Achalasia is a rare primary oesophageal motor disorder caused by degeneration or dysfunction of the inhibitory innervation of the oesophageal smooth muscle, resulting in incomplete relaxation of the lower sphincter and absent peristalsis in the oesophageal body.3
The presenting complaints at the time of diagnosis are dysphagia, postprandial and/or nocturnal regurgitation, weight loss, chest pain and cough. Pulmonary disease associated with achalasia is typically brought about by aspiration of contaminated matter from the dilated oesophagus into the respiratory tree.4
is a normal inhabitant in the oral cavity and upper intestinal tract of humans. It is believed that pulmonary actinomycosis occurs by aspiration of contaminated secretions from the oropharynx.5
Actinomycosis may appear as endobronchial or pleuroparenchymal disease, and bronchial foreign bodies (chicken and fish bones, grape seeds, beans, teeth, dental prostheses, alimentary material) or broncholiths may favour secondary colonisation by Actinomyces
Pulmonary actinomycosis has been reported in patients with hiatus hernia and gastro-oesophageal reflux disease.1
There is one case report of achalasia cardia in association with pulmonary actinomycosis2
which has been misdiagnosed as lung malignancy. Our case is the second of its type, with haemoptysis as the presentation, which was treated initially as tuberculosis. Tuberculosis is a masquerader of pulmonary actinomycosis,7
as are fungal infections. In conclusion, the unusual presentation of achalasia cardia as haemoptysis, the misdiagnosis of pulmonary actinomycosis as tuberculosis, and association of achalasia cardia and pulmonary actinomycosis are reported here. A thorough workup is needed in such situations to avoid toxicity of antitubercular medications, lung resections and, importantly, patient morbidity and mortality.
- Achalasia cardia may have presenting signs unrelated to the oesophagus itself, and aspiration pneumonia with unusual organisms must be kept in mind.
- The association of achalasia cardia with pulmonary actinomycosis is reported as the second case of its type.
- Not every non-resolving pneumonia with cavitation is due to tuberculosis.
- A proper history and thorough workup is needed to reach an early diagnosis and thus avoid drug toxicities, unnecessary surgery, and patient morbidity.