Rare Abdominopelvic Actinomycosis Causing an Intestinal Band Obstruction and Mimicking an Ovarian Malignancy.

Sakthivel Chinnakkulam Kandhasamy,Rajesh Nachiappa Ganesh,Ashok Kumar Sahoo,Byshetty Rajendar,Mangala Goneppanavar,Vishnu Prasad Nelamangala Ramakrishnaiah

doi:10.7759/cureus.2721

Sakthivel Chinnakkulam Kandhasamy, Rajesh Nachiappa Ganesh + Show 4 more

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https://doi.org/10.7759/cureus.2721

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Abstract

Actinomyces israelii, a commensal of the bronchial and gastrointestinal tracts, is responsible for the majority of actinomycostic infections in humans. Actinomycosis has widely varying clinical presentations ranging from asymptomatic states to infiltrative mass lesions that mimic malignant abdominopelvic disease. Described as one of the most misdiagnosed diseases, actinomycosis poses challenges to accurate preoperative diagnosis. A 67-year-old woman with no significant medical history presented with features of acute intestinal obstruction. Computed tomography revealed a terminal ileal stricture causing intestinal obstruction and a right ovarian mass lesion. On laparotomy, a granular mass (2×2 cm) at the base of the mesentery and a right ovarian hard nodular growth (3×3 cm) were found that were connected by a dense fibrotic band, causing ileal obstruction with a transitional zone that was 10 cm proximal to the ileocecal junction. The mesenteric granular mass was excised together with the dense fibrotic band, and a right salpingo-oophorectomy was also undertaken. On postoperative histopathological examination, band formations by dense inflammatory tissue with neutrophilic infiltration were observed; moreover, there were sulfur granules that showed a positive reaction on Periodic Acid Schiff staining. The resected ovarian parenchyma showed infiltration by bacterial colonies with Splendore-Hoeppli phenomenon and evoked dense neutrophilic infiltration. The postoperative period was uneventful, and the patient was placed on penicillin therapy for a year. Abdominopelvic actinomycosis should constitute part of the differential diagnosis when evaluating mass lesions, especially in elderly women with a history of intrauterine device (IUD) use.

Highlights

Actinomycosis is a rare disease caused by the gram-positive anaerobic bacteria Actinomyces israelii, a commensal microrganism of the alimentary, respiratory, and urogenital systems
Long-standing intrauterine device (IUD) use may render the patient susceptible to pathogenicity by this commensal organism, and infection often presents as a mass lesion that mimics malignancy and should be differentiated from other conditions
We present the case of a 67-year-old woman with features of acute intestinal obstruction caused by dense fibrotic bands as well as a right ovarian mass mimicking a malignancy

Summary

Introduction

Actinomycosis is a rare disease caused by the gram-positive anaerobic bacteria Actinomyces israelii, a commensal microrganism of the alimentary, respiratory, and urogenital systems. We present the case of a 67-year-old woman with features of acute intestinal obstruction caused by dense fibrotic bands as well as a right ovarian mass mimicking a malignancy. A dense fibrotic band extended between the two masses, causing ileal obstruction, and a transitional zone was present 10 cm proximal to the ileocecal junction (Figure 2). Both the mesenteric granular mass and the dense fibrotic band were excised, a right salphingooophorectomy was conducted, and resected specimens were sent for histopathological examination. 3D – This section shows the Splendore-Hoeppli phenomenon characterized by the bright magenta pink color on Period acid Schiff staining, ×400 (arrow). Periodic Acid Schiff staining, ×100. 3D – This section shows the Splendore-Hoeppli phenomenon characterized by the bright magenta pink color on Period acid Schiff staining, ×400 (arrow). 3E (inset) – This section shows negative staining for fungal organisms on staining by the Gomori Methenamine Silver stain, ×100

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