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Tubo-ovarian abscess secondary to actinomycosis: unexpectedpresentation and its treatment
Received: 3 January 2014 /Accepted: 4 November 2014 /Published online: 15 November 2014# Springer-Verlag Berlin Heidelberg 2014
Abstract This is a case of an ovarian actinomycosis diag-nosed as a complex ovarian cyst by ultrasound in asymptom-atic patient. The ovarian tumour markers were within normal.The tube and ovary were removed laparoscopically. She re-ceived 2 weeks of daily IV 1 g of ceftriaxone, followed by6 months of oral amoxicillin. CT scan did not show evidenceof actinomycosis elsewhere. She did not give any history ofintrauterine contraceptive use.
Keywords Actinomycosis . Intrauterine device .
Actinomycosis is an uncommon, chronic granulomatous dis-ease caused by filamentous, gram-positive, non-spore-forming anaerobic or microaerophilic bacteria. ActinomycesIsraelii is the major human pathogen .
Actinomycetes are commensal inhabitants of the oral cav-ity and intestinal tract , but acquire pathogenicity throughinvasion of breached or necrotic tissue. As the infection pro-gresses, granulomatous tissue, extensive reactive fibrosis andnecrosis, abscesses, draining sinuses and fistulas are formed. The disease tends to spread by contiguity. Lymphadenop-athy is not a clinical feature. Haematogenous dissemination isalso rare . Pelvic actinomycosis is typically associated withthe use of intrauterine device (IUD) .
A 31-year-old lady was referred to the gynaecology clinicbecause of an ultrasound finding of a complex right ovariancyst of 544945 mm (Fig. 1). The ultrasound was per-formed because of the past history of severe right iliac fossapain which lasted only for a day and subsided completelyafter. The ovarian tumour markers (CA125, CA19-9, CEA,BHCG, lactic dehydrogenase, alpha feto protein) were withinnormal values. She has only one child whom she deliveredvaginally. The combined pills were her method for contracep-tion. She had no previous history of use of intrauterine con-traceptive device. All her previous cervical smears were neg-ative and none of them showed actinomycosis. Preoperativefull blood count revealed normal white cell count. Laparosco-py showed signs of pelvic infection in the form of omentaladhesions to the anterior parietal peritoneum and adhesionsbetween the liver and the diaphragm (Fitz Hugh Curtis syn-drome). There was right adnexal mass. The ovary could not bevisualized separate from themass. This picture was suggestiveof chronic inflammatory mass. The right adnexal mass wasremoved intact through the laparoscopic Endo Catch. The cystcontained yellowish thick material.
The histology report (Figs. 2, 3 and 4) came as right tubo-ovarian abscess with actinomyces like organisms. Daily intra-venous ceftriaxone (1 g) were given through a long line for2 weeks. This is followed by 6 months of oral amoxicillin.
Postoperative CT scan did not show any other lesion in theabdomen or the pelvis.
Ovarian actinomycosis is rare because the structure of theovary is resistant to surrounding inflammatory disease .It has been assumed that bacteria enter the ovary when the
M. Moustafa (*)Frimley Park Hospital, Surrey, UKe-mail: email@example.com
Gynecol Surg (2015) 12:5355DOI 10.1007/s10397-014-0871-3
surface is broken by the process of ovulation. Timely detec-tion and treatment prevents complications such as pelvicactinomycotic masses leading to frozen pelvis. A delay indiagnosis can even be fatal . Direct extension fromestablished ileocaecal actinomycosis was believed to involvethe female genital tract .
Computed tomography is the most useful imagingmodality. It determines the location and extent of thedisease, occasionally contributes to an accurate preoper-ative diagnosis through fine needle aspiration and isused for monitoring the radiologic response to treatmenton follow-up examinations .
Although actinomycetes are sensitive to penicillin,surgery is usually performed to eradicate the inflamma-tory process . The usual recommended antibioticregimen is intravenous penicillin G (1824 million
units/day) for 26 weeks, followed by oral penicillinor amoxicillin for 612 months .
In this case, there were no clinical features to suggestthat the adnexal mass is an ovarian abscess. CT/MRIscan has not been done initially, as the tumour markerswere normal. However, preoperative diagnosis of anovarian abscess by CT/MRI scan may help to speedthe surgery. The laparoscopic findings of omental andliver adhesions were suggestive of pelvic infection. It isvery difficult to know how she gets infected with acti-nomycosis as there was no history of IUD use orileocaecal disease. Postoperative CT scan was requestedto exclude any hidden source of actinomycosis. Long-term treatment of penicillin was required to minimizethe recurrence of actinomycosis and to treat other un-recognized source.
Very few cases of ovarian actinomycosis without a previ-ous history of IUD have been reported .
Fig. 1 Ultrasound images of thetubo-ovarian abscess
Fig. 2 The tubo-ovarian abscess after surgical removal Fig. 3 Microscopy. Actinomycosis. H&E 400
54 Gynecol Surg (2015) 12:5355
Tubo-ovarian actinomycosis was diagnosed in a healthywoman who had never used the intrauterine contraceptivedevice and with no past history of pelvic infection. Treatmentof actinomycosis consists of adequate surgery, such as drain-age of the abscess and reduction of infected tissue and long-term antibiotic therapy.
Acknowledgments The author is grateful to Dr. Emma Hutley(consultant microbiologist) and Dr. Richard Stitson (consultanthistopathologist) for their help in preparation of this article.
Conflict of interest MagdyMoustafa declares that he has no conflict ofinterest.
Informed consent was obtained from the patient for which identifyinginformation is included in this article.
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Fig. 4 Microscopy. Actinomycosis. Grocott silver 400
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Tubo-ovarian abscess secondary to actinomycosis: unexpected presentation and its treatmentAbstractIntroductionCase presentationDiscussionConclusionReferences