Abdominal and pelvis actinomycosis: a diagnostic and surgical challenge for the general surgeon. ISSN Abdominal and pelvic actinomycosis is a fairly rare chronic suppurative infectious disease of very infrequent presentation. The most frequent clinical presentation of the disease involves the neck, the entire facial area, the thorax and the abdomino-pelvic cavity. The latter has been associated with the chronic use more than five years of the intrauterine contraceptive device IUD.
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Actinomycosis is a chronic bacterial infection caused by Actinomyces , Gram-positive anaerobic bacteria. Its symptomatology imitates some malignant pelvic tumours, tuberculosis, or nocardiosis, causing abscesses and fistulas.
Actinomycoses are opportunistic infections and require normal mucous barriers to be altered. No epidemiological studies have been conducted to determine prevalence or incidence of such infections. To analyse the clinical cases of pelvic actinomycosis reported worldwide, to update the information about the disease. A systematic review of worldwide pelvic actinomycosis cases between and was performed, utilising the PubMed, Scopus, and Google Scholar databases.
The following information was analysed: year, country, type of study, number of cases, use of intrauterine device IUD , final and initial diagnosis, and method of diagnosis. Pelvic actinomycosis is confusing to diagnose and should be considered in the differential diagnosis of pelvic chronic inflammatory lesions. It is commonly diagnosed through a histological report, obtained after a surgery subsequent to an erroneous initial diagnosis. A bacterial culture in anaerobic medium could be useful for the diagnosis but requires a controlled technique and should be performed using specialised equipment.
Actinomycosis is an uncommon condition whose symptomatology imitates some malignant pelvic tumours, tuberculosis, or nocardiosis because it spreads progressively and continuously [ 3 ].
This pathology invades tissue layers, causing the formation of abscesses and fistulae. Its diagnosis is difficult, and it results in increased morbimortality. Actinomyces belong to the phylum Actinobacteria and to the order Actinomycetales. Hundreds of Actinomyces species exist, most of which inhabit the soil. Others are associated with plants, which participate in nitrogen fixation, and a few species live in human beings as saprophytic bacteria [ 2 ].
It should be highlighted that most Actinomyces spp. Actinomycoses are opportunistic chronic infections [ 4 ], as Actinomyces have a low potential for virulence in connection with fimbriae. Therefore, they require normal mucosal barriers to be altered through trauma, surgery, or an infection. In this way, they cross the mucosal membrane or epithelial surface [ 4 — 6 ]. For example, a pulmonary infection can be caused by bronchoaspiration [ 5 , 7 ], or a pelvic infection can originate from the use of an intrauterine device IUD , which can injure or perforate the mucosal membrane of the uterus and facilitate infection [ 3 ].
Currently, various clinical characteristics of actinomycosis have been described, and the bacterium has been observed in various anatomical sites e. Other clinical types include thoracic actinomycosis, the third most common type of actinomycosis, which includes pulmonary, bronchial, and laryngeal actinomycosis [ 3 ], and abdominal actinomycosis, where the appendix, caecum, and colon are the most common sites of infection.
Actinomycosis of the central nervous system is located chiefly in the cerebral abscess. Actinomycosis of the urogenital tract is the second most common clinical form of actinomycosis, and the principal clinical presentation is pelvic actinomycosis [ 3 , 5 , 8 ]. Pelvic actinomycosis can affect any age group, with no preference for occupation or season and is secondary to perforation or fistulation [ 4 ]. Other possible causes include bacterial vaginosis, which fosters an anaerobic environment and is associated with other microorganisms [ 51 ]; the presence of tumours [ 66 ]; and the use of IUDs [ 3 — 5 ].
The possibility of a contagion through oral sex has been considered because these bacteria are part of the oral cavity microbiota [ 72 ]. One possible route of dissemination is through IUDs, which fosters the growth of microorganisms through wires that are left in the exocervix. In addition, the IUD changes the carbohydrate metabolism in endometrial cells, fostering still more inflammation.
Another probable route is the perineum, where the microorganisms could extend from the anus up through the cervicovaginal zone [ 4 ]. The most common aetiological agent is Actinomyces israelii [ 5 , 73 ]. Other reported species include A. The symptoms of pelvic actinomycosis associated with the use of an IUD can imitate symptoms of gynaecological malignant tumours, uterine myoma, or adenomyosis when presenting as a genital mass without fever [ 3 ].
The infection can disseminate to the uterine tubes and can cause salpingitis and the subsequent destruction of the ovarian parenchyma [ 4 ]. Organs such as the bladder, ileocaecal iliac fossa and rectosigmoid region, colon, urethra, and extension to the skin have been reportedly affected in various published cases. The diagnosis of pelvic actinomycosis is obtained using various techniques because culturing Actinomyces spp.
First, the signs and symptoms of the patients are considered and can point to a possible abdominal infection, vaginitis, abscess, or possible tumour-forming process.
The most common symptoms are weight loss, nonspecific abdominal or pelvic pain, breakthrough bleeding or abundant vaginal flow, and, on rare occasions, fever [ 3 , 4 , 51 ]. Upon medical exploration, the affected zone is palpated to detect hard masses, and a gynaecological exam is performed to check for inflammation of the vaginal mucous membrane, yellowish secretion with a bad smell, or some visible damage to the mucous membrane [ 4 , 51 ].
In laboratory studies, it is possible to identify leucocytosis, erythropaenia, and high sedimentation rate; high values of C-reactive protein; and tumour marker values within the reference ranges or slightly elevated like Ca Alpha-fetoprotein , and cancer antigen 15—3 [ 3 , 4 , 51 ].
Diagnostic images, such as computed tomography, magnetic resonance, ultrasound, X-rays, and laparoscopy are helpful, as they can be used to observe the affected zone, such as a tumour-forming mass that can induce either actinomycosis or a carcinogenic process [ 4 , 51 , 73 ]. In most cases, histological visualisation of biopsy or aspirated samples is employed, where bacilli in the tissue with their typical ramifications, such as in interconnected breasts, are observed.
Cervicovaginal cells are collected for Papanicolaou Pap staining. In many cases, the diagnosis is made a posteriori through a histological examination of samples obtained surgically during laparotomy or laparoscopy, but rarely in a preoperative manner. Histological studies of tissues show inflammatory changes of suppurative and granulomatous nature, connective proliferation, and sulphur granules, which have also been identified in infections caused by Nocardia brasiliensis, Actinomadura madurae, and Staphylococcus aureus.
These granules are particles of yellowish colour, which, when viewed by the naked eye, are formed by groups of filamentous Actinomyces surrounded by neutrophils [ 73 ]. Two methods exist for completely identifying the causal agent: culture and identification through biochemical tests and identification through sequencing of the 16S rRNA segment, which offers greater precision.
Although these methods are very efficient, they are not well reported in the literature due to the conditions under which they must be performed, requiring an anaerobic culture environment and the necessary equipment, which is costly. Clindamycin, tetracycline, and erythromycin are an alternative in cases of allergy to penicillin [ 4 , 5 ]. In addition to these medicines, it has been observed that Actinomyces is also sensitive to third-generation cephalosporins, ciprofloxacin, trimethoprim-sulfamethoxazole, and rifampicin [ 4 ].
However, the elimination of the injured tissue and surgical drainage are necessary measures in some cases [ 5 ], and, in these patients, the duration of antimicrobial therapy could be reduced 3 months [ 3 ]. Beedham et al. Clinical cases of pelvic actinomycosis have been reported in Africa, Oceania, Asia, Europe, and America. However, as pelvic actinomycosis is an uncommon infection, no epidemiological studies have been conducted to determine its prevalence or incidence.
A systematic review of worldwide cases of pelvic actinomycosis between the years and was performed. Abstracts of articles identified to be relevant for the objective of this paper were read; studies whose abstract or full text was unavailable were automatically excluded.
When an abstract complied with inclusion criteria, the full text was analysed. Case reports that lacked a diagnostic method and a final diagnosis of pelvic actinomycosis were excluded. Studies published in a language that was not English, Spanish, French, or Portuguese were not included. The following information was extracted and analysed from the compiled studies: year, country, type of study, number of cases, prior use of IUD and duration, initial diagnosis, treatment, definitive diagnosis, and method of definitive diagnosis Figure 1.
The search yielded a total of studies; were excluded from the title, abstract, and language screening; 96 more were excluded for not being available in full text format and for not meeting the selection criteria when reading the full article. A total of 63 studies including 86 case reports of pelvic actinomycosis, along with 8 cross-sectional studies of reports examining populations for cases of Microorganisms Similar to Actinomyces MSA , were included for this review Figure 1.
From the African continent, 3 articles of clinical cases were found, totalling 8 clinical cases. The pathology that was first diagnosed in these cases was an ovarian tumour. The method of diagnosis that was utilised to definitively diagnose patients with actinomycosis was histopathological reporting Table 1.
The most common treatments were hysterectomy, laparotomy, and antibiotic therapy. No follow-up data was presented. From Oceania, 1 article was published that included 3 clinical cases with the following ages: 56, 70, and 37 years; two of them were copper IUD users. In the three cases, malignant lesions were initially diagnosed; the final diagnosis was performed postoperatively.
Salpingo-oophorectomy along with antibiotic therapy was used in all the cases; patients fully recovered after treatment. Table 2. Fourteen articles of 16 clinical cases came from Asia, the age of the patients ranged between 25 and 86 years, and the average age was The majority of patients were IUD users, with a usage time of 1 year to more than 20 years; most of the studies did not specify the type of IUD used.
However, cases in nonusers were also reported, despite the well-known relationship between IUD use and pelvic actinomycosis. The most common presumptive diagnostic was malignant lesions, while, in other cases, Crohn's disease and acute peritonitis were also suspected. The most utilised diagnostic method was histological reporting after surgical interventions, which were invasive in most cases, such as hysterectomy and salpingo-oophorectomy along with antibiotic therapy.
Most of the patients had a full recovery or at least a significant improvement after follow-up; only a case of renal sequelae was reported. Table 3. Twenty clinical case report articles including 39 cases of pelvic actinomycosis originated from Europe, in which ages ranged from 18 to 65 years; average age was 40 years SD The cases principally included female IUD users, with a usage time ranging from 1.
The predominant presumptive diagnosis was malignant lesion; other suspected diagnoses included Crohn's disease, acute appendicitis, endometrial infection, pelvic inflammatory disease, and abscesses.
Postoperative histopathological reports were the most common definitive diagnostic methods. The most common treatments used were damaged tissue excision, laparotomy, and salpingo-oophorectomy together with antibiotic therapy.
The majority of the articles do not have follow-up information, nonetheless studies reporting patient follow-up stated that they fully recovered after treatment, and there is one report of death Table 4. With regard to America, 16 articles with reports of 20 clinical cases exist. The ages of patients ranged between 18 and 58 years with an average age of All patients were IUD users except one case, and the time of device use ranged from 22 months to 33 years. Tubo-ovarian and pelvic abscesses along with malignant lesions were the conditions with the greatest diagnostic confusion.
Similar to the other summaries, the postsurgical histological reports were the most reported definitive diagnostic methods. Salpingo-oophorectomy and laparotomy along with prolonged antibiotic therapy were the most used therapeutic measures.
After treatment most of the patients had a full or significant recovery. Table 5. Eight cross-sectional studies of reports worldwide that examine populations for cases of actinomycosis or MSA were analysed. The prevalence of pelvic actinomycosis was low. In this type of report, the diagnosis methods reviewed were the Pap reports. However, it is important to emphasise that what is reported in these analyses are MSA. Only 3 articles reported actinomycosis as such, and only one report completely identified the causal agent through culture and biochemical assays Table 6.
According to the analysis of the articles presented, Europe was the continent on which the greatest number of cases of pelvic actinomycosis was reported, followed by Asia and America.
Paulina Daniels S. Universidad de los Andes, Santiago, Chile. Pelvic actinomycosis is a chronic granulomatous disease quite uncommon; it is caused by positive Gram bacilli, and clinically it may appear as a pelvic neoplasia. We present a case report in which the infection was pursued actively, achieving excellent results with medical treatment. Figura 1. TAC de abdomen y pelvis donde se observa proceso infiltrativo anexial derecho e hidroureteronefrosis derecha.
2019, Number 2