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Pelvic actinomycosis with secondary liver abscess, an unusual presentation
Letters to the Editor—Brief Communication / European Journal of Obstetrics & Gynecology and Reproductive Biology 163 (2012) 238–242
239
J.L. Cartmill* Department of Obstetrics and Gynaecology, Altnagelvin Area Hospital, Glenshane Road, Co. Londonderry, Northern Ireland BT47 6SB, United Kingdom *Corresponding author. Tel.: +44 02871 345171 E-mail address: [email protected] (J.L. Cartmill) 9 November 2011 http://dx.doi.org/10.1016/j.ejogrb.2012.04.008
Pelvic actinomycosis with secondary liver abscess, an unusual presentation
Fig. 1. Contrast-enhanced axial CT imaging of the abdomen demonstrates a small low-attenuation area in the periphery of the right lobe of liver (arrow). Biopsy showed inflammatory change and eosinophilic granules in keeping with actinomycete organisms.
Dear Editor, A previously healthy 38-year-old woman presented to the gynaecology out-patient clinic with a three-week history of intermittent fever and a tender mass in her lower abdomen. The patient denied weight loss or anorexia. Her last menstrual period had been three weeks prior to presentation and she reported regular menstrual periods. She had had an intrauterine contraceptive device (IUCD) in situ for four years. She denied any history of previous pelvic infection, inter-menstrual or post-coital bleeding. Her cervical smears had always been negative, her last smear having been performed three years previously. She denied any urinary symptoms. On examination, the patient was afebrile and abdominal palpation revealed a non-tender mass in the region of the left iliac fossa. Laboratory tests revealed anaemia (Hb 9.2 g/dL) leucocytosis (16.5 109/L), neutrophilia (13.9 109/L) and an elevated alkaline phosphatase level (146 U/L). Transvaginal ultrasound showed an endometrial thickness of 7.7 mm and a mixed echogenic mass, posterior to the uterus, measuring 5.7 cm 8.6 cm 5.1 cm, thought to represent a pedunculated fibroid with areas of internal degeneration. Serum levels of carcinoembryonic antigen (CEA), alpha fetoprotein (AFP) and beta human chorionic gonadotrophin (beta hCG) were normal but cancer antigen 125 (CA-125) was raised at 77 kU/L. Magnetic resonance imaging (MRI) of the pelvis demonstrated bilaterally enlarged and abnormal appearing ovaries with inflammatory or infiltrative neoplastic tissue in the right upper pelvis extending across the pelvis and closely related to bowel loops. Notably, no focal abnormality was seen in the liver. At this juncture, the differential diagnoses were pelvic malignancy with possible metastatic spread, tuberculosis and actinomycosis. Swabs were taken to exclude gonorrhoea and Chlamydia trachomatis infection: both were negative. The IUCD was removed (but regrettably, not sent for culture) and a pipelle endometrial biopsy performed. The histology report revealed chronic endometritis and organisms with centrally branching filaments representing actinomyces. Computerised tomography (CT) imaging was requested to clarify the nature of the omental abnormality demonstrated on MRI and determine if a percutaneous biopsy was possible. However, a 2.4 cm irregular low-attenuation density area (Fig. 1) was now noted in the right lobe of the liver. Omental sampling was deemed unnecessary
as histological examination of the ultrasound-guided liver biopsy revealed collections of eosinophilic granules consistent with actinomyces-induced abscess formation. A diagnosis of disseminated actinomycosis was made and the patient was commenced on amoxicillin, initially intravenously for two weeks and then orally for three months. At 3-month follow-up, the patient remained symptomatic with fever and right upper quadrant pain. A further MRI revealed a marked increase in the size of the liver lesion, which now measured 8.1 cm 3.3 cm. Fifty millilitres of frank pus was aspirated from the liver abscess. Culture of the aspirated fluid grew mixed anaerobes as well as Actinomyces israelii. Antibiotics were re-commenced, but this time co-amoxiclav was used intravenously for two weeks and then orally. Further ultrasound-guided drainage of the liver abscess was required 5 months later due, in part, to poor compliance with antibiotic treatment. Our patient was counselled accordingly and continued on co-amoxiclav for a further 7 months until symptom-free. The patient remained asymptomatic and was discharged 18 months after initial presentation with no indication for repeat imaging. Pelvic actinomycosis and its association with IUCD use is well documented, with long-term users being at an increased risk of developing actinomyces infections [1]. Disseminated actinomycosis with hepatic involvement secondary to pelvic actinomycosis associated with IUCD use is very rare, with few documented cases [2–4]. Previous cases have been successfully treated with highdose penicillin or tetracycline [2–4]. Actinomyces-like organisms are exquisitely sensitive to penicillin, but the possibility of mixed infections, as observed in this case, may require the use of broaderspectrum agents [5]. References [1] Westhoff C. IUDs and colonization or infection with actinomyces. Contraception 2007;75:S48–50. [2] Miyamoto MI, Fang FC. Pyogenic liver abscess involving Actinomyces: case report and review. Clinical Infectious Diseases 1993;16(2):303–9. [3] Kim HS, Park NH, Park KA, Kang SB. A case of pelvic actinomycosis with hepatic actinomycotic pseudotumor. Gynecologic and Obstetric Investigation 2007; 64(2):95–9. [4] Keilin S, Abrahamian F, Attar B. Intrauterine device related hepatic abscess. The American Journal of Gastroenterology 2005;100:S495. [5] Wong VK, Turmezei TD, Weston VC. Actinomycosis. British Medical Journal 2011;343:d6099.
Letters to the Editor—Brief Communication / European Journal of Obstetrics & Gynecology and Reproductive Biology 163 (2012) 238–242
240
Kate O’Kelly* Core Trainee 1, Nottingham City Hospital, Hucknall Road, Nottingham, UK Jafaru Abu Robert Hammond Nottingham City Hospital, Hucknall Road, Nottingham, UK Mary Jensen Centre for Contraception and Sexual Health, Victoria Health Centre, Glasshouse Street, Nottingham, UK R. Angus O’Connor Irshad Soomro Nottingham City Hospital, Hucknall Road, Nottingham, UK *Corresponding author at: Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK. Tel.: +44 7540999706 E-mail address: katyo’[email protected] (K. O’Kelly) 15 January 2012 http://dx.doi.org/10.1016/j.ejogrb.2012.04.009
The painful black umbilicus Dear Editor, We want to report an interesting case of a 38-year-old woman, para 2 live 2, who presented to the outpatient clinic with a complaint of a painful black umbilicus for eighteen months. There was no history of any surgery on the abdomen. Her menstrual cycles were
regular with average flow and mild dysmenorrhea only. Her last childbirth was nine months back. She had taken anti-tubercular treatment for tuberculosis of the intestine in 2008 for nine months. There was no other significant past medical/surgical or family history. On abdominal examination there was a dark brownish nodule replacing whole of the umbilicus. It was fixed to the underlying skin and was minimally tender. Speculum and vaginal examinations revealed a healthy looking cervix and vagina and a multiparous-size mobile uterus. Fine needle aspiration cytology (FNAC) from the nodule suggested endometriosis. The patient underwent excision of the endometriotic nodule with umbilical reconstruction under general anesthesia, and was discharged the same evening. Histopathology confirmed umbilical endometriosis. Pre-operative and post-operative pictures and the specimen are shown in Fig. 1. The patient is symptom-free at one year follow-up. Endometriosis affects 5–10% of fertile women [1]. It commonly occurs in the pelvic organs but has been described in almost every part of the body including the bowel, bladder, lungs, brain and surgical scars [2], and rarely, as in our case, the umbilicus. Extrapelvic endometriosis has a mean age of presentation of 34 years [3]. Patients are usually in the reproductive age group and present commonly with swelling, pain, discharge or cyclical bleeding from the umbilicus after umbilical scar. There may be associated symptoms of coexistent pelvic endometriosis and a history of laparoscopic surgery for this condition [4]. Our patient never had any pelvic surgery in the past, not even dilatation and curettage and she had never been diagnosed with pelvic endometriosis preor post-operatively. Umbilical endometriosis has been described as flesh colored, brownish, dark-bluish, or simply a subcutaneous mass. It ranges in size from 0.5 cm to 3 cm, but can enlarge to even larger sizes. The lesion becomes painful, larger and bleeds about the time of menses. Microscopically, umbilical endometriosis shows endometrial glands and stroma in the deep dermis and subcutis with glands present in a background of fibroadipose tissue. The presence of skeletal muscle indicates a deeper depth of the lesion. In cases of scant stroma or
Fig. 1. Showing pre-op, post-op picture,the histopathological image and specimen of primary umbilical endometriosis.
239
J.L. Cartmill* Department of Obstetrics and Gynaecology, Altnagelvin Area Hospital, Glenshane Road, Co. Londonderry, Northern Ireland BT47 6SB, United Kingdom *Corresponding author. Tel.: +44 02871 345171 E-mail address: [email protected] (J.L. Cartmill) 9 November 2011 http://dx.doi.org/10.1016/j.ejogrb.2012.04.008
Pelvic actinomycosis with secondary liver abscess, an unusual presentation
Fig. 1. Contrast-enhanced axial CT imaging of the abdomen demonstrates a small low-attenuation area in the periphery of the right lobe of liver (arrow). Biopsy showed inflammatory change and eosinophilic granules in keeping with actinomycete organisms.
Dear Editor, A previously healthy 38-year-old woman presented to the gynaecology out-patient clinic with a three-week history of intermittent fever and a tender mass in her lower abdomen. The patient denied weight loss or anorexia. Her last menstrual period had been three weeks prior to presentation and she reported regular menstrual periods. She had had an intrauterine contraceptive device (IUCD) in situ for four years. She denied any history of previous pelvic infection, inter-menstrual or post-coital bleeding. Her cervical smears had always been negative, her last smear having been performed three years previously. She denied any urinary symptoms. On examination, the patient was afebrile and abdominal palpation revealed a non-tender mass in the region of the left iliac fossa. Laboratory tests revealed anaemia (Hb 9.2 g/dL) leucocytosis (16.5 109/L), neutrophilia (13.9 109/L) and an elevated alkaline phosphatase level (146 U/L). Transvaginal ultrasound showed an endometrial thickness of 7.7 mm and a mixed echogenic mass, posterior to the uterus, measuring 5.7 cm 8.6 cm 5.1 cm, thought to represent a pedunculated fibroid with areas of internal degeneration. Serum levels of carcinoembryonic antigen (CEA), alpha fetoprotein (AFP) and beta human chorionic gonadotrophin (beta hCG) were normal but cancer antigen 125 (CA-125) was raised at 77 kU/L. Magnetic resonance imaging (MRI) of the pelvis demonstrated bilaterally enlarged and abnormal appearing ovaries with inflammatory or infiltrative neoplastic tissue in the right upper pelvis extending across the pelvis and closely related to bowel loops. Notably, no focal abnormality was seen in the liver. At this juncture, the differential diagnoses were pelvic malignancy with possible metastatic spread, tuberculosis and actinomycosis. Swabs were taken to exclude gonorrhoea and Chlamydia trachomatis infection: both were negative. The IUCD was removed (but regrettably, not sent for culture) and a pipelle endometrial biopsy performed. The histology report revealed chronic endometritis and organisms with centrally branching filaments representing actinomyces. Computerised tomography (CT) imaging was requested to clarify the nature of the omental abnormality demonstrated on MRI and determine if a percutaneous biopsy was possible. However, a 2.4 cm irregular low-attenuation density area (Fig. 1) was now noted in the right lobe of the liver. Omental sampling was deemed unnecessary
as histological examination of the ultrasound-guided liver biopsy revealed collections of eosinophilic granules consistent with actinomyces-induced abscess formation. A diagnosis of disseminated actinomycosis was made and the patient was commenced on amoxicillin, initially intravenously for two weeks and then orally for three months. At 3-month follow-up, the patient remained symptomatic with fever and right upper quadrant pain. A further MRI revealed a marked increase in the size of the liver lesion, which now measured 8.1 cm 3.3 cm. Fifty millilitres of frank pus was aspirated from the liver abscess. Culture of the aspirated fluid grew mixed anaerobes as well as Actinomyces israelii. Antibiotics were re-commenced, but this time co-amoxiclav was used intravenously for two weeks and then orally. Further ultrasound-guided drainage of the liver abscess was required 5 months later due, in part, to poor compliance with antibiotic treatment. Our patient was counselled accordingly and continued on co-amoxiclav for a further 7 months until symptom-free. The patient remained asymptomatic and was discharged 18 months after initial presentation with no indication for repeat imaging. Pelvic actinomycosis and its association with IUCD use is well documented, with long-term users being at an increased risk of developing actinomyces infections [1]. Disseminated actinomycosis with hepatic involvement secondary to pelvic actinomycosis associated with IUCD use is very rare, with few documented cases [2–4]. Previous cases have been successfully treated with highdose penicillin or tetracycline [2–4]. Actinomyces-like organisms are exquisitely sensitive to penicillin, but the possibility of mixed infections, as observed in this case, may require the use of broaderspectrum agents [5]. References [1] Westhoff C. IUDs and colonization or infection with actinomyces. Contraception 2007;75:S48–50. [2] Miyamoto MI, Fang FC. Pyogenic liver abscess involving Actinomyces: case report and review. Clinical Infectious Diseases 1993;16(2):303–9. [3] Kim HS, Park NH, Park KA, Kang SB. A case of pelvic actinomycosis with hepatic actinomycotic pseudotumor. Gynecologic and Obstetric Investigation 2007; 64(2):95–9. [4] Keilin S, Abrahamian F, Attar B. Intrauterine device related hepatic abscess. The American Journal of Gastroenterology 2005;100:S495. [5] Wong VK, Turmezei TD, Weston VC. Actinomycosis. British Medical Journal 2011;343:d6099.
Letters to the Editor—Brief Communication / European Journal of Obstetrics & Gynecology and Reproductive Biology 163 (2012) 238–242
240
Kate O’Kelly* Core Trainee 1, Nottingham City Hospital, Hucknall Road, Nottingham, UK Jafaru Abu Robert Hammond Nottingham City Hospital, Hucknall Road, Nottingham, UK Mary Jensen Centre for Contraception and Sexual Health, Victoria Health Centre, Glasshouse Street, Nottingham, UK R. Angus O’Connor Irshad Soomro Nottingham City Hospital, Hucknall Road, Nottingham, UK *Corresponding author at: Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK. Tel.: +44 7540999706 E-mail address: katyo’[email protected] (K. O’Kelly) 15 January 2012 http://dx.doi.org/10.1016/j.ejogrb.2012.04.009
The painful black umbilicus Dear Editor, We want to report an interesting case of a 38-year-old woman, para 2 live 2, who presented to the outpatient clinic with a complaint of a painful black umbilicus for eighteen months. There was no history of any surgery on the abdomen. Her menstrual cycles were
regular with average flow and mild dysmenorrhea only. Her last childbirth was nine months back. She had taken anti-tubercular treatment for tuberculosis of the intestine in 2008 for nine months. There was no other significant past medical/surgical or family history. On abdominal examination there was a dark brownish nodule replacing whole of the umbilicus. It was fixed to the underlying skin and was minimally tender. Speculum and vaginal examinations revealed a healthy looking cervix and vagina and a multiparous-size mobile uterus. Fine needle aspiration cytology (FNAC) from the nodule suggested endometriosis. The patient underwent excision of the endometriotic nodule with umbilical reconstruction under general anesthesia, and was discharged the same evening. Histopathology confirmed umbilical endometriosis. Pre-operative and post-operative pictures and the specimen are shown in Fig. 1. The patient is symptom-free at one year follow-up. Endometriosis affects 5–10% of fertile women [1]. It commonly occurs in the pelvic organs but has been described in almost every part of the body including the bowel, bladder, lungs, brain and surgical scars [2], and rarely, as in our case, the umbilicus. Extrapelvic endometriosis has a mean age of presentation of 34 years [3]. Patients are usually in the reproductive age group and present commonly with swelling, pain, discharge or cyclical bleeding from the umbilicus after umbilical scar. There may be associated symptoms of coexistent pelvic endometriosis and a history of laparoscopic surgery for this condition [4]. Our patient never had any pelvic surgery in the past, not even dilatation and curettage and she had never been diagnosed with pelvic endometriosis preor post-operatively. Umbilical endometriosis has been described as flesh colored, brownish, dark-bluish, or simply a subcutaneous mass. It ranges in size from 0.5 cm to 3 cm, but can enlarge to even larger sizes. The lesion becomes painful, larger and bleeds about the time of menses. Microscopically, umbilical endometriosis shows endometrial glands and stroma in the deep dermis and subcutis with glands present in a background of fibroadipose tissue. The presence of skeletal muscle indicates a deeper depth of the lesion. In cases of scant stroma or
Fig. 1. Showing pre-op, post-op picture,the histopathological image and specimen of primary umbilical endometriosis.