Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 6  |  Issue : 4  |  Page : 468-471  

Bilateral ovarian actinomycosis masquerading as ovarian malignancy; without any history of intra-uterine contraceptive device


Department of Pathology, SRL Diagnostics – KCDC, Mysore, Karnataka, India

Date of Web Publication17-Sep-2013

Correspondence Address:
Anitha Basavaraj Chalageri
Department of Pathology, SRL Diagnostics - KCDC, L 25/2A, Irwin Road, Mysore - 570 001, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.118295

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  Abstract 

Actinomycosis in the pelvic region is an uncommon diagnosis. This infection is caused by Actinomyces israelii, a gram-positive anaerobic saprophyte bacterium that is a normal inhabitant of the upper intestinal tract in humans. Pelvic actinomycosis is difficult to diagnose pre-operatively and is diagnosed, in most cases, accidentally. Actinomycosis can mimic pelvic and abdominal malignancies. A case report of a 35-year-old female patient with a fixed pelvic mass is presented. Despite the broad use of tumor markers, sonography and computerized tomography, the differentiation between benign and malignant pelvic masses is still a clinical challenge. Accurate differential diagnosis is necessary because the treatment strategies vary greatly. A case of actinomycotic inflammatory disease, which was misdiagnosed as an advanced ovarian cancer, is reported.

Keywords: Actinomycosis, actinomycotic pelvic inflammatory disease, intra-uterine device, intra-uterine device-associated pelvic actinomycosis, papanicolaou smears, sulphur granules


How to cite this article:
Srinivas GN, Chalageri AB, Gupta A, Vijayanand M. Bilateral ovarian actinomycosis masquerading as ovarian malignancy; without any history of intra-uterine contraceptive device. Med J DY Patil Univ 2013;6:468-71

How to cite this URL:
Srinivas GN, Chalageri AB, Gupta A, Vijayanand M. Bilateral ovarian actinomycosis masquerading as ovarian malignancy; without any history of intra-uterine contraceptive device. Med J DY Patil Univ [serial online] 2013 [cited 2024 Feb 24];6:468-71. Available from: https://journals.lww.com/mjdy/pages/default.aspx/text.asp?2013/6/4/468/118295


  Introduction Top


Actinomycosis is a chronic suppurative granulomatous infection characterized by the formation of abscesses, multiple draining sinuses and appearance of tangled mycelial masses or sulfur granules in the discharges and tissue sections. [1] Human actinomycotic disease is described in cervicofacial, thoracic and abdominal regions where the list comprises 20% of the affliction. [1],[2] The lesion of the genital tract is thought to have its origin from a focus in the ileocaecal segment of the intestine. [1] Ascending type of actinomycotic infection involving the adnexa following insertion of intrauterine contraceptive device have been reported. [1]

Female genitalia is relatively a rare site for pelvic actinomycosis, the detection rate being as low as 2%. [3] Pelvic actinomycosis is often unsuspected clinically as Actinomyces do not inhabit the vaginal canal. Adnexal involvement is usually secondary to infection in the gastrointestinal canal. [1] Almost 85% of cases occur in women who have had an intra-uterine device (IUD) in place for 3 or more years. [4] The diagnosis of actinomycosis can be confirmed by culture. However, it is often difficult to culture Actinomyces. In fact, the isolation rate of Actinomyces in patients with pelvic actinomycosis is as low as 2%. [4] Therefore, a diagnosis of actinomycosis can be made from the finding of sulfur granules within the inflammatory exudate on histologic examination after surgery. However, it may be possible to diagnose actinomycosis before surgery by the finding of Actinomyces-like organisms on Papanicolaou smears. [4]

We discuss a case of a patient with ovarian actinomycosis who presented with bilateral tuboovarian masses, without history of IUD implantation and underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy for the same.


  Case Report Top


A 35-year-old female presented with abdominal pain, weight loss, and poor appetite for the past 6 months before consultation. She had no history of IUD implantation and had undergone tubectomy 8 years back. Physical examination revealed a pelvic mass. Laboratory examination showed leucocytosis (18,000/mm 3 ) and anemia (hemoglobin, 9.4 g/dl). The serum cancer antigen-25 level was 20.4 U/ml (normal, 0-35 U/ml). Ultrasonogram showed a hypoechoic pelvic mass pushing the urinary bladder. Abdominopelvic contrast enhancing computed tomogram scan showed a large, predominantly solid, pelvic mass involving bilateral adnexa and pushing the urinary bladder anteriorly. Possible presence of an advanced ovarian cancer with local dissemination was suspected. Cervical smear reported elsewhere showed nonspecific inflammatory changes.

On exploratory laparotomy, bilateral ovaries were seen to be replaced by a mass, extending to the lateral pelvic wall and involving the broad ligament. The findings were suggestive of a malignant tumor; hence, a total hysterectomy with bilateral salpingo-oophorectomy was performed and sent for histopathological examination.

On gross examination, the specimen consisted of the uterus with cervix with bilateral tuboovarian masses [Figure 1]. Uterus measured 11.0 cm × 6.0 cm × 4.0 cm. Cut section showed normal endomyometrium and a unhealthy cervix. Ovarian masses measured 12.0 cm × 7.0 cm × 5.0 cm and 7.0 cm × 5.0 cm × 4.0 cm respectively. The larger mass was partly cystic. The masses showed grey-white cut surface with areas of yellowish discoloration, hemorrhage and multiple foci of necrosis [Figure 2].
Figure 1: Gross Specimen

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Figure 2: Cut surface of the tubo-ovarian mass

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Extensive sections were taken and microscopically ovaries showed areas of fibrosis, dense collections of chronic inflammatory cells and multiple microabscesses enclosing many bacterial colonies composed of central basophilic material with radiating eosinophilic filaments [Figure 3], [Figure 4], [Figure 5]. The final diagnosis was disseminated pelvic actinomycosis. The filamentous organisms were positive for grams and periodic acid schiff stains. They were negative for Ziehl Neelsen stain, confirming them to be Actinomyces.
Figure 3: Filamentous bacterial colonies. [H & E, 5X]

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Figure 4: Bacterial colonies surrounded by ovarian stroma. [H & E, 10 X]

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Figure 5: Bacterial colonies surrounded by fibrotic stroma. [H & E ,10 X]

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  Discussion Top


Actinomycosis produces a characteristic granulomatous inflammatory response, with abscess formation followed by necrosis and extensive reactive fibrosis. [5] Usually caused by A. israelii, but it can be also caused by Actinomyces bovis, Actinomyces ericksonii, Actinomyces naeslundii, Actinomyces viscosus, or Actinomyces odontolyticus. Actinomyces species are gram positive, anaerobic or microaerophilic, nonspore-forming bacilli which produces sulfur granules in the tissue. [5] Clinical actinomycosis includes cervicofacial (60%), thoracic (15%), abdominal/pelvic (25%) forms. [5] Actinomycotic infections are endogenous in origin. The organism normally is of low pathogenicity and multiplies in a favorable environment provided by the injured necrotic tissue. [5] Female genitalia is relatively a rare site for pelvic actinomycosis. [1],[3] Pelvic actinomycosis is often unsuspected clinically as Actinomyces do not inhabit the vaginal canal. [1],[3] Adnexal involvement is usually secondary to infection in the gastrointestinal canal. [1],[3] Ovarian actinomycosis is rare because the structure of the ovary is resistant to surrounding inflammatory disease. [6] It has been assumed that bacteria enter the ovary when its surface is broken by the process of ovulation. [3] Patients complain of abdominal pain (85%), weight loss (44%), and foul-smelling vaginal discharge (24%). [5] The infection is acquired by ascending infection from the lower genital tract or a spread from an intestinal lesion. [5] This lead to the formation of granulation tissue, dense fibrosis, and abscess formation in the pelvis. It can produce a hard mass in the pelvis and may compress the ureter or intestines. [5] Thus, the clinical findings of pelvic actinomycosis are similar to those of tuboovarian abscesses or pelvic malignancies. [5],[7] However, radiological findings can help in few cases. [5]

Diagnostic dilemma is further aggravated by low yield and slow growth of Actinomyces species in culture (50%). [5] The clinical, laboratory and radiological findings of the disease are so nonspecific, as well as, lack of definite serologic tests makes it very difficult to establish the diagnosis preoperatively. In fact, a preoperative diagnosis is established in less than 10% of all cases. [5] In most cases, the diagnosis is made during the operation and confirmed by pathologic examination or at autopsy. For a definitive diagnosis, it is necessary to demonstrate microscopically either the pathogen itself or the sulfur granules on the slides of the biopsy materials or smear materials from the tract of the sinus. [5]

With the increasing popularity of Intrauterine contraceptive device (IUCD), actinomycotic infection is on an increase. The prevalence of actinomycosis in IUD wearers ranges from 1.6% to 11.6%.

Likewise, long forgotten tampoons and pessaries may also be associated with pelvic actinomycosis in women.  Actinomyces israelii Scientific Name Search eported to be associated with I.U.C.D. [1]

When actinomycosis is diagnosed early and treated with appropriate antibiotic therapy, the prognosis is excellent. Timely detection and treatment prevents complications such as pelvic actinomycotic masses leading to frozen pelvis. A delay in diagnosis can even be fatal. [8]


  Conclusion Top


In conclusion, pelvic actinomycosis can mimic an infiltrating malignancy and re-evaluation of the radiological features along with a preoperative ultrasound guided biopsy, a history of IUD use, A. israelii detection on Papanicolau smears and absence of serum tumor markers may help in reaching a diagnosis. It is also important to look for infection at other sites.

 
  References Top

1.Shroff CP, Deodhar KP, Patkar VD, Fonseca JH. Tubo-ovarian actinomycosis. J Postgrad Med 1981;27:29-32.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.Loth MF. Actinomycosis of the fallopian tube. Am J Obstet Gynecol 1956;72:919-21.  Back to cited text no. 2
[PUBMED]    
3.Singh S, Batra A, Dua S, Duhan A. Ovarian actinomycosis: Presenting as ovarian mass without any history of intra-uterine copper device. J Glob Infect Dis 2012;4:222-3.  Back to cited text no. 3
[PUBMED]    
4.Iwasaki M, Nishikawa A, Akutagawa N, Fujimoto T, Teramoto M, Kudo R. A case of ovarian actinomycosis. Infect Dis Obstet Gynecol 2003;11:171-3.  Back to cited text no. 4
    
5.Kumar N, Das P, Kumar D, Kriplani A, Ray R. Pelvic actinomycosis mimicking: An advanced ovarian cancer. Indian J Pathol Microbiol 2010;53:164-5.  Back to cited text no. 5
[PUBMED]  Medknow Journal  
6.Koshiyama M, Yoshida 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 Gynecol Reprod Biol 1999;87:95-9.  Back to cited text no. 6
[PUBMED]    
7.Putman HC Jr, Dockerty MB, Waugh JM. Abdominal actinomycosis; an analysis of 122 cases. Surgery 1950;28:781-800.  Back to cited text no. 7
[PUBMED]    
8.Munot MV, Tambekar R, Veerkar V, Shinde P. Actinomycotic salphingitis: A complication of misplaced Cu-T. J Obstet Gynecol India 2007;57:442-3.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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