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LETTER TO EDITOR Table of Contents   
Year : 2010  |  Volume : 53  |  Issue : 4  |  Page : 870-871
Tubo-ovarian actinomycosis mimicking as ovarian malignancy: Report of three cases


1 Department of Pathology, Sri Aurobindo Institute of Medical sciences. Indore, India
2 Department of Microbiology, Sri Aurobindo Institute of Medical sciences. Indore, India

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Date of Web Publication27-Oct-2010
 

How to cite this article:
Munjal K, Nandedkar S, Subedar V, Jain S. Tubo-ovarian actinomycosis mimicking as ovarian malignancy: Report of three cases. Indian J Pathol Microbiol 2010;53:870-1

How to cite this URL:
Munjal K, Nandedkar S, Subedar V, Jain S. Tubo-ovarian actinomycosis mimicking as ovarian malignancy: Report of three cases. Indian J Pathol Microbiol [serial online] 2010 [cited 2019 Dec 10];53:870-1. Available from: http://www.ijpmonline.org/text.asp?2010/53/4/870/72020


Sir,

Actinomycosis is a chronic suppurative granulomatous infection characterized by the formation of abscesses, multiple draining sinuses, and appearance of sulphur granules, which are actually the colonies of the organism. Human actinomycotic disease is described in cervicofacial, thoracic, abdominal, and pelvic regions. [1] Intrauterine contraceptive devices (IUCD) appear as the principal favorable factor of actinomycosis involving the female genital tract. On occasions, the inflammation from the endometrium spreads through the fallopian tubes to produce pelvic inflammatory disease and sometimes tubo-ovarian abscess. [2],[3] Many cases of actinomycotic infection involving the adenexae following insertion of IUCD have been reported. [1],[2],[3] It is important to remark that the ovarian infection by actinomyces species can also occur in patients without an IUCD and has been reported similar to the findings in our case. [4],[5]

We here present three unusual cases of tubo-ovarian actinomycosis in the absence of IUCD and clinically mimicking as malignancy.

Case 1. A 31-year-old female, para two, came with complains of pain in abdomen and loss of appetite. Ultrasonography (USG) showed a right sided, tubo-ovarian mass, which was confirmed on exploratory laparotomy. The mass, measuring 4×3.5×3 cm, was adherent to the surrounding pelvic structures, loops of intestine, posterior abdominal wall, and gave way spilling purulent material into the peritoneal cavity. Uterine surface showed granulation tissue and adhesion to intestinal loops.

Case 2. A 25-year-old female presented with a history of pain in abdomen; on pelvic examination a tender lump was felt in right side. USG confirmed it to be a tubo-ovarian mass, measuring 5×4×3 cm, which showed dense adhesions with colon on exploratory laparotomy.

Case 3. A 35-year-old female, with a history of infertility, came with complaints of backache, vaginal discharge, and fever. USG showed a right sided tubo-ovarian mass measuring 7×5.5×4 cm adherent to cecum. A provisional diagnosis of teratoma was given and the patient was taken up for surgery.

None of the three cases had ever used an IUCD in the past. USG findings were quite similar in all the three cases showing one sided tubo-ovarian mass adherent to surrounding structures. With a provisional diagnosis of ovarian malignancy, the patients underwent surgery. Intraoperative findings confirmed the right-sided tubo-ovarian masses, densely adherent to the surrounding pelvic structures. Panhysterectomy was performed in all the three cases and the specimen received in the laboratory showed right-sided tubo-ovarian mass. Cut surface showed grayish white areas with yellow purulent material [Figure 1]a-c. Histological examination of the masses revealed acute inflammatory exudates of nutrophils, with surrounding granulation tissue composed of plasma cells and lymphocytes. In the abscess, granules were seen as basophillic structures showing filamentous radiations with eosinophilic clubbed ends, surrounded by polymorphonuclear lucocytes, reminiscent of an actinomycotic granulomas [Figure 2] confirmed by Gram's and acid fast staining. Microbiological examination of the purulent material showed a Gram-positive and nonacid fast filamentous organism, which was confirmed to be actinomycetes on culture. Postoperatively, all the three patients were kept on penicillin and streptomycin treatment to which they responded well.
Figure 1: Gross photographs of all the three cases: (a) Case 1 showing tubo-ovarian mass with yellow purulent areas; (b) Case 2 showing tubo-ovarian mass with grayish white and yellow necrotic pus filled areas; (c) Case 3 showing a large tubo-ovarian mass with peripheral solid grayish white areas and central necrosis

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Figure 2: Photomicrograph showing the actinomycotic colony surrounded by inflammatory infiltrate (H and E, ×100)

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   Discussion Top


Pelvic actinomycosis is uncommon and may present a diagnostic dilemma because of an atypical clinical presentation. Tubo-ovarian actinomycosis is insidious in its course and often presents as a pelvic mass that mimics a pelvic malignancy. [3],[5] Nonspecific symptoms of this form of the disease (lower-quadrant abdominal pain and weight loss) and low grade fever (or no fever) may persist for months to years. In our patients, weight loss, lower abdominal and pelvic pain, and clinical course were more consistent with a pelvic tumor than with an acute infectious process. It can be diagnosed by histological and microbiological examination. The hematoxylin-eosin (H and E) staining of the sections demonstrates the bacterial colony "sulphur granule' in the center of the abscess characterized by radiating filaments with eosinophilic club like ends. Smear examination of pus will show Gram-positive and nonacid fast branching filamentous rods, which on anaerobic cultures will grow the actinomycotic colonies. Once the diagnosis is established, the infection can be treated with good results with penicillin. Quiet often an initial diagnosis of ovarian carcinoma, as in our cases, is considered. Surgeons should be aware of this infection and a diligent search for potentially pathogenic actinomyces should be done to spare women morbidity from excessive surgical procedures.

 
   References Top

1.Westrom L, Bengtsson LP, Mardh P. The risk of pelvic inflammatory diseases in women using intrauterine contraceptive devices as compared to non-users. Lancet 1976;2:221-4.  Back to cited text no. 1
    
2.McLeod R, Smith S, Poore TE, Lindsey JL, Remington JS. Tubo-ovarian actinomycosis and the use of intrauterine devices. West J Med 1980;132:531-5.  Back to cited text no. 2
    
3.Güngör T, Parlakyigit EE, Dumanli H. Actinomycotic tubo-ovarian abscess mimicking pelvic malignancy. Gynecol Obstet Invest 2002;54:119-21.  Back to cited text no. 3
    
4.Marwah S, Marwah N, Singh I, Gupta A, Jaiswal TS. Ovarian actinomycosis in absence of intrauterine contraceptive device: An unusual presentation. Acta Obstet Gynecol Scand 2005;84:602-3.  Back to cited text no. 4
    
5.Atay Y, Altintas A, Tuncer I, Cennet A. Ovarian actinomycosis mimicking malignancy. Eur J Gynaecol Oncol 2005;26:663-4.  Back to cited text no. 5
    

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Correspondence Address:
Kavita Munjal
3, Navratan Bagh, Opp. Primary St. Paul School, Indore - 452001, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.72020

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    Figures

  [Figure 1], [Figure 2]

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