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(Radiology. 2001;220:76-80.)
© RSNA, 2001

Gastrointestinal Imaging

Abdominopelvic Actinomycosis Involving the Gastrointestinal Tract: CT Features1

In-Jae Lee, MD 2, Hyun Kwon Ha, MD, Chul Min Park, MD, Jeong Kon Kim, MD, Jung Hoon Kim, MD, Tae Kyung Kim, MD, Jin Cheon Kim, MD, Kyoung Sik Cho, MD and Yong Ho Auh, MD 3

1 From the Departments of Radiology (I.J.L., H.K.H., J.K.K., J.H.K., T.K.K., K.S.C., Y.H.A.) and General Surgery (J.C.K.), University of Ulsan, Asan Medical Center, 388-1 Poongnap-dong, Songpa-ku, Seoul, 138-736, Korea; and the Department of Radiology, Korea University Medical Center, Anam Hospital, Seoul (C.M.P.). Received September 28, 2000; revision requested November 3; revision received January 3, 2001; accepted January 16. Address correspondence to H.K.H. (e-mail: hkha@www.amc.seoul.kr).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
PURPOSE: To assess the computed tomographic (CT) features of abdominopelvic actinomycosis involving the gastrointestinal tract.

MATERIALS AND METHODS: CT scans were analyzed in 18 patients with pathologically proved abdominopelvic actinomycosis involving the gastrointestinal tract. Eight patients had a history of using intrauterine contraceptive devices. Bowel site, wall thickness, length, bowel involvement patterns, inflammatory infiltration, and features of peritoneal or pelvic mass, if present, were evaluated at CT.

RESULTS: Of the gastrointestinal tract, the sigmoid colon was most commonly involved (50%). All patients showed concentric (n = 15) or eccentric (n = 3) bowel wall thickening, with a mean thickness of 1.2 cm and a mean length of 8.3 cm. The thickened bowel enhanced homogeneously in nine patients and heterogeneously in the other nine. Inflammatory infiltration was mostly diffuse and severe. In 17 patients, a peritoneal or pelvic mass (mean maximum diameter, 3.2 cm) was seen adjacent to the involved bowel and appeared to be heterogeneously enhanced in most cases; infiltration into the abdominal wall was seen in four patients.

CONCLUSION: Actinomycosis should be included in the differential diagnosis when CT scans show bowel wall thickening and regional pelvic or peritoneal mass with extensive infiltration, especially in patients with abdominal pain, fever, leukocytosis, or long-term use of intrauterine contraceptive devices.

Index terms: Abdomen, CT, 70.12112, 75.12112, 80.12112 • Abdomen, infection, 70.2044, 80.2044 • Actinomycosis, 70.2044, 80.2044 • Colon, diseases, 75.2044 • Pelvic organs, diseases, 70.2044, 80.2044


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Abdominopelvic actinomycosis is a chronic progressive suppurative disease characterized by the formation of multiple abscesses, draining sinuses, abundant granulation, and dense fibrous tissue. This infection is considered to be caused by Actinomyces israelii organisms, which are gram-positive anaerobic bacteria; these organisms are not regarded as virulent human pathogens and are best considered as opportunistic pathogens, as they are normally present in healthy individuals, especially in the oral cavity and tonsillar crypts and in the colon (1,2). Although the presumptive diagnosis can be made with identification of sulfur granules in the Papanicolaou smears of pus from the abscess or discharged material from a sinus tract (3), the definite diagnosis requires histologic confirmation of actinomycotic granules or culture of the A israelii organisms, or both (1); however, the success rate is fewer than 50% of cases (4). This disease usually follows perforation of an abdominal viscus owing to inflammatory or neoplastic disease, surgery, or trauma (5–8) and is commonly associated with long-term use of an intrauterine device (9–11).

Direct spread into adjacent tissue appears to be the primary route of propagation after penetration of the organism through the mucosal barrier (1,4). Thus, the aggressive nature of the infiltration has been well described as one of the important radiologic characteristics of this infection (12–14). Computed tomography (CT) has been useful for determining the anatomic location and extent of the disease and for monitoring the effectiveness of treatment (1,9,15). However, despite the fact that segments of the gastrointestinal tract, such as the appendix and colon, are the organs most commonly involved by actinomycosis, there have been limited reports in the literature regarding their radiologic features.

The purpose of this study was to assess the CT features of abdominopelvic actinomycosis involving the gastrointestinal tract.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
A computerized search of the medical records of two institutions (Asan Medical Center, Seoul, Korea; Korea University Medical Center, Seoul, Korea) from October 1993 to October 1998 resulted in 29 patients with abdominopelvic actinomycosis. Of these, 11 patients were excluded from the analysis, as their CT scans were not available (n = 5) or only abdominal solid organs (three ovaries, two livers, and one kidney) were involved (n = 6). Therefore, CT scans in 18 patients (one man, 17 women; age range, 26–67 years; mean age, 41 years) with gastrointestinal tract involvement constituted the basis of this study. Of the 17 female patients, seven had a history of persistent intrauterine device use until the development of the infection, and one had had the intrauterine device removed 1 month before the infection. None of the patients was immunocompromised.

The clinical symptoms and signs in these patients included abdominal pain (n = 16), fever (n = 13), palpable mass (n = 4), and oliguria (n = 1). The duration of these symptoms and signs ranged from 5 days to 6 months. Positive laboratory findings included leukocytosis in 14 patients whose white blood cell counts were 10,200–15,900/mm3 (10.2–15.9 x 109/L) at the time of admission. Their diagnoses were based on the detection of sulfur granules in the surgical specimens (n = 14) or in percutaneously obtained discharge or aspirates (n = 4); positive culture results were obtained in two patients.

Colonoscopy had been performed in eight patients. Surgical procedures were segmental bowel resection (n = 6), hysterectomy (n = 3), right hemicolectomy (n = 2), excision of mass (n = 2), and omentectomy (n = 1). Results of barium studies (eight barium enema examinations and two small-bowel follow-through studies) were available in 10 patients.

CT (9800 Quick System; GE Medical Systems, Milwaukee, Wis [n = 10] or Somatom Plus-S; Siemens, Erlangen, Germany [n = 8]) had been performed with 8- or 10-mm section thickness at 8- or 10-mm intervals from the diaphragm to the symphysis pubis. Approximately 600–900 mL of contrast material (E-Z-CAT; E-Z-Em, Westbury, NY) was administered orally in all patients before scanning; 100–120 mL of contrast material (iopamidol, Iopamiro 300; Bracco, Milan, Italy or iopromide, Ultravist 300; Schering, Berlin, Germany) was administered intravenously as a bolus at a rate of 2.5–3.0 mL/sec in all patients, with injection starting approximately 65–70 seconds prior to scanning.

At CT, two radiologists (I.J.L., H.K.H.) who were unaware of the final diagnosis reviewed the following items independently:

  1. Site and length of involved bowel were assessed.
  2. Bowel wall thickening—the bowel wall was considered to be thickened when it exceeded 3 mm in thickness when the lumen was well distended (16). The bowel wall thickening patterns were divided into concentric or eccentric. Concentric bowel wall thickening was also subdivided into even or uneven thickening.
  3. Bowel contrast enhancement patterns were divided into homogeneous and heterogeneous. The target sign, which indicated multilayered concentric enhancement, was regarded as one of the heterogeneous forms of enhancement.
  4. Perirectal, pericolic, or perienteric infiltration was arbitrarily graded as 1, 2, or 3. Grade 1 perirectal infiltration was defined as no or minimal infiltration within the perirectal space; grade 2, when the infiltration extended to the pararectal space but not to the pelvic side wall; and grade 3, when infiltration extended to the pelvic side wall. Pericolic or perienteric infiltration was defined as grade 1 if it was less than 1 cm from the outer margin of the involved bowel wall; grade 2, if it was 1 cm or more but less than 3 cm; and grade 3, if it was more than 3 cm.
  5. Location and morphologic characteristics (size, margin, and attenuation) of possible peritoneal or pelvic mass were assessed. Peritoneal or pelvic masses, if present, were divided into four categories: cystic, predominantly cystic (the cystic portion occupying more than two-thirds of the mass), predominantly solid (the solid portion occupying more than two-thirds of the mass), and solid lesions. The degree of contrast enhancement of the solid components within the mass was compared with that of the aorta; it was marked when it enhanced nearly the same amount as the aorta did.
  6. Lymphadenopathy—the size and location of enlarged nodes—was assessed.
  7. Urinary involvement (hydronephrosis or hydroureter) was assessed.
  8. Ascites was assessed.
  9. Bowel obstruction was assessed.
  10. Observation of the other solid abdominal organs was taken into consideration.

When interpretations differed, a consensus between the two readers was used. In addition, barium study results were evaluated by the same two radiologists (I.J.L., H.K.H.), and one radiologist (I.J.L.) obtained information regarding colonoscopic and biopsy findings by means of reviewing only the reports.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
The involved sites in the gastrointestinal tract were the sigmoid colon in nine patients, the transverse colon in four, the rectum in two, the cecum and appendix and the distal ileum in two, and both the ascending colon and cecum in one. The bowel wall was thickened in all 18 patients. At CT, the thickened bowel wall was concentric in 15 patients and eccentric in three; in the 15 patients with concentric bowel wall thickening, the thickening was uneven in 11 and even in four (Fig 1). The thickness of the involved bowel was 0.7–1.7 cm (mean thickness, 1.2 cm), and the length was 5–16 cm (mean length, 8.3 cm). The thickened bowel enhanced homogeneously in nine patients and heterogeneously in the other nine patients. No patients showed the target sign in the thickened wall. Perirectal, pericolic, or perienteric infiltration was observed in 17 patients (94%), with grade 1 infiltration in six, grade 2 infiltration in seven, and grade 3 infiltration in four (Fig 2); therefore, inflammatory infiltration was mostly diffuse and severe.



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  		Figure 1. Abdominopelvic actinomycosis involving the rectum in a 44-year-old woman. Contrast material-enhanced transverse CT scan shows a predominantly cystic mass (M) in the left adnexa. The rectum shows concentric uneven bowel wall thickening (arrowheads) and diffuse perirectal inflammatory infiltration. U = uterus.

 


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  		Figure 2. Abdominopelvic actinomycosis involving the cecum, appendix, and distal ileum in a 44-year-old woman. Contrast-enhanced transverse CT scan shows diffuse and severe inflammatory infiltration in the mesentery at the right lower quadrant. The wall of the cecum (C) and distal ileum (*) are concentrically and unevenly thickened.

 
In 17 patients (94%), a peritoneal or pelvic mass was seen adjacent to the involved bowel and appeared to be predominantly cystic in eight patients (Fig 1), predominantly solid in six, and purely solid in three (Fig 3); most of these masses appeared to be heterogeneously enhanced. The masses were located at the pelvis in 11 patients, the greater omentum in four, and the mesentery near the appendix and distal ileum in two (Fig 2); the abdominal wall was also involved in all of the four patients with a mass in the greater omentum (Fig 3). The mean maximum diameter of these masses was 3.2 cm (range, 1.2–4.8 cm). The margins of these masses were irregular and indistinct in 16 patients and smooth in one. In 13 of these 17 patients, the mass contained solid components showing marked contrast enhancement.



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  		Figure 3. Abdominopelvic actinomycosis involving the transverse colon in a 42-year-old woman. Contrast-enhanced transverse CT scan shows an ill-defined well-enhancing solid mass (M) in the greater omentum, with extension to the adjacent anterior abdominal wall. Also noted is focal wall thickening of the transverse colon (arrowheads).

 
Lymphadenopathy was noted in five patients (28%) but was minimal and involved the paraaortic (n = 3) and mesenteric (n = 2) lymph nodes. The urinary tract was involved in nine patients (50%), with hydronephrosis and hydroureter in six and hydroureter in three; in all of these patients, ureteral obstruction was caused by the extension of the peritoneal or pelvic mass or inflammatory infiltration. A small amount of ascites was present in three patients (17%). No patient showed bowel obstruction and concomitant abdominal solid organ involvement.

Barium study findings included tapered luminal narrowing (n = 4), mucosal fold thickening (n = 4), and nodularity (n = 2). In one patient with involvement of the ascending colon, there was a mass along the right paracolonic gutter that compressed the ascending colon, which was proved as pericolonic abscess caused by diverticulitis associated with actinomycotic infection (Fig 4).



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  		Figure 4a. Right-sided diverticulitis associated with actinomycosis infection in a 42-year-old woman. (a) Contrast-enhanced transverse CT scan shows diffuse pericolic inflammatory infiltration surrounding the colon (arrowheads) and thickening of the adjacent perirenal fascia and peritoneum (arrows). (b) Anteroposterior radiograph obtained at double-contrast barium enema examination reveals an extraluminal mass (arrows) compressing the ascending colon and cecum, along with serrated margins, multiple nodular defects, and fold thickening at the involved site of the colon. Also noted is a diverticulum (arrowhead) in the ascending colon. The appendix was not filled with barium or air at the time of the examination. Segmental resection surgery was used to confirm diverticulitis, and sulfur granules in the pericolic abscess were confirmed at pathologic examination.

 


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  		Figure 4b. Right-sided diverticulitis associated with actinomycosis infection in a 42-year-old woman. (a) Contrast-enhanced transverse CT scan shows diffuse pericolic inflammatory infiltration surrounding the colon (arrowheads) and thickening of the adjacent perirenal fascia and peritoneum (arrows). (b) Anteroposterior radiograph obtained at double-contrast barium enema examination reveals an extraluminal mass (arrows) compressing the ascending colon and cecum, along with serrated margins, multiple nodular defects, and fold thickening at the involved site of the colon. Also noted is a diverticulum (arrowhead) in the ascending colon. The appendix was not filled with barium or air at the time of the examination. Segmental resection surgery was used to confirm diverticulitis, and sulfur granules in the pericolic abscess were confirmed at pathologic examination.

 
Colonoscopic findings, which were available in eight patients, revealed a varying degree of luminal narrowing in every patient. Also, nodules of varying sizes were found in every patient; central umbilication within the nodule was demonstrated in four patients. Mucosal abnormalities were found in four patients and included edema or hyperemia in four and focal ulceration in two. Biopsy was performed at four to six sites in each lesion, and all revealed chronic inflammation without identification of the characteristic sulfur granules.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Human actinomycosis has a worldwide distribution and is present with equal frequency in city and rural dwellers (1). Although it has been reported that there is no discernible sex predilection, a majority of patients (94%), as in our study, are women (1,8). The organisms are indigenous in the oral cavity, gastrointestinal tract, and genital tract, with opportunistic infection occurring when the mucosal barrier is broken, leading to multiple abscess formation, fistula, or mass lesion (1,5). Moreover, dental caries are common reservoirs of A israelii organisms (4). Actinomycosis commonly occurs in three distinct forms. The majority of the clinical disease is cervicofacial (55%), with only 20% occurring in an abdominopelvic form and 15% as a thoracopulmonic form (4,8). Although the clinical features depend on which organs are involved, common symptoms and signs include fever and leukocytosis (1,12). High-dose intravenous penicillin injection is the treatment of choice (8,17). Therefore, early diagnosis is important to minimize the morbidity of this disease and avoid unnecessary surgery; the response to treatment with high doses of penicillin is usually favorable (4,12).

Abdominopelvic actinomycosis has been associated with abdominal surgery, such as appendectomy, or bowel perforation or trauma (6–8). The association with longstanding intrauterine device use has been also emphasized as a risk factor in young women (9–11); eight (47%) of the 17 women in our study had histories of intrauterine device use. The results of our study demonstrated that diverticulitis can also be associated with this infection.

Various abdominal organs may be involved in abdominopelvic actinomycosis and include the gastrointestinal tract, ovaries, liver, gallbladder, and pancreas (1,18). Although the pathogenesis is not fully understood, the ileocecal region, including the appendix, is the most commonly involved site (1,19). However, development of abdominal actinomycosis after acute appendicitis has decreased because of early diagnosis, a lower incidence of perforated appendicitis, and improved antibiotic therapy (8). In many instances, the gastrointestinal tract appears to be secondarily involved. The results of our study showed that the portions of the gastrointestinal tract commonly involved were, in decreasing order of frequency, the sigmoid colon, transverse colon, rectum, cecum, appendix, distal ileum, and ascending colon. The common occurrence at the rectosigmoid colon contributes to the high frequency of pelvic involvement.

The radiologic findings in the colon and small intestine at barium study include mural invasion with stricture formation, mass effect with tapered narrowing of the lumen, and thickened mucosal folds (7,12,18,20,21). In certain instances, anal fistula may develop in actinomycosis involving the anorectum (18,22). Such radiologic findings are similar to those in Crohn disease, intestinal tuberculosis, and excavated malignant tumors (8,12,23,24). However, as demonstrated in the eight patients who underwent colonoscopy in our study, the mucosal changes are minimal or absent in contrast with other inflammatory or neoplastic conditions.

The use of CT in patients with abdominopelvic actinomycosis is important for suggesting the diagnosis and determining the anatomic location and extent of this disease, as well as for monitoring the effectiveness of treatment and for follow-up in cases of possible recurrence (6,12,15). However, until more recently, there have been limited reports in the literature describing the CT features of gastrointestinal tract involvement patterns in patients with abdominopelvic actinomycosis (12,20,25). In our study, the main CT feature when the gastrointestinal tract was involved was bowel wall thickening (mostly concentric). The mean wall thickness of 1.2 cm and the mean length of 8.3 cm observed in our study overlap considerably with those of other inflammatory bowel diseases.

However, rather than bowel wall thickening, the most important CT feature for the correct diagnosis was a large mass adjacent to the involved bowel. Such a mass, as was seen in 17 of the 18 patients in our study, appeared to be predominantly cystic or solid. Most cases of rectosigmoid colon involvement showed predominantly cystic masses, whereas cases involving the transverse colon or appendix demonstrated predominantly or purely solid masses.

Abundant granulation and dense fibrous tissues in the solid components of these masses may cause marked contrast enhancement after infusion of contrast material; the hypervascular nature of such lesions was also demonstrated at visceral angiography (12,26,27). It is also interesting to note that there were similar imaging features in all four patients with a large heterogeneous mass at the greater omentum and bowel wall thickening of the adjacent transverse colon. Although unknown at the time of this writing, the omental masses are presumed to have developed from the spread of pelvic or supramesocolonic infection rather than from colonic perforation. Soft-tissue strands were also prominent and surrounded the involved bowel or mass.

The fact that the lesion extended to the abdominal wall in four patients and that the genitourinary tract was involved in half the patients in our study confirms the tendency of this disease to have an aggressiveness with a propensity for crossing fascial planes or boundaries and for involving multiple compartments. Such a pattern may be attributed to the proteolytic enzyme produced by A israelii, which is the most common cause of this disease (6). However, our data also suggest that actinomycosis in the pelvis is a serious disease, but one with a pattern of spread through contiguous tissues, which, in many respects, is no different from that of intestinal tuberculosis or Crohn disease or many other entities that closely simulate them. CT features of a mass and extensive infiltration pattern also closely resemble a complicated gastrointestinal malignancy. However, because of the size of the bacterium, the organism of actinomycosis usually does not spread via the lymphatic system; therefore, regional lymphadenopathy is uncommon or develops late (4,8). Also, despite the extensive inflammatory infiltration in the perirectal, pericolonic, or perienteric spaces, the disease processes do not appear to spread into the whole peritoneal cavity. Furthermore, ascites is absent or minimal.

In conclusion, although not specific, actinomycosis should be included in the differential diagnosis when CT scans show bowel wall thickening and a regional pelvic or peritoneal mass with an extensive infiltration pattern, especially in patients with abdominal pain, fever, leukocytosis, or long-term intrauterine device use.


   ACKNOWLEDGMENTS
 
We thank Bonnie Hami, MA, University Hospitals of Cleveland, for her editorial assistance in the preparation of this manuscript.


   FOOTNOTES
 
2 Current address: Department of Radiology, Hallym University Sacred Heart Hospital, Anyang, Korea. Back

3 Current address: UMDNJ, University Hospitals, Newark, NJ. Back

Author contributions: Guarantor of integrity of entire study, H.K.H.; study concepts, H.K.H.; study design, H.K.H., I.J.L.; literature research, I.J.L., J.H.K.; clinical studies, K.S.C.; data acquisition, C.M.P., J.H.K.; data analysis/interpretation, J.K.K.; manuscript preparation, H.K.H., I.J.L.; manuscript definition of intellectual content, I.J.L.; manuscript editing, H.K.H., I.J.L.; manuscript revision/review, Y.H.A., T.K.K., J.C.K., K.S.C.; manuscript final version approval, H.K.H.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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