Tubo-ovarian abscess secondary to actinomycosis: unexpected presentation and its treatment
© Springer-Verlag Berlin Heidelberg 2014
Received: 3 January 2014
Accepted: 4 November 2014
Published: 15 November 2014
This is a case of an ovarian actinomycosis diagnosed as a complex ovarian cyst by ultrasound in asymptomatic patient. The ovarian tumour markers were within normal. The tube and ovary were removed laparoscopically. She received 2 weeks of daily IV 1 g of ceftriaxone, followed by 6 months of oral amoxicillin. CT scan did not show evidence of actinomycosis elsewhere. She did not give any history of intrauterine contraceptive use.
Actinomycosis is an uncommon, chronic granulomatous disease caused by filamentous, gram-positive, non-spore-forming anaerobic or microaerophilic bacteria. Actinomyces Israelii is the major human pathogen .
Actinomycetes are commensal inhabitants of the oral cavity and intestinal tract , but acquire pathogenicity through invasion of breached or necrotic tissue. As the infection progresses, granulomatous tissue, extensive reactive fibrosis and necrosis, abscesses, draining sinuses and fistulas are formed . The disease tends to spread by contiguity. Lymphadenopathy is not a clinical feature. Haematogenous dissemination is also rare . Pelvic actinomycosis is typically associated with the use of intrauterine device (IUD) [5–12].
Postoperative CT scan did not show any other lesion in the abdomen or the pelvis.
Ovarian actinomycosis is rare because the structure of the ovary is resistant to surrounding inflammatory disease . It has been assumed that bacteria enter the ovary when the surface is broken by the process of ovulation. Timely detection and treatment prevents complications such as pelvic actinomycotic masses leading to frozen pelvis. A delay in diagnosis can even be fatal . Direct extension from established ileocaecal actinomycosis was believed to involve the female genital tract .
Computed tomography is the most useful imaging modality. It determines the location and extent of the disease, occasionally contributes to an accurate preoperative diagnosis through fine needle aspiration and is used for monitoring the radiologic response to treatment on follow-up examinations .
Although actinomycetes are sensitive to penicillin, surgery is usually performed to eradicate the inflammatory process . The usual recommended antibiotic regimen is intravenous penicillin G (18–24 million units/day) for 2–6 weeks, followed by oral penicillin or amoxicillin for 6–12 months .
In this case, there were no clinical features to suggest that the adnexal mass is an ovarian abscess. CT/MRI scan has not been done initially, as the tumour markers were normal. However, preoperative diagnosis of an ovarian abscess by CT/MRI scan may help to speed the surgery. The laparoscopic findings of omental and liver adhesions were suggestive of pelvic infection. It is very difficult to know how she gets infected with actinomycosis as there was no history of IUD use or ileocaecal disease. Postoperative CT scan was requested to exclude any hidden source of actinomycosis. Long-term treatment of penicillin was required to minimize the recurrence of actinomycosis and to treat other unrecognized source.
Tubo-ovarian actinomycosis was diagnosed in a healthy woman who had never used the intrauterine contraceptive device and with no past history of pelvic infection. Treatment of actinomycosis consists of adequate surgery, such as drainage of the abscess and reduction of infected tissue and long-term antibiotic therapy.
The author is grateful to Dr. Emma Hutley (consultant microbiologist) and Dr. Richard Stitson (consultant histopathologist) for their help in preparation of this article.
Conflict of interest
Magdy Moustafa declares that he has no conflict of interest.
Informed consent was obtained from the patient for which identifying information is included in this article.
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