Preoperative Diagnosis and Medical Treatment of Pelvic Actinomycosis

Hong Jue Lee; Su Jin Lee; Young Jae Kim; Sung Hee Kim; Jung Han Lee; Seung Ryoung Kim; Sam Hyun Cho

doi:10.4167/jbv.2008.38.2.89

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Lee, Lee, Kim, Kim, Lee, Kim, and Cho: Preoperative Diagnosis and Medical Treatment of Pelvic Actinomycosis

Original Article

J Bacteriol Virol 2008;38(2):89-95.

Published online: 18 February 2008

DOI: https://doi.org/10.4167/jbv.2008.38.2.89

Preoperative Diagnosis and Medical Treatment of Pelvic Actinomycosis

Hong Jue Lee, Su Jin Lee, Young Jae Kim, Sung Hee Kim¹, Jung Han Lee¹, Seung Ryoung Kim¹, Sam Hyun Cho^∗,

Department of Obstetrics and Gynecology, Hanyang University Hospital, Seoul, Republic of Korea

¹Department of Obstetrics and Gynecology, Hanyang Guri Hospital, Guri, GyeongGi-Do, Republic of Korea

^∗Corresponding author: Sam Hyun Cho. Department of Obstetrics and Gynecology, Hanyang University Hospital, 17 HaengDang-dong, Seongdong-gu, Seoul, 133-792, Republic of Korea. Phone: +82-2-2290-8417, Fax: +82-2-2296-8412, e-mail: chosh@hanyang.ac.kr

Received 19 May 2008 Revised 10 June 2008 Accepted 11 June 2008

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

The diagnosis of the pelvic actinomycosis is seldom made preoperatively because of no reliable or specific clinical manifestation which has tendency to mimic advanced gynecological malignancy and the relative infrequency of the disease. To explore the method for improvement of preoperative diagnosis and possibility of avoiding the surgical management of pelvic actinomycosis, we collected and summarized the data of age, parity, state of menopause, history of intrauterine device (IUD) use, symptoms, laboratory findings, radiologic findings, provisional diagnosis and treatment from 14 cases diagnosed pathologically and treated in Hanyang University Hospital from 2000 to 2007. Eleven (78.6%) of 14 cases were IUD users. Most common complaints were lower abdominal pain (71.4%) and vaginal discharge (57.1%) which were followed by fever (28.6%) and back pain (28.6%). Four cases (28.6%) were identified as pelvic actinomycosis before operation and in 3 cases (21.4%) malignancy was provisional preoperative diagnosis. Pelvic actinomycosis was suspected via abdominal computed tomography (CT) or cervicovaginal cytology and confirmed via endometrial biopsy or fine needle aspiration biopsy. Two cases that were diagnosed before operation and received only antibiotics therapy had no recurrence. It was suggested that pelvic actinomycosis could be suspected via abdominal CT and cervicovaginal cytology in IUD users, and endometrial biopsy and fine needle aspiration biopsy may help establish the diagnosis before the operation. Adequate preoperative antibiotics therapy could make extensive exploratory surgery avoided or conservative surgery feasible.

Keywords: Pelvic actinomycosis, Abdominal CT, Cervicovaginal cytology, Endometrial biopsy, Fine needle aspiration biopsy

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Table 1.

General characteristics of 14 patients with pelvic actinomycosis

General characteristics		No	%
Age	20∼29	1	7.1
	30∼39	4	28.6
	40∼49	6	42.9
	50∼59	1	7.1
	60+	2	14.3
Menopause	No	11	78.6
	Yes	3	21.4
History of IUD use	No	3	21.4
	Yes	11	78.6
Parity	Nullipara	1	7.1
	Primipara	4	28.6
	Multipara	9	64.3
Abortion	0	1	7.1
	1∼3	10	71.4
	4∼8	3	21.4

Table 2.

Clinical characteristics of 14 patients with pelvic actinomycosis

Clinical characteristics		No	%
Clinical symptoms	lower abdominal pain	10	71.4
	vaginal discharge	8	57.1
	back pain	4	28.6
	fever	4	28.6
	frequency	2	14.3
	vaginal bleeding	1	7.1
	palpable mass	1	7.1
	weight loss	1	7.1
Laboratory findings	leukocytosis (>12,000/mm³)	7	50.0
	anemia (<10 g/dl)	2	14.3
	increased CRP^a (>0.3 mg/dl)	10	90.0
	increased CA125^b (>35 U/ml)	3	33.3

^a CRP (C-reactive protein); Number of tested patient were 11.

^b CA125; Number of tested patient were 9

Table 3.

Provisional diagnosis of 14 patients with pelvic actinomycosis

	Total	No. of Preoperative diagnosis
Tubo-ovarian abscess	7 (50.5)	2
Cancer	3 (21.4)	1
Myoma uteri	2 (14.3)	0
Endometritis	2 (14.3)	1
Total (%)	14 (100.0)	4

Table 4.

Summary of preoperatively diagnosed 4 cases of pelvic actinomycosis

	Clinical manifestation	Positive finding	Confirmative procedures	Antibiotics therapy
Case 1	37 years old, G4P1 IUD user Lower abdominal pain Vaginal discharge	Abdominal CT: Poorly-defined heterogeneous inflammatory mass in the left ovary with extensive mesenteric fat infiltration Unenhanced diffuse thickening of cervix Localized wall thickening of cecum and sigmoid colon secondary to actinomycosis	Fine needle aspiration biopsy	Penicillin G 10–40millon unit IV × 6 weeks Ampicillin 2 g PO × 10 weeks
Case 2	70 years old, G6P6 IUD user Vaginal discharge	Pap smear	Endometrial biopsy	2^nd generation cephalosporin IV × 5 days Ampicillin 2 g PO × 2weeks
Case 3	39 years old, G6P2 IUD user Palpable mass, back pain Fever	Abdominal CT: Enhancing multiseptated huge mass of right ovary and adnexa. Another mass of left ovary and adnexa. Combined extensive mesenteric inflammatory change. IUD insertion state. Pap smear	Right salpingooophorectomy Adnesiolysis	Ubacillin(Ampicillin/Sulbactam) 18 g IV × 2 weeks Ampicillin 1.5 g PO × 4 weeks
Case 4	44 years old, G7P1 IUD user Lower abdominal pain Frequency	Abdominal CT: Irregular shaped soft tissue attenuated mass in the left anterior aspect of bladder IUD insertion state	Total abdominal hysterectomy Left salpingooophorectomy Partial omentectomy Segmental resection of sigmoid colon Partial cystectomy Incidental appencectomy Adhesiolysis	Penicillin G 10million unit × 2 weeks Augmentin PO × 2 weeks (Amoxicillin 750 mg Clavulanic acid 450 mg)

Table 5.

Preoperative diagnosis rate in various case series studies

Study	Year of diagnosis	No. of cases	IUD user (%)	Preoperative Diagnosis		Treatment		Recurrence
Study	Year of diagnosis	No. of cases	IUD user (%)	Malignancy	Actinomycosis	Surgery	Antibiotics only	Recurrence
Choi et al., 2002 (2)	1991∼2000	12	11 (91.7%)	5 (41.7%)	0 (0.0%)	12	0	No
Bae et al., 2007 (1)	1995∼2005	12	11 (91.7%)	3 (25%)	5 (41.6%)	12	0	No
Hwang et al., 2007 (10)	1998∼2006	9	9 (100.0%)	4 (44.4%)	3 (33.3%)	7	2	No
Lee et al., 2007 (14)	1999∼2007	8	8 (100.0%)	1 (12.5%)	2 (25.0%)	6	2	No
Lee el al., 2008	2000∼2007	14	11 (78.6%)	3 (21.4%)	4 (28.6%)	12	2	1

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