral medication and showed a good clinical response on followup. Coodley et al. described a case with chronic obstructive pulmonary disease and cancer, diagnosed on BAL smear and culture. 1 Morikawa et al. documented a ’balls in hole‘ appearance on CT with ’actinomycotic sulfur granules‘ on BAL. 2 Senechal et al. described an alcoholic with a lung cavity mimicking TB, wherein, BAL confirmed Actinomyces spp. 3 Costiniuk et al. reported another case with tracheal bronchus, diagnosed on BAL. 4 The index case highlights a rare and challenging diagnosis of pulmonary actinomycosis with endobronchial disease diagnosed on BAL. Multiple choice questions (MCQ)