An Uncommon Case of Pelvic and Abdominal Wall Mass: Presumed Pelvic Actinomycosis

Abstract

When a woman presents with a solid tumor in the pelvis and abdominal wall and an increased level of CA125, malignancy is always diagnosed first. If the patient also has signs of inflammation, such as fever and increased levels of white blood cell (WBC) and C-reactive protein, the findings are mostly attributed to necrosis of the tumor. In this article, we present a patient with a tumor in the cul-de-sac and another in the lower abdominal wall below the navel that was misdiagnosed with malignancy but was eventually cured using medication. A 41-year-old woman, gravida 2, para 2, was admitted to our hospital, because she had experienced lower abdominal pain and fever for 3 months. Prior to hospitalization, she had been in good health, and her menstruation had been normal. She had not traveled abroad or kept any pets in that recent period. The symptoms subsided and relapsed repeatedly. Body temperature was sometimes above 38°C. Her condition did not improve, although she had been seeing a medical practitioner. The patient was thin, short, and mentally sound and did not look very sick. She admitted having an intrauterine device (IUD) implanted 14 years prior to admission. Her body temperature was 37°C and pulse rate was 76/minute. Gynecologic examination revealed the following: no abnormal vaginal discharge, normal looking cervix with no tender points, an IUD implanted in the uterus, flat and soft abdomen that demonstrated no tenderness or rebound pain upon palpation. The posterior wall of the cervix and the abdominal wall below the navel each had a fist-sized tumor. Digital anal examination showed that the tumor in the cul-de-sac (rectouterine pouch) was hard. Laboratory test results revealed the following: WBC, 23,900/mm 3 ; hemoglobin, 9.6 g/dL; mean corpuscular volume, 89.4 fL; C-reactive protein, 19.5 mg/dL; erythrocyte sedimentation rate (ESR), 121 mm/h and 128 mm/2 h. Liver function and renal function tests were normal, and electrolyte levels were normal. With regards to the tumor markers, CA125 increased to 135.7 IU/mL, α-fetoprotein was 1.2 ng/mL, squamous cell antigen of the cervix was 0.1 ng/mL, β-human chorionic gonadotropin was 0.1 mIU/mL, lactate dehydrogenase was 261 IU/L. All of the results were within the reference ranges. Ultrasonic examination results revealed that both the cervix and the uterine body were normal; however, between the posterior wall of the uterus and the rectum, as well as beneath the lower abdominal wall below the navel, two tumors, 7 cm in size, round and solid with irregular margins, were found, respectively (Figures 1 and 2). Ultrasonic examination results also revealed that the ovaries were normal. Again, computed tomography (CT) scan confirmed that between the posterior wall of the uterus and the rectum was a tumor, 8 × 7 × 6.8 cm, with a blurred and irregular margin, solid, and uneven density (Figures 3 and 4),