Year : 2010 | Volume
: 53 | Issue : 1 | Page : 164--165
Pelvic actinomycosis mimicking: An advanced ovarian cancer
Narender Kumar1, Prasenjit Das1, Dinesh Kumar2, Alka Kriplani3, Ruma Ray1,
1 Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
2 Department of Radiology and Gynaecology All India Institute of Medical Sciences, New Delhi, India
3 Department of Obstetrics, All India Institute of Medical Sciences, New Delhi, India
Department of Pathology, All India Institute of Medical Sciences, New Delhi-110029
|How to cite this article:|
Kumar N, Das P, Kumar D, Kriplani A, Ray R. Pelvic actinomycosis mimicking: An advanced ovarian cancer.Indian J Pathol Microbiol 2010;53:164-165
|How to cite this URL:|
Kumar N, Das P, Kumar D, Kriplani A, Ray R. Pelvic actinomycosis mimicking: An advanced ovarian cancer. Indian J Pathol Microbiol [serial online] 2010 [cited 2021 Jan 23 ];53:164-165
Available from: https://www.ijpmonline.org/text.asp?2010/53/1/164/59216
A 32-year-old female presented with low grade fever, abdominal pain, weight loss, and poor appetite for the past six months before consultation. She had an intra uterine device (IUD) implanted two years back and was removed four month earlier because of pelvic discomfort. Physical examination revealed a pelvic mass (20 weeks size) occupying the whole pelvis with ill defined margins.
On admission, laboratory examination showed leukocytosis (15,000/mm 3 ) and anemia (hemoglobin, 9 g/dl). The CA125 level was 15.9 U/ml (normal, 0-35 U/ml). Abdominopelvic contrast enhancing computed tomogram scan showed a large solid pelvic mass measuring 85 X 45 mm 2 , occupying bilateral adnexae (left > right), pushing the urinary bladder anteriorly, involving the mesocolic fat, causing asymmetric thickness of the sigmoid colon. The mass seemed to compress the left ureter causing marked hydronephrotic changes. Ultrasonogram also showed a hypoechoic mass to push the urinary bladder [Figure 1].
Possible presence of an advanced ovarian cancer with local dissemination was suspected. On exploratory laparotomy, bilateral ovaries were seen to be replaced by a tumor mass, extending to the lateral pelvic wall and involving the left broad ligament, sigmoid colon, and part of ascending colon. It was also extending anteriorly and adherent with urinary bladder. The findings were suggestive of an aggressive malignant tumor; hence, a subtotal hysterectomy with right ovariaectomy and sigmoid colon resection was performed and sent for histopathological examination.
Grossly, the mass showed grey-white cut surface with areas of yellowish discolouration, hemorrhage and necrosis. Extensive sections were taken and microscopically the final diagnosis was disseminated pelvic actinomycosis. There were colonies of filamentous organisms surrounded by splendore-hoeppli reaction in the background of florid organizing inflammation. The filamentous organisms were positive for Grams, periodic acid Schiff, and silver methinamine stains. They were negative for Ziehl Nelson stain, confirming them to be actinomycosis. These colonies and inflammation were seen everywhere including the wall of sigmoid colon and right ovary [Figure 2]. Extensive fibrosis was noted causing adhesion among different organs.
Actinomycosis produces a characteristic granulomatous inflammatory response, with abscess formation followed by necrosis and extensive reactive fibrosis.  Usually caused by A. israelii but it can be also caused by A. bovis, A. ericksonii, A. naeslundii, A. viscousus, or A. odonlyticus. Actinomyces species are gram-positive, anaerobic, or microaerophilic; nonspore-forming bacilli which produces sulphur granules in the tissue. 
Clinical actinomycosis includes cervicofacial (60%), thoracic (15%), abdominal/pelvic (25%) forms.  Patients complain about abdominal pain (85%), weight loss (44%), and foul-smelling vaginal discharge (24%). The infection is acquired by ascending infection from the lower genital tract or a spread from an intestinal lesion.  These led to formation of granulation tissue, dense fibrosis, and abscess formation in the pelvis. It can produce a hard mass in the pelvis and may compress the ureter or intestines.  Thus, the clinical findings of pelvic actinomycosis are similar to those of tuboovarian abscesses or pelvic malignancies.  However, radiological findings can help in few cases. Though it is known that this infection can spread locally, it usually involves different tissue planes without destroying them, similar to our case [Figure 1]b and c. This lesion also showed compression but no infiltration into urinary bladder. The prevalence of actinomycosis in IUD wearers ranges from 1.6% to 11.6%. The colonization rates for progestasert, plastic IUDs, and copper IUDs are 14.3%, 10.8%, and 6.69%, respectively.  In our case, the copper T was taken out four months back, a relative long latency made the diagnosis further difficult.
There have been several reports of pelvic actinomycosis mimicking malignancies. Hoffman et al. reported two cases of actinomycotic pelvic inflammatory disease simulating an advanced ovarian carcinoma and advanced cervical carcinoma respectively. Koshiyama et al. reported pelvic actinomycosis, which was treated with neoadjuvant carboplatin, doxorubicin, and cyclophosphamide, because it was misdiagnosed as an advanced ovarian cancer.
Diagnostic dilemma is further aggravated by low yield and slow growth of Actinomyces species in culture (50%).  The clinical, laboratory, and radiologic findings of the disease are so nonspecific, as well as, lack of definite serologic test makes it very difficult to establish the diagnosis preoperatively. In fact, a preoperative diagnosis is established in less than 10% of all cases. In most cases, the diagnosis is made during the operation and confirmed by pathologic examination or at autopsy. For a definitive diagnosis, it is necessary to demonstrate microscopically either the pathogen itself or the sulphur granules on the slides of the biopsy materials or smear materials from the tract of the sinus. In conclusion, pelvic actinomycosis can mimic an infiltrating malignancy and re-evaluation of the radiological features along with a preoperative ultrasound guided biopsy may help in reaching a diagnosis. Pelvic actinomycosis must be included in differential diagnosis of infiltrating intra-abdominal disorders in a reproductive women with IUD in situ or in whom IUD had been taken off in past. The latency period of the IUD insertion and the infection can vary and a careful history may help to make clinical suspicion of this entity.
|1||Weese WC, Smith IM. A study of 57 cases of Actinomycosis over 36 year period. A diagnostic "failure" with good prognosis and treatment. Arch Int Med. 1975;135:1562-8.|
|2||Yoo KL, Jae MB, Yeon JP. Pelvic actinomycosis with hydronephrosis and colon stricture simulating an advanced ovarian cancer. J Gynecol Oncol. 2008;19:154-6. |
|3||Putman HC, Dockerty MB, Waugh JM. Abdominal actinomycosis: an analysis of 122 cases. Surgery 1950;28:781-801.|
|4||Ashwin C, Soheil AH: Incidence of actinomycosis associated with intrauterine devices. J Reprod Med 1994;39:584-7.|
|5||Hoffman MS, Roberts WS, Solomon P, Gunasekarin S, Cavanagh D. Advanced actinomycotic pelvic inflammatory disease simulating gynecologic malignancy; A report of two cases. J Reprod Med 1991;36:543-5. |
|6||Koshiyama M, Yoshida M, Fujii H, Nanno H, Hayashi M, Tauchi K, et al. Ovarian actinomycosis complicated by diabetes mellitus simulating an advanced ovarian carcinoma. Eur J Obstet Gynecol Reprod Biol 1999;87:95-9.|