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 ¤  Abstract
 ¤ Introduction
 ¤ Case Report
 ¤ Discussion
 ¤  References
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Table of Contents  
CASE REPORT
Year : 2010  |  Volume : 64  |  Issue : 7  |  Page : 329-332
 

Tubo-ovarian Actinomycosis: A case report with brief review of literature


Department of Pathology, Nilratan Sircar Medical College, Kolkata, India

Date of Web Publication18-Aug-2012

Correspondence Address:
S Dasgupta
Demonstrator, P-255 C.I.T. Road, Kolkata - 700010
India
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DOI: 10.4103/0019-5359.99872

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 ¤ Abstract 

Pelvic actinomycosis is an uncommon condition, often associated with the use of intrauterine contraceptive device (IUCD). Pelvic actinomycosis is rare accounting for 3% of all human actinomycotic infections. Ovarian actinomycosis is even rarer. Here, we present a 24-year-old woman using an IUCD for 3 1 / 2 years with right-sided adnexal mass, which was diagnosed postoperatively as tubo-ovarian actinomycosis. Many times, an appropriate management is overlooked or delayed due to its non-specific and variable clinical and radiological features. Sometimes, it can even mimic an advanced pelvic malignancy. Therefore, the gynecologist should consider the possibility of this infection to spare the patient from morbidity of radical surgical procedure.


Keywords: Actinomycosis, IUCD, pelvic inflammatory disease, tubo-ovarian mass


How to cite this article:
Dasgupta S, Ghosh S, Sengupta S G, Sarkar R. Tubo-ovarian Actinomycosis: A case report with brief review of literature. Indian J Med Sci 2010;64:329-32

How to cite this URL:
Dasgupta S, Ghosh S, Sengupta S G, Sarkar R. Tubo-ovarian Actinomycosis: A case report with brief review of literature. Indian J Med Sci [serial online] 2010 [cited 2014 Oct 25];64:329-32. Available from: http://www.indianjmedsci.org/text.asp?2010/64/7/329/99872



 ¤ Introduction Top


Pelvic actinomycosis is an uncommon condition, often associated with an intrauterine contraceptive device. It usually has an insidious course with non-specific and variable clinical features and thus it is difficult to diagnose. Many times, it can simulate advanced pelvic malignancy and hence an appropriate management is overlooked or delayed. Here, we present a case with right-sided adnexal mass, which post-operatively came out to be a case of tubo-ovarian actinomycosis associated with IUCD.


 ¤ Case Report Top


A-24-years old woman, para 2+0 was admitted to hospital with chronic lower abdominal pain for 1 year, associated with fever for 10 days. The patient had been an IUCD user for 3½ years. Physical examination revealed tenderness in lower abdomen. The IUCD was removed in OPD. Pelvic ultrasound revealed right adnexal SOL with irregular margins. Laboratory tests revealed leukocytosis (18,600/ cumm) and elevated C-Reactive Protein concentration (21.3 mg/dl). CA-125 was within normal range. The patient did not have any history of sexually transmitted disease, and her serology was HIV negative.

Exploratory laprotomy was carried out. Intra-operative findings were as follows- Right-sided irregular tubo-ovarian mass with localized abscess formation in pelvis and ascites. There was an intense adhesion to the pelvic wall and surrounding organs including uterus, appendix, and large bowel, which caused rectal injury during dissection. This was repaired followed by sigmoid colostomy. Right-sided tubo-ovarian mass and appendix was resected.

On gross examination, the tubo-ovarian mass measured 8.5 × 4 × 3 cms. Ovary and tube could not be identified separately. Cut section showed a variegated appearance with mostly grayish-white tissue with areas of necrosis, cavity formation, and small yellowish nodules.[Figure 1] On histopathological examination, sections from the tubo-ovarian mass showed presence of chronic abscess with polymorphs, surrounding granulation tissue, and fibrosis. A few characteristic colonies of organisms are noted at the center of the abscesses. [Figure 2] Appendix showed features of acute appendicitis with acute inflammatory exudate covering the serosa. Margin of rectal perforation showed areas of hemorrhage, necrosis, edema, dense inflammatory cell infiltration, and granulation tissue formation.
Figure 1: Cut section of tubo-ovarian mass - variegated appearance with necrosis, cavity formation, and small yellowish nodule

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Figure 2: Photomicrograph showing chronic abscess with polymorphs, surrounding granulation tissue, fibrosis, and colonies of actinomyces at the center of the abscesses. (100 ×). Inset: PAS positive colonies (×400)

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Periodic Acid Schiff stain done revealed PAS positive colonies of organism. [Figure 3] Gram stain showed gram positive colonies. Growth of  Actinomyces israelii Scientific Name Search confirmed by anaerobic culture.
Figure 3: PAS positive colonies of actinomyces (×400)

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The patient received antibiotic therapy with crystalline penicillin 24,000,000 IU per day intravenously for 4 weeks, followed by continued therapy with ampicillin for another 6 months, and the subsequent follow-up was uneventful.


 ¤ Discussion Top


Actinomycosis is a chronic suppurative and granulomatous bacterial infection caused by Actinomyces israelii, which is a slow growing, filamentous, gram positive, non-spore forming anaerobic, or microaerophilic bacteria. Actinomyces species are normally found in human oropharynx, gastrointestinal tract, and vagina, and they grow slowly under conditions of reduced oxygen. They are opportunistic pathogens causing infection after disruption of mucus membrane and spreads into surrounding tissue regardless of tissue planes. [1] The most frequent site of human infection is cervico-facial region, accounting for about 40 to 50% of cases. Approximately 15% cases occur in thorax. [2] 20% cases occur in abdomen and pelvis. [2],[3] Pelvic actinomycosis is rare accounting for 3% of all human actinomycotic infections. [1] Ovarian actinomycosis is rarer because structure of an ovary is resistant to surrounding inflammatory disease. [4] It has been assumed that bacteria enter the ovary when its surface is broken by the process of ovulation. The first report of the association of actinomyces -like organism in the genital canal of women employing endocervical contraceptive was by Barth in 1928. [5] Early reports of pelvic actinomyces can be found in 1979 in Canada. [5] It is well-known that IUD users are at risk of pelvic actinomycosis. Almost 85% of cases of pelvic actinomycosis occur in women who have had an IUD in place for more than 3 years. [6] It is more common in plastic IUD than in copper devices. [7] Actinomyces israelii infection in IUCD users varies from 1.65% to 11.6% in different series. [8] Actinomycosis has been reported as a cause of 1 to 16% of all pelvic infections. [9] Pelvic actinomyces causes endometritis, salpingo-oophoritis, tubo-ovarian abscess, and a palpable adnexal mass mimicking a pelvic malignancy. [1] The right ovary and  Fallopian tube More Details are most frequently affected with or without parametrial disease. [7] Ultimately, extension to abdominal wall or deep pelvic structures can occur. Scribner D. R Jr et al. (2000) found extensive adhesion to rectosigmoid colon, which was repaired and followed by colostomy. [10] In our case too, adhesion to rectum and other pelvic structures caused rectal injury during dissection, ultimately leading to sigmoid colostomy.

Diagnosis of actinomycosis can be difficult preoperatively because of the insidious nature of the infection with non-specific signs and symptoms and inconclusive radiological findings of solid invasive mass often giving the impression of gynecological or gastrointestinal malignancies. Koshiyama et al. has reported cases of actinomycotic pelvic inflammatory disease simulating advanced ovarian and cervical carcinomas. [4] Hence, final diagnosis rests in most instances on post-operative examination of the specimen, histopathology, and culture as was in our case.

Once diagnosed, pelvic actinomycosis can be managed primarily by antibiotics. Parental therapy may be required for severe infection before changing to an oral route. High dose must be given for prolonged courses. [1] Penicillin is the drug of choice. In those allergic to penicillin, options include tetracycline and clindamycin. Our patient was given initial intravenous penicillin for 4 weeks followed by oral treatment for 6 months. Generally, the disease is treated until there is an evidence of complete resolution. Surgery is needed to drain abscess and in complicated cases presenting with pelvic mass as in our case.

In conclusion, although IUD is a highly effective reversible contraceptive method, users and doctors should remember the risk of complications including pelvic inflammatory disease. Pelvic actinomycosis should always be considered in patients with pelvic mass, especially those using an IUD. High degree of suspicion, deliberate examinations, careful evaluation of investigation results, and images may spare patients from radical and excessive surgical intervention.

 
 ¤ References Top

1.Simsek A, Perek A, Cakcak IE, Durgun AV. Pelvic actinomycosis presenting as a malignant pelvic mass: A case report. J Med Case Reports 2011;5:40.  Back to cited text no. 1
    
2.Weese WC, Smith IM. A study of 57 cases of actinomycosis over a 36 year period. A diagnostic "failure" with good prognosis after treatment. Ach Intern Med 1975;135;1562-8.  Back to cited text no. 2
    
3.Russo TA Tn. Mandel, Douglas and Bennet's principles and practice of infectious disease. Newyork, Churchill Livingstone: Agents of Actinomycosis; 1995. p. 2280-6.  Back to cited text no. 3
    
4.Koshiyama M, Yashida M, Fujii H, Nanno H, Hayashi M, Tauchi K, et al. Ovarian actinomycosis complicated by diabetes mellitus simulating an advanced ovarian carcinoma. Eur J Obstet Gynaecol Reprod Biol 1999;87:95-9.  Back to cited text no. 4
    
5.DTP Evans. Actinomyces Israeli in the female genital tract, a review. Genitourin Med 1993;69:54- 9.  Back to cited text no. 5
    
6.Schmidt WA. IUDs, inflammation and infection: Assessment after two decades of IUD use. Hum Pathol 1982;13:878-81.  Back to cited text no. 6
    
7.O' Brien PK. Abdominal and endometrial actinomycosis associated with an intrauterine device. Can Med Assoc J 1975;112:596-7.  Back to cited text no. 7
    
8.Mc Cornick JF, Scorge RD. Unilateral tubo ovarian actinomycosis in the presence of an intrauterine device. Am J Clin Pathol 1977;68:622-6.  Back to cited text no. 8
    
9.Meja Salazar YR, Hernández González M, Martínez Reyes Z, Carrera Rivapalacio A. Tuboovarian actinomycosis. A report of a case. Ginecologia Y Obstretica de Mexico 2004;72:162- 5.  Back to cited text no. 9
    
10.Scribner DR Jr, Baldwin J, Johnson GA. Actinomycosis mimicking a pelvic malignancy. A case report. J Reprod Med 2000;45:515-8.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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