DOI: 10.1148/radiol.2362031034
(Radiology 2005;236:492-494.)
© RSNA, 2005
Case 85: Pelvic Actinomycosis in Association with an Intrauterine Device1
Rutger J. Lely, MD and
Hendrik W. van Es, MD, PhD
From the Department of Radiology, St Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands. Received July 2, 2003; revision requested September 10; revision received December 3; accepted January 23, 2004.
Address correspondence to R.J.L. (e-mail: kinglely{at}yahoo.com).
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History
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A 45-year-old woman with a medical history of constipation and irritable bowel syndrome presented with cramps in the left lower abdomen. She had experienced these symptoms for about 2 months. The symptoms were accompanied by decreased appetite and weight loss of 6 kg over 2 months. For a few weeks, she experienced fevers up to 39°C and cold shivers. Physical examination revealed tenderness in the left lower quadrant of the abdomen, without a palpable mass. A mass anterior to the rectum was felt with digital rectal examination. Laboratory findings included an elevated C-reactive protein level of 160 mg/L (normal range, < 10 mg/L), an elevated erythrocyte sedimentation rate of 108 mm/h (normal range, < 20 mm/h), and a high white blood cell count of 17.9 x 109/L (normal range, [4.3–10.0]x 109/L). Contrast material–enhanced abdominal computed tomography (CT) was performed.
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Imaging Findings
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CT images of the abdomen and pelvis were obtained with intravenous, oral, and rectal administration of contrast material, and they showed left-sided hydronephrosis and dilatation of the ureter (Figure, part a). Hydronephrosis and dilatation of the ureter were caused by a mass on the left side of the uterus in the vicinity of the ovary or in the ovary itself (Figure, part b). The oval-shaped mass represented a fluid collection, with an enhancing ring that was consistent with an abscess. Indurated fat was seen in the perirectal space (Figure, part c). An intrauterine device (IUD) was present in the uterus (Figure, part c). Free fluid was seen on the left side of the rectum (Figure, part d).
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Figure a. Sequential transverse abdominal and pelvic CT images obtained after administration of oral, rectal, and intravenous contrast material. (a) Abdominal CT image shows hydronephrosis (arrow) of the left kidney. (b) Pelvic CT image shows an abscess (arrow). B = bladder, U = uterus. (c) Pelvic CT image shows an IUD (short arrow) and infiltrated perirectal fat (long arrow). B = bladder, R = rectum. (d) Pelvic CT image shows perirectal fluid (arrow). T = tampon.
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Figure b. Sequential transverse abdominal and pelvic CT images obtained after administration of oral, rectal, and intravenous contrast material. (a) Abdominal CT image shows hydronephrosis (arrow) of the left kidney. (b) Pelvic CT image shows an abscess (arrow). B = bladder, U = uterus. (c) Pelvic CT image shows an IUD (short arrow) and infiltrated perirectal fat (long arrow). B = bladder, R = rectum. (d) Pelvic CT image shows perirectal fluid (arrow). T = tampon.
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Figure c. Sequential transverse abdominal and pelvic CT images obtained after administration of oral, rectal, and intravenous contrast material. (a) Abdominal CT image shows hydronephrosis (arrow) of the left kidney. (b) Pelvic CT image shows an abscess (arrow). B = bladder, U = uterus. (c) Pelvic CT image shows an IUD (short arrow) and infiltrated perirectal fat (long arrow). B = bladder, R = rectum. (d) Pelvic CT image shows perirectal fluid (arrow). T = tampon.
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Figure d. Sequential transverse abdominal and pelvic CT images obtained after administration of oral, rectal, and intravenous contrast material. (a) Abdominal CT image shows hydronephrosis (arrow) of the left kidney. (b) Pelvic CT image shows an abscess (arrow). B = bladder, U = uterus. (c) Pelvic CT image shows an IUD (short arrow) and infiltrated perirectal fat (long arrow). B = bladder, R = rectum. (d) Pelvic CT image shows perirectal fluid (arrow). T = tampon.
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Discussion
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The combination of an IUD and a pelvic abscess was suggestive of pelvic actinomycosis. Results of CT-guided needle aspiration confirmed the diagnosis of actinomycosis caused by Actinomyces naeslundii. The patient was treated with antibiotics. A ureteral stent was placed cystoscopically through the left ureter to decompress the hydronephrosis. Follow-up CT and ultrasonographic (US) images showed evidence of regression of the tubo-ovarial abscess, and the ureteral stent was removed. Oral antibiotic therapy was continued for 6 months (500 mg of amoxicillin administered four times per day).
Actinomyces species are gram-positive, non–acid-fast anaerobic filamentous bacteria. They are true bacteria, but they have been mistaken for fungi in the past. They are normal inhabitants of the human body, and they tend to reside in the oropharynx and bowel (1–3). Actinomyces israelii is the most common of the Actinomyces species; however, Actinomyces naeslundii, Actinomyces viscosus, and Actinomyces eriksonii cause clinically similar diseases (1). In 1878, Israel described human actinomycosis (4). In 1973, Henderson described the relationship between IUDs and pelvic actinomycosis (5).
The three clinical types of Actinomyces infection are cervicofacial, thoracic, and abdominal (6,7). The Actinomyces species act as opportunistic pathogens and normally do not cross normal human mucosal borders. However, in cases of low tissue oxygen tension or mucosal disruptions, as with an appendectomy, actinomycosis can result (1,7). Pelvic actinomycosis normally begins as a subacute or chronic disease months or years before a patient presents herself to a physician (3). Usually, the symptoms include lower abdominal pain, cachexia, vaginal discharge, and nausea (1,3). Hydronephrosis due to ureteral compression by the pelvic abscess can also be the abnormality (3). As the disease progresses, it can become severe, with tubo-ovarian abscess formation leading to a "frozen pelvis" and mimicking pelvic cancer (3).
Infections of the female genital tract with actinomyces can be caused by surgery, perforation of the bowel, or foreign bodies, such as IUDs (7). Actinomycosis in association with an IUD usually involves the pelvis, and patients present with symptoms similar to the symptoms of salpingo-oophoritis, tubo-ovarian abscess, or pelvic abscess (7).
A cervical smear can be obtained if one is suspicious of pelvic inflammatory disease. To diagnose actinomycosis, Papanicolaou smears must be obtained. The characteristic histologic finding of actinomyces israelii on cervical Papanicolaou smears is yellow or brown sulfur granules. Actinomyces meyeri is the only other actinomyces species associated with sulfur granules in histologic specimens (8). Those granules consist of bacteria colonies that result from secretion of polysaccharide proteins that keep the bacterial elements and tissue debris together (1,2,6). The histologic differential diagnosis on the basis of Papanicolaou smears includes other bacteria, fungi, mucus strands, spermatozoa, and materials such as fibrin, contraceptive cream, IUD-associated material, cotton, and synthetic fibers (1,3). All these entities may be mistaken for actinomyces. Gram stain of actinomycosis shows branching filamentous rods. Hematoxylin-eosin staining demonstrates eosinophilic clublike structures that radiate from the periphery of the granules. This has been named the Splendore-Hoeppli phenomenon (1). The definitive diagnosis is made with analysis of anaerobic cultures or species-specific antibodies (1).
Intraabdominal extension occurs mainly through contiguous spread, and it can cross normal anatomic barriers by producing proteolytic enzymes and result in abscesses, sinus tracts, and fistulas surrounded by indurated firm fibrotic tissue. Hematogenous spread is also possible, whereas lymphatic spread is uncommon. Actinomyces israelii is found on cultures in 3%–4% of women, regardless of whether they have an IUD (1,9).
Approximately 25% of IUDs eventually become infected by actinomyces, and 2%–4% of IUDs that are colonized by actinomyces ultimately develop serious actinomycotic infections (3). Therapy consists of administration of high doses of antibiotics (usually 4 weeks of intravenous penicillin [15–18 million U/d], followed by 6 months to 1 year of oral penicillin). Alternatives to penicillin are tetracycline, erythromycin, and clindamycin. Cephalosporins, aminoglycosides, ciprofloxacin, and metronidazole are also being used in adjunctive therapy (1). Follow-up studies are needed to evaluate the tumor mass. Adjunctive debulking surgery must be considered in patients with no regression or if the patient still has symptoms of obstructive disease, such as ureteral or bowel compression.
Imaging findings of pelvic actinomycosis are nonspecific. There can be suggestion of an abscess or an inflammatory or neoplastic process. The main imaging modality used to determine the extent of the disease is CT. CT is more sensitive in determining the extent of the disease than US (7). Radiography may depict an IUD. A barium enema examination may reveal a mass effect with widening of the presacral space. Hydronephrosis, a pelvic mass, or both may be seen at US. Magnetic resonance imaging also depicts the extent of the disease (6,7). Although imaging findings, especially in the absence of an IUD, are not diagnostic of actinomycosis, they can be helpful in the diagnosis of actinomycosis. The differential diagnosis of pelvic actinomycosis forming a pelvic mass includes benign and malignant tumors of all pelvic organs, metastatic cancers, lymphoproliferative disorders, retroperitoneal fibrosis, endometriosis, and inflammatory processes, such as a diverticular abscess, Crohn disease, or tuberculosis (1,3,6).
When a mass or an abscess is found in the pelvis in patients with an IUD, a fever, and laboratory findings that indicate the presence of an infection, pelvic actinomycosis should be considered, as treatment can consist solely of antibiotic administration instead of surgery. The microbiologist makes the final diagnosis; however, the radiologist can assist in making the diagnosis with CT- or US-guided aspiration biopsy.
Congratulations to the 89 individuals and one resident group who submitted the most likely diagnosis (pelvic actinomycosis in association with an IUD) for Diagnosis Please, Case 85. Credit was given only if actinomycosis was included in the submitted diagnosis. The names and locations of the individuals and resident groups, as submitted, are as follows:
Individual responses
- Hisashi Abe, Osaka, Japan
- Dr Jorge Ahualli, Tucuman, Argentina
- Masaaki Akahane, MD, Tokyo, Japan
- Albert J. Alter, Madison, Wis
- Juan R. Ayuso, Barcelona, Spain
- Robert Berkenblit, MD, Briarcliff, NY
- Eric L. Bressler, MD, Minnetonka, Minn
- Michael P. Buetow, MD, Okemos, Mich
- P. J. Cadman, Buckinghamshire, United Kingdom
- Haris Chrysikopoulos, MD, Kerkyra, Greece
- Marco Cura, San Antonio, Tex
- Marc G. de Baets, MD, Lugano, Switzerland
- J. F. K. de Villiers, Gisborne, New Zealand
- Jon De Witte, Athens, Ga
- Mustafa Kemal Demir, MD, Istanbul, Turkey
- Thaworn Dendumrongsup, MD, Songkla, Thailand
- Roberto Garcia Figueiras, MD, Santiago de Compostela, Spain
- Francis Flaherty, MD, Ridgefield, Conn
- Jordi Catala Forteza, Barcelona, Spain
ngeles Franco, Madrid, Spain
- Akira Fujikawa, Tokyo, Japan
- Ann S. Fulcher, MD, Richmond, Va
- Bill Gallmann, MD, Shreveport, La
- Dr Ram Prakash Galwa, Chandigarh, India
- Douglas Gardner, MD, Windsor, Ontario, Canada
- Gilles Genin, MD, Annecy, France
- Alvaro Gomez Naar, Salta, Argentina
- Daniel Gridley, MD, Goodyear, Ariz
- Ferris M. Hall, MD, Boston, Mass
- Yukihiro Hama, MD, Bethesda, MD
- Raul Hernßndez, Madrid, Spain
- Alfonso J. Holgu
n, Cali, Colombia
- Alvaro Huete, MD, Santiago, Chile
- Alberto Iaia, MD, Wilmington, Del
- S. Pinar Karakas, New Hyde Park, NY
- Myeong-Jin Kim, MD, PhD, Seoul, Korea
- Takuji Kiryu, MD, Gifu, Japan
- David S. Klein, MD, Fairfield, Conn
- Stefanos Lachanis, MD, Athens, Greece
- Mario Laguna, West Allis, Wis
- David A. Lisle, Brisbane, Australia
- Patricia Lowry, MD, Richmond, Va
- N. B. S. Mani, MD, Nassau, Bahamas
- Frank McKowne, MD, Vancouver, Wash
- Jonathan Meyer, MD, Chicago, Ill
- Manabu Minami, MD, Ibaraki, Japan
- Ari Mintz, MD, Lake Forest, Ill
- Sankar Ranjan Mondal, MD, Nassau, Bahamas
- Tammam Nehme, East Wenatchee, Wash
- Mizuki Nishino, MD, Boston, Mass
- Marcos Nogueira, MD, Brasilia, Brazil
- Michael T. O'Loughlin, MD, West Hartford, Conn
- Sanford M. Ornstein, MD, Phoenix, Ariz
- David M. Panicek, MD, New York, NY
- Narendrakumar P. Patel, MD, Newburgh, NY
- Hilton W. Pittman, Pensacola, Fla
- Mario P. Pliego, MD, Bloomington, Minn
- Dr Arturo Ramos-Pablos, Obreg
n, Mexico
- James Ravenel, MD, Charleston, SC
- Jordi Rimola, MD, Sabadell, Spain
- Mathieu H. Rodallec, Paris, France
- Javier Rodrguez Lucero, Rosario, Argentina
- Mario G. Santamarina, MD, Mendoza, Argentina
- Pierre J. Sauvage, MD, M
con, France
- Stephen Irwin Schabel, MD, Charleston, SC
- Simona Secci, MD, Cagliari, Italy
- Raymond Selouan, MD, Beirut, Lebanon
- Taro Shimono, MD, Osaka, Japan
- Grady Shue, Heidelberg, Germany
- Ken Simmons, Sydney, Australia
- S. H. Slawson, MD, Peoria, Ill
- Kouichi Sugiyama, Hamamatsu, Japan
- Amit Suri, MD, Kings Lynn, Norfolk, United Kingdom
- Norio Takahashi, MD, Fukui, Japan
- Satoru Takahashi, MD, Nijmegen, the Netherlands
- Wing H. Tam, MD, Windsor, Ontario, Canada
- Douglas L. Teich, MD, Brookline, Mass
- Kazuma Terauchi, MD, Fukuoka, Japan
- Masahiro Tomoi, MD, Kyoto, Japan
- William C. Torreggiani, Dublin, Ireland
- Meri
Tüzün, Ankara, Turkey
- Hiroyuki Ueda, Kyoto, Japan
- Filip Vanhoenacker, MD, PhD, Duffel, Belgium
- Dr Silvio Alejandro Vollmer, Rio Negro, Argentina
- Michael Weber, Berlin, Germany
- Satoru Yoshida, MD, Muroran City, Japan
- Stanko Yovichevich, MD, Sydney, Australia
- Joe Yut, Olathe, Kan
- Yu Zhang, San Francisco, Calif
Resident group responses
- Hospital of the University of Pennsylvania Radiology Residents, Philadelphia, Pa
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FOOTNOTES
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Part one of this case appeared 4 months previously and may contain larger images.
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References
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- Fiorino AS. Intrauterine contraceptive device-associated actinomycotic abscess and actinomyces detection on cervical smear. Obstet Gynecol 1996; 87:142–149.[CrossRef][Medline]
- A 43-year-old woman with left-buttock pain and a presacral mass, case 29–1990. N Engl J Med 1990; 323:183–189.[Medline]
- A 41-year-old woman with swollen left leg, pelvic mass, and bilateral hydronephrosis, case 10–1992. N Engl J Med 1992; 326:692–699.[Medline]
- Israel J. Neue beobachtungen auf dem gebiete der mykosen des menschen. Arch Pathol Anat 1878; 74:15–20.[CrossRef]
- Henderson SR. Pelvic actinomycosis associated with intrauterine device. Obstet Gynecol 1973; 41:726–732.[Medline]
- O'Connor KF, Bagg MN, Croley MR, Schabel SI. Pelvic actinomycosis associated with intrauterine devices. Radiology 1989; 170:559–560.[Abstract/Free Full Text]
- Hochsztein JG, Koenigsberg M, Green DA. US case of the day: actinomycotic pelvic abscess secondary to an IUD with involvement of the bladder, sigmoid colon, left ureter, liver, and upper abdominal wall. RadioGraphics 1996; 16:713–716.[Medline]
- Clarridge JE 3rd, Zhang Q. Genotypic diversity of clinical actinomyces species: phenotype, source, and disease correlation among genospecies. J Clin Microbiol 2002; 40:3442–3448.[Abstract/Free Full Text]
- Lippes J. Pelvic actinomycosis: a review and preliminary look at prevalence. Am J Obstet Gynecol 1999; 180:265–269.[CrossRef][Medline]
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History
Imaging Findings
