Table 4 Publications of cases of pelvic actinomycosis in Europe. Tunisia [ 11 ] Total cases 8. In many cases, the diagnosis is made a posteriori through a histological examination of samples obtained surgically during laparotomy or laparoscopy, but rarely in a preoperative manner. Pelvic actynomycosis as the result of a long standing use of an intrauterine device.
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This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. This article has been cited by other articles in PMC. Abstract Introduction Actinomycosis is a chronic bacterial infection caused by Actinomyces, Gram-positive anaerobic bacteria. Its symptomatology imitates some malignant pelvic tumours, tuberculosis, or nocardiosis, causing abscesses and fistulas.
Actinomycoses are opportunistic infections and require normal mucous barriers to be altered. No epidemiological studies have been conducted to determine prevalence or incidence of such infections. Objective To analyse the clinical cases of pelvic actinomycosis reported worldwide, to update the information about the disease. Methods A systematic review of worldwide pelvic actinomycosis cases between and was performed, utilising the PubMed, Scopus, and Google Scholar databases.
The following information was analysed: year, country, type of study, number of cases, use of intrauterine device IUD , final and initial diagnosis, and method of diagnosis. Results 63 articles met the search criteria, of which 55 reported clinical cases and 8 reported cross-sectional studies. Conclusions Pelvic actinomycosis is confusing to diagnose and should be considered in the differential diagnosis of pelvic chronic inflammatory lesions. It is commonly diagnosed through a histological report, obtained after a surgery subsequent to an erroneous initial diagnosis.
A bacterial culture in anaerobic medium could be useful for the diagnosis but requires a controlled technique and should be performed using specialised equipment.
Actinomycosis is an uncommon condition whose symptomatology imitates some malignant pelvic tumours, tuberculosis, or nocardiosis because it spreads progressively and continuously [ 3 ]. This pathology invades tissue layers, causing the formation of abscesses and fistulae. Its diagnosis is difficult, and it results in increased morbimortality. Actinomyces belong to the phylum Actinobacteria and to the order Actinomycetales. Hundreds of Actinomyces species exist, most of which inhabit the soil.
Others are associated with plants, which participate in nitrogen fixation, and a few species live in human beings as saprophytic bacteria [ 2 ]. It should be highlighted that most Actinomyces spp.
Actinomycoses are opportunistic chronic infections [ 4 ], as Actinomyces have a low potential for virulence in connection with fimbriae. Therefore, they require normal mucosal barriers to be altered through trauma, surgery, or an infection. In this way, they cross the mucosal membrane or epithelial surface [ 4 — 6 ]. For example, a pulmonary infection can be caused by bronchoaspiration [ 5 , 7 ], or a pelvic infection can originate from the use of an intrauterine device IUD , which can injure or perforate the mucosal membrane of the uterus and facilitate infection [ 3 ].
Currently, various clinical characteristics of actinomycosis have been described, and the bacterium has been observed in various anatomical sites e.
Other clinical types include thoracic actinomycosis, the third most common type of actinomycosis, which includes pulmonary, bronchial, and laryngeal actinomycosis [ 3 ], and abdominal actinomycosis, where the appendix, caecum, and colon are the most common sites of infection.
Actinomycosis of the central nervous system is located chiefly in the cerebral abscess. Actinomycosis of the urogenital tract is the second most common clinical form of actinomycosis, and the principal clinical presentation is pelvic actinomycosis [ 3 , 5 , 8 ]. Pelvic actinomycosis can affect any age group, with no preference for occupation or season and is secondary to perforation or fistulation [ 4 ].
Other possible causes include bacterial vaginosis, which fosters an anaerobic environment and is associated with other microorganisms [ 51 ]; the presence of tumours [ 66 ]; and the use of IUDs [ 3 — 5 ].
The possibility of a contagion through oral sex has been considered because these bacteria are part of the oral cavity microbiota [ 72 ]. One possible route of dissemination is through IUDs, which fosters the growth of microorganisms through wires that are left in the exocervix.
In addition, the IUD changes the carbohydrate metabolism in endometrial cells, fostering still more inflammation. Another probable route is the perineum, where the microorganisms could extend from the anus up through the cervicovaginal zone [ 4 ]. The most common aetiological agent is Actinomyces israelii [ 5 , 73 ]. Other reported species include A. The symptoms of pelvic actinomycosis associated with the use of an IUD can imitate symptoms of gynaecological malignant tumours, uterine myoma, or adenomyosis when presenting as a genital mass without fever [ 3 ].
The infection can disseminate to the uterine tubes and can cause salpingitis and the subsequent destruction of the ovarian parenchyma [ 4 ]. Organs such as the bladder, ileocaecal iliac fossa and rectosigmoid region, colon, urethra, and extension to the skin have been reportedly affected in various published cases. The diagnosis of pelvic actinomycosis is obtained using various techniques because culturing Actinomyces spp. First, the signs and symptoms of the patients are considered and can point to a possible abdominal infection, vaginitis, abscess, or possible tumour-forming process.
The most common symptoms are weight loss, nonspecific abdominal or pelvic pain, breakthrough bleeding or abundant vaginal flow, and, on rare occasions, fever [ 3 , 4 , 51 ]. Upon medical exploration, the affected zone is palpated to detect hard masses, and a gynaecological exam is performed to check for inflammation of the vaginal mucous membrane, yellowish secretion with a bad smell, or some visible damage to the mucous membrane [ 4 , 51 ].
In laboratory studies, it is possible to identify leucocytosis, erythropaenia, and high sedimentation rate; high values of C-reactive protein; and tumour marker values within the reference ranges or slightly elevated like Ca Alpha-fetoprotein , and cancer antigen 15—3 [ 3 , 4 , 51 ]. Diagnostic images, such as computed tomography, magnetic resonance, ultrasound, X-rays, and laparoscopy are helpful, as they can be used to observe the affected zone, such as a tumour-forming mass that can induce either actinomycosis or a carcinogenic process [ 4 , 51 , 73 ].
In most cases, histological visualisation of biopsy or aspirated samples is employed, where bacilli in the tissue with their typical ramifications, such as in interconnected breasts, are observed. Cervicovaginal cells are collected for Papanicolaou Pap staining. In many cases, the diagnosis is made a posteriori through a histological examination of samples obtained surgically during laparotomy or laparoscopy, but rarely in a preoperative manner.
Histological studies of tissues show inflammatory changes of suppurative and granulomatous nature, connective proliferation, and sulphur granules, which have also been identified in infections caused by Nocardia brasiliensis, Actinomadura madurae, and Staphylococcus aureus. These granules are particles of yellowish colour, which, when viewed by the naked eye, are formed by groups of filamentous Actinomyces surrounded by neutrophils [ 73 ].
Two methods exist for completely identifying the causal agent: culture and identification through biochemical tests and identification through sequencing of the 16S rRNA segment, which offers greater precision.
Although these methods are very efficient, they are not well reported in the literature due to the conditions under which they must be performed, requiring an anaerobic culture environment and the necessary equipment, which is costly. The usual treatment for actinomycosis consists of high and prolonged doses of penicillin G 20 million units per day or amoxicillin for 4 to 6 weeks, followed by penicillin V 4 g per day orally for 6 to 12 months.
Clindamycin, tetracycline, and erythromycin are an alternative in cases of allergy to penicillin [ 4 , 5 ]. In addition to these medicines, it has been observed that Actinomyces is also sensitive to third-generation cephalosporins, ciprofloxacin, trimethoprim-sulfamethoxazole, and rifampicin [ 4 ].
However, the elimination of the injured tissue and surgical drainage are necessary measures in some cases [ 5 ], and, in these patients, the duration of antimicrobial therapy could be reduced 3 months [ 3 ]. Beedham et al. Clinical cases of pelvic actinomycosis have been reported in Africa, Oceania, Asia, Europe, and America.
However, as pelvic actinomycosis is an uncommon infection, no epidemiological studies have been conducted to determine its prevalence or incidence. A systematic review of worldwide cases of pelvic actinomycosis between the years and was performed. Abstracts of articles identified to be relevant for the objective of this paper were read; studies whose abstract or full text was unavailable were automatically excluded.
When an abstract complied with inclusion criteria, the full text was analysed. Case reports that lacked a diagnostic method and a final diagnosis of pelvic actinomycosis were excluded.
Studies published in a language that was not English, Spanish, French, or Portuguese were not included. The following information was extracted and analysed from the compiled studies: year, country, type of study, number of cases, prior use of IUD and duration, initial diagnosis, treatment, definitive diagnosis, and method of definitive diagnosis Figure 1.
This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. This article has been cited by other articles in PMC. Abstract Introduction Actinomycosis is a chronic bacterial infection caused by Actinomyces, Gram-positive anaerobic bacteria. Its symptomatology imitates some malignant pelvic tumours, tuberculosis, or nocardiosis, causing abscesses and fistulas. Actinomycoses are opportunistic infections and require normal mucous barriers to be altered. No epidemiological studies have been conducted to determine prevalence or incidence of such infections. Objective To analyse the clinical cases of pelvic actinomycosis reported worldwide, to update the information about the disease.
Vok South Korea [ 15 ]. Discussion According to the analysis of the articles presented, Europe was the continent on which the greatest number of cases of pelvic actinomycosis was reported, followed by Asia and America. ND Incomplete tumourectomy, ileal resection, partial cystectomy, colostomy and actinomiicosis ureterocutaneostomy, and penicillin Significant improvement 1 43Maeda et al. Case Reports in Medicine.
Telmaran Laboratory results upon admission to the emergency department proved severe anaemia haemoglobin 8. Austin Journal of Obstetric and Ginecology. Only 3 articles reported actinomycosis as such, and only one report completely identified the causal agent through culture and biochemical assays Table 6. Laparotomy, total hysterectomy, bilateral salpingo-oophorectomy, and anterior resection No date of resolution. Under a Creative Commons license.
ACTINOMICOSIS PELVICA PDF
England [ 67 ]. Spain [ 31 ]. Actinomyces in cervical cytology. Laparotomy, total hysterectomy, bilateral salpingo-oophorectomy, and anterior resection No date of resolution. Czech Republic [ 46 ]. Incomplete tumourectomy, ileal resection, partial cystectomy, colostomy and bilateral ureterocutaneostomy, and penicillin Significant improvement. Postsurgical histopathological report of samples from the abdominal wall abscess.