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Tubo-ovarian actinomycosis.
Actinomycotic infection of the female genital tract is rare. Actinomycosis is a chronic suppurative granulomatous infection that is characterized by formation of abscesses, multiple draining sinuses and appearance of tangled mycelial masses or granules in the discharges and tissue sections. 2 cases of tubo-ovarian actinomycosis are reported. The 1st case presented clinical with gastrointestinal symptoms and a ventral scar hernia following an operation for a non-healing abdominal wound 6 months earlier. The 2nd case sought medical attention for backache and leucorrhea of 4 years' duration. Exploratory laparotomy in the 1st case revealed tubo-ovarian masses; the vermiform appendix was not traceable. The uterine cavity in the 2nd case harbored a wooden stick. Direct extension from established ileocacal actinomycosis was believed to involve the female genital adnexae in the past. Association of tubo-ovarian actinomycosis with the presence of a foreign body in the female genital tract has been reported sporadically in the literature, yet an increase in the incidence may be expected because of the frequent use of intrauterine contraceptive devices in recent times. It is suggested that in women presenting clinically with vague abdominal symptoms, backache and discharge, actinomycosis should be considered and ruled out with the help of cytologic and proper microbial culture methods. Once the diagnosis is established, the infection can be treated with good results with penicillin.
Actinomycosis is a chronic suppurative granulomatous infection characterized by formation of abscesses, multiple draining sinuses and appearance of tangled mycelial masses or granules in the discharges and tissue sections. Human actinomycotic disease is described in cervicofacial, thoracic and abdominal regions where the last comprises 20%of the affliction.[6] The lesion of the genital tract is thought to have its origin from a focus in the ileocaecal segment of the intestine. Recently ascending type of actinomycotic infection involving the adnexae following insertion of intrauterine contraceptive device have been reported.[2],[3],[4],[7],[9],[11] Most of the reported cases are in the western literature with only a few references in the Indian sub-continent.[8],[10]
Case 1 A sixty year old Hindu female, para six, with a history of I. U. C . D . in the past, and menopausal for 10 years sought medical attention for pain in the abdomen, loss of appetite and flatulence of twenty-one days' duration. She gave a history of operation done elsewhere six months ago for a non-healing abdominal wound. Her previous case notes were not available. On examination, the anterior abdominal wall showed a ventral scar hernia. Bimanual gynaecologic examination revealed a mass through the right laterial fornix extending up to the right umbilical region. The cervix could not be felt. A clinical diagnosis of right sided ovarian tumour was made and an exploratory laparotomy was planned. Investigations Haemoglobin was 10 gm%; E.S.R. was 34 ;mm/hr. (Wintrobe's method). Total leucocyte count was 10,500/mmi with a differential leucocyte count of P-68%, E-4% and L-28%. Her blood group was 'B' Rh positive. Fasting blood sugar was 100 mg% and post prandial sugar was 266 mg% which was later controlled to 140 mg%; blood urea nitrogen was 21 mg%. Operation notes On exploratory laparotomy, bilateral tubo ovarian masses were seen, densely adherent to the surrounding pelvic structures and the posterior abdominal wall. On the right side, the mass was 4 cm x 4 cm x 3 cm in size and adherent to the loops of intestine; the mass gave way spilling purulent material into the peritoneal cavity. The vermiform appendix was not traceable. Left sided mass was separated and panhysterectomy was performed. The purulent material was examined for culture and antibiotic sensitivity and was found to be sterile after three days of incubation. Pathologic examination The specimen consisted of uterus, 5 cm x 4 cm x 2 cm in size with a left tubo-ovarian. mass. The tube was 5 cm, long and 1 cm broad at the fimbrial end; the ovary was converted into a 4 cm x 5 cm x 1 cm sized oval cyst, with thickened and fibrosed walls. Cut surface of the tube and ovary showed necrotic material studded with yellowish specs [Fig. 1]. Uterine cavity did not contain any foreign body. Histologic examination revealed atrophic endometritis. The myometrium was infiltrated with chronic inflammatory cells. The tubo-ovarian mass showed chronic granulation tissue rich in plasma cells; interspersed in between were basophillic structures showing filamentous radiations with clubbed ends having an eosinophilic rim, surrounded by polymorphonuclear leucocytes reminiscent of an actinomycotic granuloma [Fig. 2] confirmed by Gram's and PAS stains. During the immediate post-operative period, the patient was febrile. She responded well to penicillin and streptomycin treatment. By the end of one month following operation her wound showed complete healing and she was discharged. Case 2 A 45 year old Hindu female, para 6, and menopausal for the last three years presented with the complaints of backache and vaginal discharge of four years' duration. The patient sought help of a village-woman for prevention oŁ conception eight years ago. She did not know what exactly was done. On internal pelvic examination, the uterus was found to be atrophic and fixed posteriorly; the cervix was flushed with vagina. The cervical os was oozing purulent discharge. The vaginal fornices were clear. Smears collected for exfoliative cytology to rule out malignancy revealed plenty of squamous epithelial cells showing inflammatory eosinophilia, polymor-phonuclears and bacterial clumps. There was no evidence of malignancy. Patient was treated with colpomine vaginal tablets, yet she did not respond favourably. An exploratory laparotomy was planned. Investigations Haemoglobin was 9.5 gm%; total leucocyte count was 11.000/mm3 with a differential leucocyte count of P-73%, L-26% and E-1%. Blood group was 'O' Rh positive. Blood urea nitrogen was 12 mg%; serum creatinine was 1.4 mg% and random blood sugar was 120 mg%. Urine culture gave a growth of Pseudomonas pyocyaneus resistant to all antibiotics. Operation notes At laparotomy, the uterus was found to be atrophic and fixed posteriorly to the sigmoid colon. On the right side, the ovary and the fallopian tube were seen as a single mass with dense adhesions with the surrounding pelvic structures. The adhesions were separated as the uterus was clamped with vulsellum; perforation of the uterus occurred at the site through which a wooden stick covered with purulent material stuck out. The stick was removed which was 7 cm. long and 4 mm broad. The right sided tubo-ovarian mass was removed with the uterus. The normal looking left ovary was left behind. The cervix was removed separately. Pathologic examination The uterus measured 5 cm x 4 cm x 3 cm in size with a 4 cm x 3 cm sized, right sided, tubo-ovarian mass which was firm and irregular in size. Cut surface of the mass showed multiple yellowish areas 3-5 mm in size. [Fig. 3]. The wooden stick was softened and swollen. Histologic examination revealed an atrophic myometrium with endometritis. The cervix showed' features of chronic cervicitis. Sections from the tubo-ovarian mass showed clumps of mycelia characteristic of actinomyces surrounded by polymorphonuclear infiltrate and chronic granulation tissue, confirmed by Gram's and PAS stains. Immediate post-operative period was uneventful. The patient was treated with ampicillin and chloromycetin. The abdominal surgical wound healed properly, but the vaginal wound continued to discharge. Staph. aureus sensitive to gentamicin, kanamycin and tetracycline was grown. Anaerobic culture failed to grow actinomyces.
Female genitalia is relatively a rare site for pelvic actinomycosis.[2], [6] Pelvic actinomycosis is often unsuspected clinically as actinomyces do not inhabit the vaginal canal. Adnexal involvement is usually secondary to infection in the gastrointestinal canal. In the first case, it is probable that the primary infection resided in the ileocaecal junction and the appendix, extended towards the abdominal wall forming a non-healing abdominal wound involving the tubo-ovarian structures as well. Following the first operation, the patient still had abdominal discomfort as a result of residual infection leading to pelvic adhesions. Ascending infection due to an I.U.C.D. can be ruled out since the patient wore it fifteen years ago. In the second case, the infection was of ascending nature because of the presence of a wooden stick for eight years acting as a foreign body causing tissue damage in the uterine cavity and the endocervical canal. Actinomycotic infections are endogenous in origin. Organism normally present is of low pathogenicity and multiplies in a favourable environment provided by the injured necrotic tissue. Association of actinomycosis to a foreign body like fishbone in the large intestine is reported.[5] With increasing popularity of I.U.C.D., actinomycotic infection is on an increase. Likewise, long forgotton tampons and pessaries may also be associated with pelvic actinomycosis in women. Actinomyces israelli is reported to be associated with I.U.C.D.[1],[2],[3],[4],[7],[9] In conclusion, we suggest that in women presenting clinically with vague abdominal symptoms, backache and vaginal discharge, actinomycosis should be considered and ruled out with the help of cytologic and proper, microbial culture methods. Once the diagnosis is established, the infection can be treated with good results with pencillin.[5], [8], [10] It is also important to look for other sites for actinomycosis, in the absence of which the possibility of existence of foreign bodies in the genital tract should be considered.
We thank Dr. J. V. Bhatt, M.D., Dean L.T.M. Medical College and Hospital for allowing us to publish this article. Thanks are also due to Mr. C. V. Desai for his help in taking the photographs.
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