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Actinomycosis mimicking pelvic malignancy
283
Int. J. Gynecol. Obstet.. 1989,30: 283-286 International Federation of Gynecology and Obstetrics
Actinomycosis mimicking pelvic malignancy B.A. Snowman, V.K. Malviya, W. Brown, J.M. Malone, Jr. and G. Deppe Wayne State University School of Medicine, Division of Gynecologic Oncology and Department of Obstetrics and Gynecology, Hutzel Hospital, 4707 St. Antoine, Detroit, MI 48201 (USA) (Received September 7th, 1988) (Revised and accepted November 4th, 1988)
Abstract Pelvic actinomyces, usually a complication of an intrauterine device (IUD), is uncommon and may present a diagnostic dilemma because of an atypical clinical presentation. We present a patient with a cervical tumor, extensive parametrial induration with involvement of the posterior bladder wall, and regional lymph nodes which mimicked advanced cervical cancer and presented a significan t diagnostic problem.
Keywords: plasms .
Actinomycosis;
Cervix;
Neo-
Case report
A 26-year-old woman, gravida 2, para 2, presented with the complaint of a right groin mass. The patient denied symptoms of abnormal vaginal bleeding, dysuria, fever chills, weight loss or gastrointestinal dysfunction. An IUD (Lippes loop) had been in place for 4 years prior to its removal 1 year previously. There was no past history of abnormal pap smears. Physical examination revealed a healthy appearing, afebrile patient in no acute distress. Significant findings included a 0020-7292/89/$03.50
0 1989 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
tender, woody, right inguinal lymph node 3 cm in diameter and two nontender, woody, left inguinal lymph nodes each 0.5 cm in diameter. Bimanual examination revealed a hard, superficially ulcerated, friable cervix, approximately 4 cm in size. Bilateral parametrial induration extending to both the pelvic sidewalls was present. The uterosacral ligaments were also indurated. A clinical diagnosis of Stage III-B carcinoma of the cervix was made. The patient was admitted to the hospital for examination under anesthesia, cervical and inguinal lymph node biopsies and cystoscopy * Significant laboratory findings revealed a WBC count of 7300/ mm3, BUN of 10 mg/dl, and creatinine of 0.4 mg/dl. Diagnostic radiographic studies were limited because of the patient’s history of intravenous contrast allergy. Ultrasound of the pelvis revealed a 5 x 6 cm right parametrial mass with a necrotic center. The mass was contiguous with the cervix and appeared to invade the posterior surface of the urinary bladder (Fig. 1). These findings appeared to confirm the clinical impression of cervical cancer with bladder involvement. At cystoscopy, areas of marked irregularity of the right posterolateral bladder mucosa were biopsied. The patient underwent a D and Case Report
284
Snowman et al.
Fig. 1. Pelvic ultrasound showing a 5 x 6 cm right parametrial mass (M) with a necrotic center. The mass is contiguous with the cervix and appears to invade the posterior wall of the bladder (B). The uterus (LJ)is also seen. (R) patient’s right, (L) patient’s left.
C, cervical biopsies and right inguinal lymph node excision. Frozen section of one right inguinal lymph node demonstrated actinomycotic-like granules (Fig. 2). Bladder biopsies showed non-specific chronic inflammation and all specimens were negative for acid fast bacilli. Final cultures of the surgical specimen reported Actinomyces israelii and Wolinella recta (Fig. 2). This is a recently described species, previously not reported in association with Actinomyces israelii[ 11. Discussion Pelvic actinomycosis which otherwise rarely is encountered in the female genital tract is directly related to the use of an IUD. In one series, 80% of patients afflicted with Int J Gynecol Obstet 30
pelvic actinomycosis had IUDs in place for more than 3 years [2]. Presenting symptoms may include pelvic mass, weight loss, fever, change in bowel habits and menstrual patterns. Bladder involvement, however, is rare. The differential diagnosis includes pelvic neoplasms, abscesses, terminal ileitis and pelvic tuberculosis, and in this case cervical malignancy. This serious infection commonly results in permanent infertility and is not related to life style, sexual habits, race, socioeconomic status or the type of IUD used. Microorganisms responsible for IUD related infections are often associated with IUD or string surface deposits [3]. These deposits are frequently encountered on IUDs which have been in place for 2 years or more
ActinomycosC mimicking pelvic malignancy
Fig. 2. Frozen section of right inguinal lymph node biopsy showing actinomycotic-like and peripheral protein “clubs”. H and E stain x1000.
and are uniformly seen on IUDs in place for 3 years or more. The biotransformation process may be interrupted by changing IUDs every 2 years [3]. Actinomycosis is caused by an anaerobic microorganism that does not penetrate intact mucous membranes. These lesions often contain anaerobic bacteria which make isolation of Actinomyces difficult. In addition to gram staining, suspected lesions should be cultured. Parenteral penicillin therapy, followed by prolonged oral therapy, is the treatment of choice. Radical surgical removal of the involved organ or debridement may be an important adjunct. Although there are probably few IUDs being placed in utero today, there are still
285
granule (G) with gram positive filaments
many women with IUDs in-situ. Many of these women elect to keep the IUD because of the convenience and reliability offered with this method of birth control. This complication, albeit rare, will continue to be encountered with prolonged IUD use. Patient education regarding the importance of changing IUDs every 2 years may help to prevent IUD-related infectious complications. References 1
Tanner AC, Badger S, Lai CH, Listgarten MA, Visconti BA, Socransky SS: Wolinella gen. nov., Wolinellasuccinogenes (Vibrio succinogenes Wolin et al.) comb. nov., and description of Bacteroides gracilb sp. nov., Wolinella recta sp. nov., Campylobacter conchs sp. nov., and Eikenella corrodens from humans with periodontal disease. Int J Syst Bacterial 31: 432, 1981,, Case Report
286
2
3
Snowman et al.
Schmidt WA, Bedrossian CWM, Ali V, Webb JA, Bastian FO: Actinomycosis and intrauterine contraceptive devices. The clinicopathologic entity. Diagnos Gynecol Obstet2: 165,198O. Schmidt WA, Schmidt KL: Intrauterine device (IUD) of pathogenic associated pathology: a review mechanisms. Scan Electron Microsc II: 735, 1986.
Int J Gynecoi Obstet 30
Address for reprints: G. DcPpe Deputment of Obstetrics and Gynecology Htliael Hospital 4707 St. Antoine Detroit, MI 48201,USA
Int. J. Gynecol. Obstet.. 1989,30: 283-286 International Federation of Gynecology and Obstetrics
Actinomycosis mimicking pelvic malignancy B.A. Snowman, V.K. Malviya, W. Brown, J.M. Malone, Jr. and G. Deppe Wayne State University School of Medicine, Division of Gynecologic Oncology and Department of Obstetrics and Gynecology, Hutzel Hospital, 4707 St. Antoine, Detroit, MI 48201 (USA) (Received September 7th, 1988) (Revised and accepted November 4th, 1988)
Abstract Pelvic actinomyces, usually a complication of an intrauterine device (IUD), is uncommon and may present a diagnostic dilemma because of an atypical clinical presentation. We present a patient with a cervical tumor, extensive parametrial induration with involvement of the posterior bladder wall, and regional lymph nodes which mimicked advanced cervical cancer and presented a significan t diagnostic problem.
Keywords: plasms .
Actinomycosis;
Cervix;
Neo-
Case report
A 26-year-old woman, gravida 2, para 2, presented with the complaint of a right groin mass. The patient denied symptoms of abnormal vaginal bleeding, dysuria, fever chills, weight loss or gastrointestinal dysfunction. An IUD (Lippes loop) had been in place for 4 years prior to its removal 1 year previously. There was no past history of abnormal pap smears. Physical examination revealed a healthy appearing, afebrile patient in no acute distress. Significant findings included a 0020-7292/89/$03.50
0 1989 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
tender, woody, right inguinal lymph node 3 cm in diameter and two nontender, woody, left inguinal lymph nodes each 0.5 cm in diameter. Bimanual examination revealed a hard, superficially ulcerated, friable cervix, approximately 4 cm in size. Bilateral parametrial induration extending to both the pelvic sidewalls was present. The uterosacral ligaments were also indurated. A clinical diagnosis of Stage III-B carcinoma of the cervix was made. The patient was admitted to the hospital for examination under anesthesia, cervical and inguinal lymph node biopsies and cystoscopy * Significant laboratory findings revealed a WBC count of 7300/ mm3, BUN of 10 mg/dl, and creatinine of 0.4 mg/dl. Diagnostic radiographic studies were limited because of the patient’s history of intravenous contrast allergy. Ultrasound of the pelvis revealed a 5 x 6 cm right parametrial mass with a necrotic center. The mass was contiguous with the cervix and appeared to invade the posterior surface of the urinary bladder (Fig. 1). These findings appeared to confirm the clinical impression of cervical cancer with bladder involvement. At cystoscopy, areas of marked irregularity of the right posterolateral bladder mucosa were biopsied. The patient underwent a D and Case Report
284
Snowman et al.
Fig. 1. Pelvic ultrasound showing a 5 x 6 cm right parametrial mass (M) with a necrotic center. The mass is contiguous with the cervix and appears to invade the posterior wall of the bladder (B). The uterus (LJ)is also seen. (R) patient’s right, (L) patient’s left.
C, cervical biopsies and right inguinal lymph node excision. Frozen section of one right inguinal lymph node demonstrated actinomycotic-like granules (Fig. 2). Bladder biopsies showed non-specific chronic inflammation and all specimens were negative for acid fast bacilli. Final cultures of the surgical specimen reported Actinomyces israelii and Wolinella recta (Fig. 2). This is a recently described species, previously not reported in association with Actinomyces israelii[ 11. Discussion Pelvic actinomycosis which otherwise rarely is encountered in the female genital tract is directly related to the use of an IUD. In one series, 80% of patients afflicted with Int J Gynecol Obstet 30
pelvic actinomycosis had IUDs in place for more than 3 years [2]. Presenting symptoms may include pelvic mass, weight loss, fever, change in bowel habits and menstrual patterns. Bladder involvement, however, is rare. The differential diagnosis includes pelvic neoplasms, abscesses, terminal ileitis and pelvic tuberculosis, and in this case cervical malignancy. This serious infection commonly results in permanent infertility and is not related to life style, sexual habits, race, socioeconomic status or the type of IUD used. Microorganisms responsible for IUD related infections are often associated with IUD or string surface deposits [3]. These deposits are frequently encountered on IUDs which have been in place for 2 years or more
ActinomycosC mimicking pelvic malignancy
Fig. 2. Frozen section of right inguinal lymph node biopsy showing actinomycotic-like and peripheral protein “clubs”. H and E stain x1000.
and are uniformly seen on IUDs in place for 3 years or more. The biotransformation process may be interrupted by changing IUDs every 2 years [3]. Actinomycosis is caused by an anaerobic microorganism that does not penetrate intact mucous membranes. These lesions often contain anaerobic bacteria which make isolation of Actinomyces difficult. In addition to gram staining, suspected lesions should be cultured. Parenteral penicillin therapy, followed by prolonged oral therapy, is the treatment of choice. Radical surgical removal of the involved organ or debridement may be an important adjunct. Although there are probably few IUDs being placed in utero today, there are still
285
granule (G) with gram positive filaments
many women with IUDs in-situ. Many of these women elect to keep the IUD because of the convenience and reliability offered with this method of birth control. This complication, albeit rare, will continue to be encountered with prolonged IUD use. Patient education regarding the importance of changing IUDs every 2 years may help to prevent IUD-related infectious complications. References 1
Tanner AC, Badger S, Lai CH, Listgarten MA, Visconti BA, Socransky SS: Wolinella gen. nov., Wolinellasuccinogenes (Vibrio succinogenes Wolin et al.) comb. nov., and description of Bacteroides gracilb sp. nov., Wolinella recta sp. nov., Campylobacter conchs sp. nov., and Eikenella corrodens from humans with periodontal disease. Int J Syst Bacterial 31: 432, 1981,, Case Report
286
2
3
Snowman et al.
Schmidt WA, Bedrossian CWM, Ali V, Webb JA, Bastian FO: Actinomycosis and intrauterine contraceptive devices. The clinicopathologic entity. Diagnos Gynecol Obstet2: 165,198O. Schmidt WA, Schmidt KL: Intrauterine device (IUD) of pathogenic associated pathology: a review mechanisms. Scan Electron Microsc II: 735, 1986.
Int J Gynecoi Obstet 30
Address for reprints: G. DcPpe Deputment of Obstetrics and Gynecology Htliael Hospital 4707 St. Antoine Detroit, MI 48201,USA