PELVIC ACTINOMYCOSIS PRESENTING AS SUSPECTED NEOPLASM – A case report

Objective

To review a case of pelvic actinomycosis which presented as a case of suspected neoplasm.

 

Case Report

A 44-year-old lady presented with a history of heavy menstrual bleeding, cramps, increased vaginal discharge and stress incontinence. She had a Mirena coil (levonogestrel-releasing intrauterine system) fitted 10 years ago, which was still in situ.

Imaging studies showed a serpiginous right-sided solid enhancing mass lesion concerning for an underlying fallopian tube neoplasm with moderate volume free fluid in the pelvis. She underwent a hysteroscopy with biopsy, laparoscopic bilateral salpingectomy, peritoneal biopsy, omental biopsy and peritoneal washings. Tumour markers, preoperative haematology and biochemical bloods were normal. Histology findings showed acute and chronic endometritis, bilateral salpingitis with abscess formation on right fallopian tube with actinomycosis.

 

Discussion

Actinomycosis is an infection caused by gram-positive bacteria. It is a rare and invasive organism that is filamentous and non-spore forming. It is found as a commensal organism within gastrointestinal, oropharyngeal and female genital tract [1]. The organism is opportunistic and results in a chronic infection that mimic malignant pelvic tumours or tuberculosis [2].

The second most prevalent clinical presentation of actinomycosis is pelvic actinomycosis, with an intrauterine device being a prominent route [2]. The facilitation of the pathogen is theorised to be through wires of the device within the cervix that cultivate bacterial growth, as well as the effects of the intrauterine device on the endometrial lining encouraging inflammation [3]. Associated symptoms are non-specific such as pelvic pain, intermenstrual bleeding, weight loss and increased vaginal secretion [3]. The infection can subsequently spread, causing destruction of ovarian parenchyma and fallopian tubes. Biochemical analysis could show raised inflammatory markers, anaemia and mildly elevated Ca 125.

Diagnostic imaging can reveal a tumour like mass [4]. Confirmatory diagnosis can be achieved via histological analysis and further microbiological investigation.

The treatment of actinomycosis involves the removal of the intrauterine device, surgical drainage and a prolonged course of penicillin-based antibiotics (4-6 weeks)[3].

 

Conclusion

Pelvic actinomycosis is a rare phenomenon. Having an intrauterine device is a known risk factor for it. It is therefore important to suspect the diagnosis for patients with an intrauterine device and pelvic mass to ensure adequate management. Once diagnosed, it is treatable, and patients make a full recovery.

 

References

1. Smego, Jr., R.A. and Foglia, G. (1998) “Actinomycosis,” Clinical Infectious Diseases, 26(6), pp. 1255–1261.

2. García-García, A. et al. (2017) “Pelvic actinomycosis,” Canadian Journal of Infectious Diseases and Medical Microbiology, 2017, pp. 1–17.

3. Ferry, T. et al. (2014) “Actinomycosis: Etiology, clinical features, diagnosis, treatment, and management,” Infection and Drug Resistance, p. 183.

4. Pérez-López, F. (2010) “Female pelvic actinomycosis and intrauterine contraceptive devices,” Open Access Journal of Contraception, p. 35.