Pelvic actinomycosis and IUD.

OBJECTIVE: To summarize knowledge about the mana-gement in women with proven actinomyces in uterine cervix and inserted intrauterine device (IUD). DESIGN: An overall review. RESULTS: Actinomycosis is an uncommon but important subacute or chronic infection caused by anaerobic or microaerophilic bacteria, mainly within the Actinomyces genus. Actinomycosis can affect various organs and tissues in the human body, often manifesting draining sinuses, abscess formation and fibrosis. The pelvic form in women is the most common in the developed countries. Long-duration treatment with antibiotics can be completely effective even in cases of heavy disease. Although pelvic actinomycosis is predominantly associated with the longstanding use of intrauterine device, the risk of future symptomatic infection is extremly low even in women with a cervical Pap smear positive for actinomyces-like organisms (ALO). Therefore the identification of actinomycetes by cytology after cervical Pap smears is not diagnostic nor predictive of any disease because the actinomycetes normally reside in the female genital tract. In the absence of symptoms, patients with ALO on a Pap test do not need antimicrobial treatment or IUD removal. Nevertheless, women choosing an IUD for contraception should know that there is very low risk of developing the infection in later years after insertion. CONCLUSION: The sources of literature conclude that removal of the intrauterine device in a patients with a positive ALO in the uterine cervix is not necessary and antibiotics treatment is not required. However, IUD must be changed at least every five years in order to limit the risk of the development of pelvic actinomycosis.

[Pseudotumoral pelvic actinomycosis : one should think of it]. / Le cas clinique du mois - Actinomycose pelvienne pseudo-tumorale : il fallait y penser.

Actinomycosis is a rare chronic disease caused by a group of anaerobic Gram positive bacteria. It may mimic a neoplasia at various anatomical levels. A pelvic localization is exceptional but has an increasing incidence since the use of intrauterine devices. In such cases, pelvic actinomycosis may present as a gynecological or a lower colonic malignancy. For all atypical clinical, with a prominent infectious or inflammatory context, the diagnosis of actinomycosis must be suggested and discussed with the pathologist to whom the biopsy will be submitted. In the absence of a preoperative diagnosis, an inadequately aggressive pelvic surgery might be performed and rendered particularly complex due to the adherent and diffusely inflammatory pattern of the disease. The treatment of choice remains a long-term therapy with antibiotics that leads to a complete clinical and radiological response in the majority of cases. We report the case of a 27-year-old woman with a clinical and radiological diagnosis of rectal carcinoma but with limited preoperative biopsy that revealed a pelvic actinomycosis and allowed a conservative and successful antibacterial treatment.

L'actinomycose est une pathologie bactérienne rare pouvant prendre un aspect pseudo-tumoral. La localisation pelvienne est exceptionnelle, mais d'incidence croissante depuis l'utilisation des dispositifs intra-utérins. La présentation peut alors évoquer une néoplasie gynécologique ou colique basse. Devant tout tableau clinique atypique suggérant une malignité pelvienne mais dominé par un contexte infectieux et/ou inflammatoire, le diagnostic d'actinomycose doit être évoqué et discuté avec le collègue anatomo-athologiste auquel les prélèvements histologiques seront soumis. En l'absence de diagnostic pré-opératoire, une chirurgie radicale peut être pratiquée de manière inadéquate et se révéler particulièrement délabrante en raison du caractère adhérent et diffusément inflammatoire de la lésion. Le traitement de choix est une antibiothérapie au long cours amenant à une résolution clinique et radiologique complète dans la majorité des cas. Nous rapportons le cas d'une patiente de 27 ans chez laquelle un diagnostic de néoplasie rectale primitive est suggéré cliniquement et radiologiquement, mais chez qui les biopsies pré-opératoires limitées ont permis un diagnostic d'actinomycose pelvienne et un traitement conservateur.

Pelvic tuberculosis, echinococcosis, and actinomycosis: great imitators of ovarian cancer.

AIMS: To evaluate the demographic, laboratory, clinical and imaging findings, surgical procedures and complications in women with final pathology results of pelvic tuberculosis (PT), pelvic echinococcosis (PE) or pelvic actinomycosis (PA) following exploratory surgery for suspicion of ovarian cancer. METHODS: Among 492 operations from January 2005 through January 2013, we retrospectively reviewed women with PT (n = 15), PE (n = 6), or PA (n = 5) mimicking ovarian cancer seen in an education and research hospital clinic. RESULTS: The mean ages of the women with PT, PE and PA were 34.2 ± 9.4, 39.1 ± 11 and 46.3 ± 3.6 years, respectively. The serum CA-125 was elevated in 14 (93%), four (67%) and four (80%) women, respectively. The average CA-125 levels were 242.8 ± 240, 104.3 ± 76.4 and 52.3 ± 18.6 IU/mL, respectively. The most common symptom was lower abdominal pain in 12 (87%), four (67%) and four (80%) women, respectively. The most common ultrasonography and computed tomography/magnetic resonance imaging finding was a pelvic mass in 11 (73%), six (100%) and five (100%) women, respectively. The most common surgical procedure was extensive adhesiolysis in 10 (67%), three (50%) and five (100%) women, respectively. CONCLUSIONS: Pelvic tuberculosis, echinococcosis and actinomycosis must be included in the differential diagnosis of women suspected to have ovarian cancer with or without ascites and elevated CA-125 levels, especially in those living in endemic countries. During surgical exploration, frozen section analysis is important to avoid unnecessarily prolonged surgical procedures and retroperitoneal lymphadenectomy, which increases morbidity in women with these curable pelvic infectious conditions.

Pseudo tumor pelvic actinomycosis revealed by colonic obstruction with hydronephrosis: Can extensive surgery be avoided? A case report.

Pelvic actinomycosis with an intrauterine device accounts for approximately 3% of all actinomycoses. It is a chronic infectious disease characterized by infiltrative, suppurative, or granulomatous inflammation, sinus fistula formation, and extensive fibrosis, and caused by filamentous, gram-positive, anaerobic bacteria called Actinomyces israelii. The slow and silent progression favors pseudo tumor pelvic extension and exposes the patient to acute life-threatening complications, namely colonic occlusion with hydronephrosis. Preoperative diagnosis is often difficult due to the absence of specific symptomatology and pathognomonic radiological signs simulating pelvic cancer. We discuss the case of a 67-year-old woman who complained of pelvic pain, constipation, and weight loss for 4 months, and who presented to the emergency department with a picture of colonic obstruction and a biological inflammatory syndrome. The computed tomography scan revealed a suspicious heterogeneous pelvic mass infiltrating the uterus with an intrauterine device, the sigmoid with extensive upstream colonic distension, and right hydronephrosis. The patient underwent emergency surgery with segmental colonic resection and temporary colostomy, followed by antibiotic therapy. The favorable clinical and radiological evolution under prolonged antibiotic therapy with the almost total disappearance of the pelvic pseudo tumor infiltration confirms the diagnosis of pelvic actinomycosis and thus makes it possible to avoid an extensive and mutilating surgery with important morbidity.

Pelvic actinomycosis three years after colporrhaphy: A case report.

A 57-year-old patient presented with vaginal discharge and was found to have a pelvic abscess with A. turicensis and Streptococcus constellatus, with likely nidus of infection being a non-absorbable suture placed during colporrhaphy three years prior. She was treated with drain placement and antibiotics. Post-hospitalization, her colporrhaphy suture was removed. Subsequently the drain output decreased and this was removed as well. She had a total course of 6 weeks of amoxicillin/clavulanate, with complete resolution of her abscess.

Mimicking uterine malignancy: Pelvic actinomycosis with giant uterine leiomyoma.

Pelvic actinomycosis is a rare disease which is hard to be distinguished from other diseases such as malignant tumors and tuberculosis due to its nonspecific clinical signs and symptoms. If pelvic actinomycosis can be diagnosed preoperatively, the patients can be cured with antimicrobial therapy avoiding surgery. It is especially of concern to distinguish pelvic actinomycosis from pelvic mass, if there is a history of intrauterine device use. We report a case of pelvic actinomycosis that was diagnosed after the postoperative pathology of a suspected uterine malignancy.

Disseminated Pelvic Actinomycosis Caused by Actinomyces Naeslundii.

Actinomycosis is a chronic bacterial infection characterized by continuous local spread, irrespective of anatomical barriers, and granulomatous suppurative inflammation. Due to its expansive local growth, it can simulate a malignant tumour. Subsequent hematogenous dissemination to distant organs can mimic metastases and further increase suspicion for malignancy. A case of severe disseminated pelvic actinomycosis associated with intrauterine device is described here. The patient presented with a pelvic mass mimicking a tumour, bilateral ureteral obstruction, ascites, multinodular involvement of the liver, lungs and spleen, inferior vena cava thrombosis and extreme cachexia. Actinomycosis was diagnosed by liver biopsy and confirmed by culture of Actinomyces naeslundii from extracted intrauterine contraceptive device (IUD). Prolonged treatment with aminopenicillin and surgery resulted in recovery with moderate sequelae.

Added-Value of Endometrial Biopsy in the Diagnostic and Therapeutic Strategy for Pelvic Actinomycosis.

The particularity of pelvic actinomycosis lies in the difficulty of establishing the diagnosis prior to treatment. The objective of this retrospective bicentric study was to evaluate the pertinence and efficacy of the different diagnostic tools used pre- and post-treatment in a cohort of patients with pelvic actinomycosis. The following data were collected: clinical, paraclinical, type of treatment, and the outcome and pertinence of the two diagnostic methods, bacteriological or histopathological, were evaluated. Twenty-seven women were included, with a pre-treatment diagnosis proposed for 66.7% (n = 18) of them. The diagnosis was established in 13.6% (n = 3) of cases through bacteriological samples, and in 93.8% (n = 15) of cases through histopathological samples, with endometrial biopsy positive in 100% of cases. The treatment was surgical with antibiotics for 55.6% (n = 15) of patients, medical with antibiotic therapy for 40.7% (n = 11) of patients, and surgical without antibiotics for one patient. All patients achieved recovery without recurrence, with a median follow-up of 96 days (4-4339 days). Our study suggested an excellent performance of histopathological analysis, and in particular endometrial biopsy, in the diagnosis of pelvic actinomycosis. This tool allowed early diagnosis and, in some cases, the use of antibiotic therapy alone, making it possible to avoid surgery.

Actinomicosis pélvica invasiva: un desafío para el ginecólogo / Invasive pelvic actinomycosis: a challenge for the gynecologist

Resumen La actinomicosis pélvica es una infección bacteriana supurativa crónica, producida por especies de Actinomyces, principalmente Actinomyces israelii, que afecta el aparato genital interno y las estructuras vecinas, asociada al uso prolongado de dispositivo intrauterino sin control en casi la totalidad de los casos descritos en mujeres. La actinomicosis pélvica suele presentarse como un absceso tubo-ovárico y con menor frecuencia como una actinomicosis pélvica invasiva (API). La API se propaga por contigüidad desde el aparato genital hacia las vísceras adyacentes, originando un tumor pélvico difuso, de consistencia leñosa, pseudotumoral, que a menudo se confunde con una neoplasia pélvica. La API representa un gran desafío para el ginecólogo por las dificultades en su diagnóstico y manejo. Se presentan dos casos de API y se revisan los procedimientos diagnósticos y terapéuticos recomendados actualmente para el enfrentamiento de esta patología.

Abstract Pelvic actinomycosis (PA) is a chronic suppurative bacterial infection, produced by Actinomyces, mainly Actinomyces israelii. It affects the internal genital tract, adjacent structures and is associated with a prolonged intrauterine device use with an inadequate control in almost all described cases in women. Pelvic actinomycosis usually presents as a tube ovarian abscess and less frequently as invasive pelvic actinomycosis (IPA). The IPA spreads contiguously from the genital tract to adjacent viscera, causing a diffuse, woody, pseudotumoral pelvic tumor that is frequently confused with a pelvic neoplasm. The IPA represents a great challenge for the gynecologist due to the difficulties in the diagnosis and management of this disease. Two cases of IPA are presented and the currently recommended diagnostic and therapeutic procedures for dealing with this pathology are reviewed.

Actinomicosis: dos casos clínicos ginecológicos. No sólo los DIUs tienen la culpa / Actinomycosis: two gynaecological clinical cases. It's not just IUDs to blame

Introducción: La actinomicosis pélvica ha sido descrita en la literatura como asociada al uso de dispositivos intrauterinos, pero no siempre guarda relación con ellos. Hallazgos clínicos: En este artículo describimos dos casos de abscesos pélvicos en dos pacientes con cirugías previas y endometriosis, sin antecedente de uso de DIU. Diagnóstico: En ambas pacientes se aisló Actinomyces turicensis en los cultivos de los abscesos, entre otros microorganismos, siendo diagnosticadas de actinomicosis pélvica. Tratamiento: Las dos pacientes precisaron de drenaje quirúrgico de los abscesos y tratamiento antibiótico durante el ingreso y, una vez que se les dio de alta, requirieron un tratamiento de mantenimiento durante meses con amoxicilina. Resultados: Las dos pacientes mostraron resolución del cuadro clínico, analítico y radiológico durante el seguimiento posterior. Conclusión: Hacemos especial hincapié en la importancia de sospechar y tratar esta infección a tiempo, para evitar cirugías agresivas, así como realizar un adecuado diagnóstico diferencial con otros procesos que pueden presentar síntomas similares.(AU)

Introduction: Pelvic actinomycosis has been described in the literature associated with the use of intrauterine devices, but it is not always related to them. Clinical findings: In this article we describe two cases of pelvic abscesses in two patients with previous surgeries and endometriosis, without a history of IUD use. Diagnosis: Actinomyces turicensis was isolated in both patients in abscess cultures, among other microorganisms, being diagnosed with pelvic actinomycosis. Treatment: The two patients required surgical drainage of the abscesses and antibiotic treatment during admission and once they were discharged, they required maintenance treatment for months with Amoxicillin. Results: Both showed resolution of the clinical, analytical and radiological features during the subsequent follow-up. Conclusion: We place special emphasis on the importance of suspecting and treating this infection in time, to avoid aggressive surgeries and to carry out an adequate differential diagnosis with other processes that can give similar symptoms.(AU)

Preoperative Diagnosis and Medical Treatment of Pelvic Actinomycosis

The diagnosis of the pelvic actinomycosis is seldom made preoperatively because of no reliable or specific clinical manifestation which has tendency to mimic advanced gynecological malignancy and the relative infrequency of the disease. To explore the method for improvement of preoperative diagnosis and possibility of avoiding the surgical management of pelvic actinomycosis, we collected and summarized the data of age, parity, state of menopause, history of intrauterine device (IUD) use, symptoms, laboratory findings, radiologic findings, provisional diagnosis and treatment from 14 cases diagnosed pathologically and treated in Hanyang University Hospital from 2000 to 2007. Eleven (78.6%) of 14 cases were IUD users. Most common complaints were lower abdominal pain (71.4%) and vaginal discharge (57.1%) which were followed by fever (28.6%) and back pain (28.6%). Four cases (28.6%) were identified as pelvic actinomycosis before operation and in 3 cases (21.4%) malignancy was provisional preoperative diagnosis. Pelvic actinomycosis was suspected via abdominal computed tomography (CT) or cervicovaginal cytology and confirmed via endometrial biopsy or fine needle aspiration biopsy. Two cases that were diagnosed before operation and received only antibiotics therapy had no recurrence. It was suggested that pelvic actinomycosis could be suspected via abdominal CT and cervicovaginal cytology in IUD users, and endometrial biopsy and fine needle aspiration biopsy may help establish the diagnosis before the operation. Adequate preoperative antibiotics therapy could make extensive exploratory surgery avoided or conservative surgery feasible.

Pelvic Actinomycosis: Is It Possible to Diagnose Preoperatively?

PURPOSE: Pelvic actinomycosis is a rare infection which presents difficulty in establishing a correct preoperative diagnosis. The aim of this study is to find diagnostic clues for pelvic actinomycosis preoperatively. METHODS: A retrospective analysis performed at Chonbuk National University Hospital identified 9 patients with a diagnosis of pelvic actinomycosis from 1998 to 2006. RESULTS: All patients were women with a history of intrauterine device (IUD) use. Abdominal pain (7 cases), palpable mass (3 cases), defecation difficulty (3 cases) and leucorrhea (2 cases) were the main presenting complaints. The median duration of presenting symptoms was 78 days (range: 10~365 days). The median duration of using an IUD unchanged was 11 years (range: 4~30 years). A correct diagnosis was made in 3 patients (33%) without exploration. All patients were treated with antibiotics after pathologic diagnosis. There was no recurrence. CONCLUSIONS: It is very difficult to diagnose pelvic actinomycosis preoperatively. Howere, if a mass or a pelvic abscess is found in women with an IUD that has been unchanged for a long time, pelvic actinomycosis should be suspected to avoid unnecessary exploration.

A clinical analysis of pelvic actinomycosis / 대한산부인과학회지

OBJECT: Pelvic actinomycosis is a relatively rare chronic suppurative and granulomatous infectious disease, caused by a gram-positive anaerobic bacteria. Actinomyces israelli is the most common subtype in human disease commonly associated with intrauterine device (IUD). This study was designed to analyze clinical and laboratory characteristics of patients with pelvic actinomycosis. METHODS: We reviewed medical records of 12 patients with pelvic actinomycosis who were admitted between January 1, 1995 and December 31, 2005. The clinical characteristics, diagnostic evaluation and surgical treatment results were retrospectively analyzed. RESULTS: The ages of the cases varied between 30 and 53 years old. Of the 12 patients, 11 patients had been using an IUD. Two cases had hydronephrosis due to infection. All our cases involved ovary and/or uterus and had predisposing factors of disease progression, including IUD, dilatation and curretage. Most common presenting symptom of patients were abdominal pain (75%). Preoperatively, 5 cases were diagnosed as actinomycosis, but 7 cases misconceived as a pelvic malignancy, secondary degenerated myoma and tuboovarian abscess. Exploration were performed in all patients. All cases were cured following surgery with subsequent antibiotics. CONCLUSION: Actinomycosis should be considered preoperatively, especially in long-term IUD usage, fever and laboratory findings that indicate the presence of pelvic infection. Radiologic findings (CT) can assist in making the diagnosis of pelvic actinomycosis. Appropriate antibiotics, as well as surgery, are important in the treatment of pelvic actinomycosis.

A clinical study of the treatment of pelvic actinomycosis / 대한산부인과학회지

OBJECTIVE: Pelvic actinomycosis is a rare disease, which make chronic granulomatous suppurative pelvic abscess caused by an anaerobic Gram positive organism Actinomyces israelii usually associated with intra-uterine devices, and difficult to diagnose exactly before operation. Pelvic actinomycosis is frequently confused with gynecologic malignancy, leading to misdiagnosis and overtreatment. We experienced 8 cases of pelvic actinomycosis and provide the advice for treatment of pelvic actinomycosis METHODS: We reviewed retrospectively the medical chart of 8 cases which have visited to Department of Obstetrics and Gynecology, College of Medicine, Anam Hospital, Korea University for pelvic actinomycosis from January 1999 to January 2007. RESULTS: The mean age of patients was 45.2 years old. Main symptoms were abdominal pain, vaginal bleeding, vaginal discharge, dysmenorrhea and fever with chilling. All cases have used the intrauterine devices for 5-20 years. 3 cases were diagnosed preoperatively by endometrial biopsy, punch biopsy, or empirically, and the others suspected to tuboovarian abscess or malignancy, and then their diagnoses were conformed by operation. 5 cases were treated by operation following antibiotics therapy, and 2 cases by antibiotics without operation, and 1 case by antibiotics therapy following operation. All cases were completely cured. CONCLUSION: In the treatment of pelvic actinomycosis, most important point is making the diagnosis before operation for decreasing complication such as bowel, bladder, and other pelvic organ injury. Inevitably, if the diagnosis was established by operation, postoperative high-dose antibiotic therapy was needed for several months.

A Case of Pelvic Actinomycosis with Right Ureter Obstruction and Hydronephrosis / 대한산부인과학회지

Pelvic actinomycosis is a rare infectious disease in female genital organ, which occurs most commonly with intrauterine device. Because of it's diverse clinical manifestation and progress, the diagnosis is made postoperatively by pathologic confirm in most cases and adequate medical treatment is required. Ureter obstruction is one of the common complication of pelvic actinomycosis, but it's management has been very variable by cases. If physician operate this after adequate management of ureter and preoperative antibiotics therapy, the risk of pelvic structure injury is reduced and then a patient can be saved from an extensive surgical procedure. We experienced a case of pelvic actinomycosis complicated by tubo-ovarian abscess with ureter obstruction and hydronephrosis, improving by Double J catheter insertion and preoperative antibiotics therapy and report it with brief review of literatures.

4 Cases of pelvic actinomycosis associated with intrauterine contraceptive device / 대한산부인과학회지

Pelvic actinomycosis is a rare chronic anaerobic infectious disease, which occurs most commonly in association with an IUD. It is difficult to diagnose the disease initially. In most cases, the diagnosis is made postoperatively because of its diverse clinical manifestations and courses. Besides it is frequently misdiagnosed as pelvic malignancy or endometriosis. If physician has a full understand to these characteristics of pelvic actinomycosis, the use of preoperative antibiotics can reduce the risk of pelvic structure injuries and then a patient can be saved from an extensive surgical procedure. We experienced four cases of pelvic actinomycosis complicated by tubo-ovarian abscess in women wearing IUD and report it with a brief review. In three cases, it was helpful that preoperative intravenous antibiotics therapy.

A Case of Pelvic and Abdominal Wall Actinomycosis / 대한산부인과학회지

Actinomyces species are gram-positive, non-acid fast anaerobic bacteria that exhibit branching, filamentous growth. More recently, It reported that female genital actinomycosis has been associated with the use of an intrauterine contraceptive device (IUD). We have experienced a case of pelvic and abdominal wall actinomycosis with mucinous cystadenoma in a 36-years-old woman using IUD and report it with brief review of literature.

A Clinical Study of Pelvic Actinomycosis / 대한산부인과학회잡지

OBJECTIVE: Actinomycosis is a rare entity, especially in the female genital tract, which presents some difficulties in establishing a correct preoperative diagnosis. Pelvic actinomycosis can mimick pelvic or intra- abdominal malignancy leading to mutilating surgical exercise. The authors surveyed 12 cases of pelvic actinomycosis for advice to detection and treatment of the pelvic actinomycosis. METHODS: The authors studied retrospectively 12 cases which have admitted to Department of Obstetrics and Gynecology, College of Medicine, University of Ulsan, Asan Medical Center for pelvic actinomycosis from January. 1, 1991 to December. 31, 2000. RESULTS: 41.7% of the cases occurred in 31-40 years age group, 91.7% of cases associated with intrauterine devices for 5-21 years. Most common complaints were abdominal pain and palpable mass, and other complaints were vaginal discharge, bowel habit change, nausea, vomiting and fever. The actinomycosis lesions involved one or both ovaries in all 12 cases. In 11 cases, the lesions extended to other areas, such as the uterus, parametrium, pelvic walls, cul-de-sac, colon and bladder. All patients underwent surgery that included removal of the lesions with ipsilateral or bilateral adnexa and, in specific cases, with extension of the lesions, hysterectomy, colostomy and primary repair of bladder or rectum. After surgery, 9 patients were treated with penicillin and the duration of treatment was 12 months in 2 patients, 6 months in 3, < or = 3 months in 3 and one patient was being treated for 2 months. Other 3 patients were treated with metronidazole, cephalosporin and aminoglycoside during 1-3 weeks. All patients were alive and well. CONCLUSION: It is needed to make an earlier and more correct diagnosis of actinomycosis, and high-dose intravenous antibiotic therapy can reduce the risk of nearby pelvic structure injuries. In cases of pelvic actinomycosis where the abscess can be completely resectable, a shorter period of antibiotic therapy can be required.