Nasir Halim, MD1, Thimmaiah Theethira, MD2, Marina Roytman, MD2, Shreyas Saligram, MD, MRCP2
1University of California San Francisco - Fresno, Freno, CA; 2University of California San Francisco - Fresno, Fresno, CA
Introduction: Thoracic Actinomyces is a rare infection but potentially aggressive. It is difficult to diagnose most often requiring surgical debridement. Actinomyces species colonize the mucosa of the body with disease potentially related to barrier injury.
Case Description/Methods: A 29 year old male with history of childhood asthma and recent dental extraction presented with odynophagia. He noted chest discomfort & fevers. Physical exam revealed an obese male but was otherwise unremarkable. Oral exam was unrevealing for lesions. Labs noted a WBC of 16.8 u/L. CT Chest revealed a 5x2x2cm posterior mediastinum collection (figure 1) abutting the esophagus with mid and distal esophagitis.
An EGD noted distal esophagitis, posterior extrinsic compression from 25 to 31cm with a mucosal fistula at 27cm with purulent drainage. Aspirated Esophageal contents were sent for culture. An IR Guided Drainage approach was not felt to be safe due to possibility of spinal injury. Patient underwent conservative treatment with PPI, Broad spectrum antimicrobial therapy. A repeat CT CAP revealed interval decreased size of mediastinal collection. Fluid cultures from endoscopy were negative. Testing for Coccidiomycosis, HIV, and Tuberculosis were negative.
On Hospital Day 4, EGD and EUS was performed to evaluate the mediastinal abscess. EGD showed that the fistula had healed but there was esophageal rings and furrows; This was biopsied. The EUS noted a 1.5 x 2cm Posterior Mediastinal Abscess. It was loculated and hard; A EUS guided FNA needle was used to obtain material for culture. Biopsies revealed >100 Eosinophil’s per HPF, consistent with esophinophilic esophagitis. FNA culture noted Actinomcyes Odontolyticus. Treatment was tailored for Penicillin-based therapy. On Hospital Day 12 , Repeat CT Chest did not identify a mediastinal collection or evidence of esophageal leak and noted resolving mural thickening of the esophagus.
Discussion: Thoracic actinomyces was diagnosed in the setting of active eosinophilic esophagitis. It is possible that EOE predisposes to Actinomyces as Actinomyces is a commensal flora of GI tract and this could have spread to mediastinum directly due to barrier injury. Increasing availability of endoscopic modalities may provide more accessible diagnostic options, which will help in targeted treatment. We report a possible association of EOE and Actinomyces and also successful minimally invasive diagnosis of actinomyces in a difficult anatomical location.
Citation: Nasir Halim, MD; Thimmaiah Theethira, MD; Marina Roytman, MD; Shreyas Saligram, MD, MRCP. P1487 - A MEDIASTINAL ABSCESS DUE TO ACTINOMCYES ODONTOLYTICUS DIAGNOSED BY ENDOSCOPIC ULTRASOUND-GUIDED FNA. Program No. P1487. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.