|Year : 2016 | Volume
| Issue : 2 | Page : 231-233
Endometrial actinomycosis associated with intrauterine contraceptive device forgotten for 44 years
Shailaja Prabhala1, Jayashankar Erukkambattu1, Menaka Basavanapalli2, Ramamurti Tanikella1
1 Department of Pathology, Kamineni Academy of Medical Sciences and Research Centre, Hyderabad, Telangana, India
2 Department of Obstetrics and Gynecology, Kamineni Academy of Medical Sciences and Research Centre, Hyderabad, Telangana, India
|Date of Web Publication||1-Mar-2016|
H. No. 8-14/1, Ravindra Nagar Colony, Street No. 8, Habsiguda, Hyderabad - 500 007, Telangana
Source of Support: None, Conflict of Interest: None
Intrauterine contraceptive devices (IUCD) are an effective way for contraception. Proper patient education at the time of placing the IUCD is important. Otherwise, they may not come for device removal at appropriate time, and it may be left in situ and forgotten, which can lead to complications at a later date. Here, we present a case of a 76-year-old lady who came with postmenopausal bleeding due to a forgotten IUCD leading to actinomycotic endometritis. The device was removed hysteroscopically under general anesthesia followed by appropriate antibiotics and the patient recovered well.
Keywords: Actinomycosis, endometrium, intrauterine contraceptive devices, postmenopausal
|How to cite this article:|
Prabhala S, Erukkambattu J, Basavanapalli M, Tanikella R. Endometrial actinomycosis associated with intrauterine contraceptive device forgotten for 44 years. Med J DY Patil Univ 2016;9:231-3
| Introduction|| |
The intrauterine device (IUD) is an effective contraceptive for many women.  Also, the association of Actinomyces with intrauterine contraceptive device (IUCD) is well-known, and approximately 7% of women using an IUCD may show Actinomyces-like organisms on a Papanicolaou test.  The association between pelvic actinomycosis and IUCD usage was first described in 1926.  The colonization of IUCD is not equivalent to infection by these organisms, and if there are no symptoms then neither antimicrobial treatment nor removal of the IUCD is indicated.  However, when IUCDs are forgotten in situ they can lead to various local/systemic complications and sometimes even disseminated infection. 
| Case Report|| |
A 76-year-old female patient presented to the gynecology outpatient department with the complaints of bleeding per vaginum and mild lower abdominal pain since 6 days. She had no other complaints. She had a single child delivered 45 years ago, which was a full term normal vaginal delivery. Her menstrual and obstetric history was not otherwise significant. She gave a history of IUCD insertion 44 years ago. She did not remember whether the IUCD was subsequently removed or expelled and had forgotten about it. She attained menopause at the age of 50 years and since then had no problems until the recent episode of postmenopausal bleeding. She had no history of diabetes mellitus, hypertension or any other comorbidities. She had no major or minor surgeries in the past.
On examination, her vitals were stable, she was nontoxic, mildly febrile with a temperature of 99° Fahrenheit. The abdomen was soft with mild tenderness in lower abdominal region. There was no organomegaly. Per speculum examination showed scanty bleeding through the os and foul smelling brownish discharge. IUCD threads were visible. The cervix was atrophic. Per vaginal examination showed an atrophic uterus that was anteverted, mobile and the fornices were free. No mass lesion was found. There was mild tenderness on cervical motion. Rest of the systemic examination was within normal limits.
On investigations, her preoperative work up was within normal limits. Urinalysis showed slightly turbid urine with albumin 2+, and plenty of pus cells under microscopy. The abdominal and pelvic ultrasound examination showed an atrophic uterus, 43 mm × 26 mm × 25 mm in size. The endometrial thickness was 4 mm and there was a linear echogenic focus in the mid-endometrial cavity.
After satisfactory preoperative evaluation, the IUCD which was a lippes loop [Figure 1] was removed hysteroscopically under general anesthesia, and endometrial biopsy was also done. Her postprocedure period was uneventful. She was discharged and advised for follow-up.
On the pathology, the specimen consisted of multiple, greyish brown, irregular bits of tissue admixed with yellowish granules altogether 2 mL in volume. The microscopy showed fragments of atrophic endometrial tissue composed mainly of stromal elements having dense acute and chronic inflammatory infiltrate. Many basophilic clumps of finely filamentous structures were present, some exhibiting the Splendore-Hoeppli phenomenon. Special stains - Gram's stain and the Silver-Methenamine stain [Figure 2]a-c were carried out, which demonstrated Actinomyces filaments. The histopathology was reported as endometrial inflammation associated with Actinomyces. The tissue was not submitted for culture so the species could not be identified.
|Figure 2: (a) Atrophic endometrium with clumps of basophilic material and dense inflammation (H and E, ×100). (b) Clumps of actinomycotic filaments (H and E, ×400). (c) Gram positive actinomycotic clumps (Gram's stain, ×100). (d) Clumps of fine black actinomycotic filaments (Silver-Methenamine stain, ×400)|
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| Discussion|| |
Actinomyces species are Gram positive, nonacid fast, anaerobic, microaerophilic bacteria that have branching and filamentous growth. Actinomyces israelli is the most common subtype associated with human infections.  They are commensals in the oral cavity and gastrointestinal tract. The predisposing factors, for acquiring the infection, are destruction of the mucosal barrier by any trauma, chronic inflammatory disease, operative procedures, and immunosuppression.  In situ IUCDs cause mild inflammatory changes in the endometrium with necrosis that creates an anaerobic environment that favors the growth of Actinomyces and also other anaerobes and especially the long-term use of IUCD (more than 5 years) also confers increased risk for actinomycosis.  Sometimes actinomycosis exhibits Splendore-Hoeppli phenomenon on tissue microscopy, that is, club-shaped configurations, which comprise of antigen-antibody complex, tissue debris and fibrin. It is thought to be a localized immunological response to fungi, bacteria, parasites or biologically inert material.  Our patient had an IUCD in situ for a prolonged period of 44 years. Chatwani and Amin-Hanjani have reported the incidence of IUCD-associated cervico-vaginal actinomycosis on Pap smear More Detailss with colonization rates of 11.4%.  Furthermore, the incidence is slightly higher for plastic devices versus metal copper IUD devices. , Our patient had a plastic lippes loop in situ associated with actinomycosis. Sozen et al. have also reported a similar case of a retained IUCD (Dalkon Shield), which was retained for 33 years associated with subsequent endometrial actinomycosis.  Phupong et al. have reported a case of lippes loop associated actinomycotic infection with uterine perforation.  The Actinomyces can also spread via hematogenous route and cause disseminated disease.  Endometrial actinomycosis can occur even in the absence of IUCD use as reported by Sharma et al.  One cannot predict which IUCD user colonized by Actinomyces will develop severe pelvic infection and hence, all IUCD users should have an annual gynecological follow-up.  The copper releasing IUD (copper T 380A) can be used for 10 years before replacement and should be removed at expiration  or at the time of menopause whichever is earlier. It must be ensured that the IUCD is removed after it has served its purpose. 
Clinicians and patients must be aware of the risks of pelvic infections especially actinomycosis when intrauterine or intravaginal devices are used and appropriate instructions are to be given to the patient with regard to the timing for the device removal.
| Conclusion|| |
Intrauterine contraceptive devices are known for their association with actinomycosis. Forgotten IUCDs left in situ for prolonged periods can lead to actinomycotic infections of the uterus, which can present as postmenopausal bleeding. Patient education is extremely important and appropriate and clear instructions should be given to the patient at the time of IUCD insertion regarding the time of its removal so as to avoid complications of a forgotten and retained IUCD.
| References|| |
Johnson BA. Insertion and removal of intrauterine devices. Am Fam Physician 2005;71:95-102.
Westhoff C. IUDs and colonization or infection with Actinomyces
. Contraception 2007;75 6 Suppl:S48-50.
Draper JW, Studdiford WE. Report of a case of Actinomyces
of the tubes and ovaries. Am J Obstet Gynecol 1926;11:603-8.
Apothéloz C, Regamey C. Disseminated infection due to Actinomyces meyeri
: Case report and review. Clin Infect Dis 1996;22:621-5.
Kayikcioglu F, Akif Akgul M, Haberal A, Faruk Demir O. Actinomyces
infection in female genital tract. Eur J Obstet Gynecol Reprod Biol 2005;118:77-80.
Carkman S, Ozben V, Durak H, Karabulut K, Ipek T. Isolated abdominal wall actinomycosis associated with an intrauterine contraceptive device: A case report and review of the relevant literature. Case Rep Med 2010;2010:340109.
Valicenti JF Jr, Pappas AA, Graber CD, Williamson HO, Willis NF. Detection and prevalence of IUD-associated Actinomyces
colonization and related morbidity. A prospective study of 69,925 cervical smears. JAMA 1982;247:1149-52.
Hussein MR. Mucocutaneous Splendore-Hoeppli phenomenon. J Cutan Pathol 2008;35:979-88.
Chatwani A, Amin-Hanjani S. Incidence of actinomycosis associated with intrauterine devices. J Reprod Med 1994;39:585-7.
Sozen I, Morgan K, Shannon JS. Postmenopausal bleeding secondary to a Dalkon Shield retained for 33 years: A case report. J Reprod Med 2005;50:216-8.
Phupong V, Sueblinvong T, Pruksananonda K, Taneepanichskul S, Triratanachat S. Uterine perforation with Lippes loop intrauterine device-associated actinomycosis: A case report and review of the literature. Contraception 2000;61:347-50.
Sharma S, Valiathan M, Rao L, Pai MV. Actinomycosis in post-menopausal female in the absence of an intrauterine contraceptive device: A rare cause of bleeding per vaginum. J Clin Diagn Res 2012;6:1062-3.
Perez-Lopez FR, Tobajas JJ, Chedrani P. Female pelvic actinomycosis and intrauterine contraceptive devices. Open Access J Contracept 2010;1:35-8.
Kriplani A, Buckshee K, Relan S, Kapila K. ′Forgotten′ intrauterine device leading to actinomycotic pyometra-13 years after menopause. Eur J Obstet Gynecol Reprod Biol 1994;53:215-6.
[Figure 1], [Figure 2]