Shah NH*, Khambati B** , Paranjpe SH***, Shah VN****..
(* Hon. Endosopic Surgeon Wadia Hospital & Railway Hospital (Byculla), ** Director Asha Nursing Home,*** Director: Velankar Hospital &Paranjpe Maternity Home, **** Anesthetist, Mumbai, India.)
Female genital organs are comparatively a rare site for pelvic actinomycosis and detection is extremely low too. Here we present a case of resurgence of pelvic actinomycosis. This patient was operated 4 years back for tubo-ovarian (TO) mass, histopathology confirming actinomycosis and 4 years later she presented with the same symptoms with ultrasonography (USG) showing possibility of chocolate cyst/ TO mass. Actinomyces usually gets a delayed treatment due to its specific and non-specific nature. Actinomyces species are usually found in the vagina, the most frequent site being the cervico-facial region and grow slowly in conditions of reduced oxygen. The radiological findings are that of a solid mass simulating gynecological malignancies or ovarian and cervical inflammatory conditions. Therefore, the gynecologist should consider the possibility of this infection to spare the patient from morbidity of radical surgical procedure.
Actinomycosis is a chronic suppurative 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 usually found in human oropharynx, gastrointestinal tract, vagina, and they grow slowly with conditions of reduced oxygen. Actinomyces is an opportunistic pathogen causing infection after disruption of the mucus membrane and spreads into surrounding tissue irrespective of tissue planes. The most common site of human infection is the cervico-facial region, accounting for 40 to 50% of cases. Approximately 15% cases occur in thorax, 20% of the cases occur in the abdomen and pelvis. Pelvic actinomycosis is an uncommon condition accounting for 3% of all human actinomycotic infections. Ovarian actinomycosis is rarer because structure of an ovary is resistant to surrounding inflammatory disease. It has been speculated that bacteria enter the ovary when its surface epithelium is broken during the process of ovulation.
A 36 years old female para 2 came with chief complaints of dysmenorrhea and vague, mild, dragging type of pain in abdomen for past 6 months. This patient was previously operated 4 years back for same complaints with ultrasonography showing a tubo-ovarian mass. A diagnostic laparoscopy was done 4 years ago which revealed a cystic mass on the right ovary and tube. Adhesions were present over the tube, ovary and the mesentery mimicking pelvic tuberculosis. The cyst was drained showing bright yellow fluid with granules. The cyst wall and fluid were sent for histopathological examination which revealed active actinomycosis. After a month or so of antibiotic treatment she stopped taking treatment despite doctor’s advice, as she found herself to be asymptomatic. Four years later she came with similar symptoms with ultrasonography again showing tubo-ovarian mass/chocolate cyst of the left ovary. Again a diagnostic laparoscopy was done, showing dense adhesions between the tubes, ovaries and the bowel. The tubes were enlarged showing a hydrosalpinx like picture with cyst of 2 by 2 cm present on both the ovaries. A separate cystic mass was found away from the uterus in the mesentery measuring 5 by 5 cm.
Figure 1. Laparoscopic view of tubo-ovarian mass.
Figure 2. Ruptured mass showing sulfur granules.
Her blood picture showed Hb – 8.5g/dl, total leukocyte count – 7200/cmm, WBC – 4.39 mil/cmm, HIV non reactive, random blood sugar – 80 mg/dl.
The mesenteric cyst was removed completely laparoscopically in an endo bag. Both the cysts in each ovary were drained with the cyst wall resected and fluid in the tubes was drained and the left sided tube was partially removed. The fluid was similar bright yellow colored with granules. Removal of the ovary and other tube was not possible due to dense adhesions between the bowel and mesentery. The cystic fluid and the cyst wall and the mesenteric cyst were sent for histopathological examination. Histopathological report confirmed actinomycosis and the patient is planned for post-operative 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.
Treatment is carried in 2 stages: 1st stage includes i.v. crystalline penicillin for 2 to 6 weeks for killing the rapidly multiplying bacteria and 2nd stage is continuous oral antibiotics for 6 months to 1 year to prevent recurrence. A thorough interrogation revealed that patient had not taken the correct treatment previously which possibly was the cause of recurrence.
Actinomycosis is a low prevalent disease. Its different anatomical locations create a diagnostic challenge to various medical specialties Due to the general circumstances with internal immunological environment of the body, it changes the behavior of this organism. The spectrum of behavior varies from commensal to pathogenic type. The first human case of Actinomycosis was reported by James Israel in 1878. The organism per se cannot penetrate an intact epithelium or mucosa. The infection spreads contiguously crossing the anatomic barriers when there is a failure in the integrity of mucosa. Hematogenous spread is less common. There has been increasing number of reports of Actinomycosis in the female genital tract, especially in women using an intrauterine contraceptive devices. The metallic devices have been particularly incriminated, possibly as they provide a focus for infection together with a chemical reducing action favorable for an opportunistic anaerobe such as A. israelii. The present reports are in contrast to old ones, where A. israelii was seen in 1.6-11.6% of intrauterine contraceptive device (IUCD) users worldwide. Astonishingly the newer trend studies show that, the increasing rate of the infection related to plastic IUCD without metal or hormonal load. This patient did not have any history of any intrauterine device use. She was however previously operated for tubal ligation surgery. Diagnosis of actinomycosis can be difficult preoperatively because of the insidious nature of the infection with non-specific signs and symptoms and unsure radiological findings of solid masses often giving the impression of gynecological or gastrointestinal malignancies. Koshiyama et al. have reported cases of actinomycotic pelvic inflammatory disease showing advanced cervical and ovarian carcinomas. Hence “final diagnosis mostly rests on post-operative examination of the specimen, histopathology, and culture” as was in this case. The complications associated with IUCD use include dissemination of actinomycosis, hepatic abscess, intracranial abscess and even death. Thus, a conclusive diagnosis has to be obtained by histopathological examination and culture of the pus/fluid material. It is very difficult and time taking to obtain a positive culture for Actinomycosis. Thus, histopathological examination played a major role in the present case in deriving the accurate diagnosis.
In conclusion, we would like to suggest that women presenting clinically with nonspecific abdominal symptoms, backache and vaginal discharge, actinomycosis should be considered and ruled out with cytological and microbial culture methods. Once the diagnosis is established, the infection can be treated with good results with long term penicillin.[1,4] It is also important to look at other sites for actinomycosis, in the absence of which the possibility of existence of foreign bodies in the genital tract should be considered.
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Shah NH, Khambati B, Paranjpe SH, Shah VN. Actinomycosis of Ovary - Resurgence JPGO 2015. Volume 2 Number 11. Available from: http://www.jpgo.org/2015/11/actinomycosis-of-ovary-resurgence.html