Peritonitis Due to Perforated Uterine Actinomycosis

Abstract

Actinomyces spp are commensal anaerobic, gram-negative bacilli that have been infrequently associated with pelvic inflammatory disease due to long-standing intrauterine devices (IUD). Actinomycosis can present with non-specific abdominal pain and progress to peritonitis. We present a case of peritonitis initially attributed to colonic perforation, and later found to have been due to pelvic Actinomycosis with uterine perforation. A 65 year-old female with a history of coronary artery disease, hypertension, and depression presented to the emergency department with a stabbing pain in her pelvis, with radiation to the left lower quadrant. This pain was intermittent over the past six months, and became more constant the day prior to admission. She denied fevers, chills, nausea, vomiting, constipation, diarrhea, hematochezia, melena, vaginal bleeding, chest pain, or dyspnea. On physical exam, vitals were stable. She had abdominal distension, guarding, and rebound tenderness. Laboratory work-up was remarkable for leukocytosis (14.2 x 103/uL) with 80% neutrophils and anemia (Hgb 10.6 g/dL and Hct 34%). A CT abdomen revealed free intraperitoneal air. It was also suggestive of colonic pneumatosis, with small amounts of intraperitoneal fluid. Non-specific findings of low-density material and small amounts of gas in the endometrial canal were also noted. The patient underwent an exploratory laparotomy, which revealed light tan fluid and fibrinous exudate throughout the abdomen. There was no evidence of enteric leak. A punched out, necrotic, 4 mm round full-thickness perforation was found in the anterior uterine fundus. Purulent material was expressed from the defect. A subtotal hysterectomy was performed. Intra-operative pelvic pus cultures grew Actinomyces spp. The patient was discharged on a total of three months of amoxicillin-clavulanate, and has continued to do well on follow-up. It was concluded that Actinomycesspp. were likely introduced to the uterus six months prior, when the patient underwent an endometrial biopsy for evaluation of post-menopausal bleeding. This is in contrast to the association of pelvic actinomycosis with longstanding IUDs. Because the mainstay of treatment is with antibiotics, it is important to recognize actinomycosis as a potential etiology when evaluating peritonitis in a patient with uterine instrumentation.1591 Figure 1. A 4 mm necrotic perforation (arrow) was found in the anterior uterine fundus.