Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 2001  |  Volume : 7  |  Issue : 1  |  Page : 37-39
Abdominal actinomycosis: Case reports


1 Department of Surgery, King Khalid University Hospital, Riyadh, Saudi Arabia
2 Department of Surgery, Riyadh Medical Complex, Riyadh, Saudi Arabia

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Date of Submission23-Jun-1999
Date of Acceptance29-Feb-2000
 

How to cite this article:
Alam MK, Khayat FA, Al-Kayali A, Al-Suhaibani YA. Abdominal actinomycosis: Case reports. Saudi J Gastroenterol 2001;7:37-9

How to cite this URL:
Alam MK, Khayat FA, Al-Kayali A, Al-Suhaibani YA. Abdominal actinomycosis: Case reports. Saudi J Gastroenterol [serial online] 2001 [cited 2019 Nov 14];7:37-9. Available from: http://www.saudijgastro.com/text.asp?2001/7/1/37/33413


Actinomycosis in human is caused by actinomyces Israeli, saprophyte bacterium of the mouth and gastrointestinal tract and an opportunistic pathogen [1],[2] . Invasive infection of abdomen by this organism comprises 25-50% of actinomycotic infections [3],[4] . However, the rarity of the disease in general and its non-specific clinical, biochemical, and radiological features are the causes for the frequently mistaking the condition as neoplasm. We present two cases of abdominal actinomycosis where the correct diagnosis was established only after histopathological evaluation. These cases are presented to raise the awareness of this rare condition, to be included in the differential diagnosis of an abdominal mass. A brief review of the literature is also presented.


   Case reports Top


Case one: A 30-year-old Bangladeshi male was admitted to Riyadh Medical Complex (RMC) with left sided abdominal pain of two months duration, associated with fever, loss of appetite and weight. He denied any alteration of bowel habit. He was febrile on admission. A hard, immobile intra­abdominal mass of 8x 5 cm in left lumbar area was found on examination. Hematological and biochemical profiles were normal. Stool examinations for parasites and occult blood were negative. Ultrasound examination revealed heterogeneous nature of the mass. CT abdomen showed a heterogeneous mass, possibly arising from left colon and infiltrating into the anterior abdominal wall [Figure - 1]. Colonoscopy revealed an extrinsic mass effect on left colon. Colonic biopsy from this site showed chronic inflammatory changes and mucosal ulcers. Abdominal neoplasm of mesenchymal origin was suspected.

A combination of antibiotics (Gentamycin, Ampicilin and Metronidazole) was started before surgery. At laparotomy, a hard mass of about 8x5 cm, arising from the descending colon, infiltrating into adjacent transverse colon and abdominal wall, was found. Liver and rest of peritoneum were normal. A limited left hemicolectomy including the mass and the surrounding infiltration and primary end to end anastomosis was performed. The postoperative course was uneventful. Combination of the antibiotics was continued postoperatively. Histopathology revealed a colonic perforation with chronic granulomatous infection compatible with actinomycosis [Figure - 2]. At this stage oral Ampicillin 500 mg-six hourly was started to continue for three months. He failed to appear for follow-up.

Case two : A 35-year-old Jordanian farmer presented with right hypochondrial pain of gradual onset for four months. The pain was associated with low grade fever, anorexia, nausea and loss of weight of 15 kg. He was initially investigated in a private clinic and treated for suspected acute cholecystitis with some relief. On admission to RMC, he was febrile (37.8°C) and ill looking. On abdominal examination, he was tender in right hypochondrium but there was no hepatomegaly. Blood investigation showed elevated ESR, high alkaline phosphatase and normal carcino embryonic antigen (CEA) and alfa­fetoprotein. Ultrasonography and CT scan revealed a right liver lobe mass with areas of necrosis [Figure - 3], CT guided aspiration cytology revealed cellular dysplasia and lymphocytic infiltrate.

Upper and lower GI endoscopy were normal. A hepatocellular carcinoma was suspected. At surgery, the mass was arising from segment 5 and 6 of the liver to which greater momentum and transverse colon were adherent. These structures were separated and the involved segments were excised with cholecystectomy. Cut surface of the mass had honeycomb appearance. Histopathologic diagnosis revealed actinomycosis of the liver. The patient received crystalline penicillin 2.5 million 6 hourly for one week. On discharge he was advised to continue oral penicillin 500 mg 6 hourly for 3 months. At last, follow-up 6 months after surgery, the patient remained asymptomatic.


   Discussion Top


Actinomycosis is a chronic granulomatous disease [5] . Abdominal infection usually occurs when the organism escapes from gastrointestinal tract following gastrointestinal surgery or perforation [6],[7] . Intraperitoneal spillage of gallstones during laparoscopic cholecystectomy has produced thoraco­abdominal actinomycoses [3] . Liver involvement is usually via the portal vein but may also occur by direct extension via hepatic artery or by duodenobiliary reflux [8],[9] . Abdominal and pelvic actinomycosis can also develop in association with the use of an intrauterine device (IUD) [10] . The organism having escaped from bowel initially proliferates, produces granulomaous inflammation and mass formation. This, later undergoes softening and abscess formation which may rupture through abdominal wall and discharge `sulfur granules' or rupture into adjacent viscera producing internal fistulae [11] . These sulfur granules are colonies of the organism actinomyces.

Actinomycosis commonly involves face and neck. The frequency of abdomen involvement is approximately 25% but occasionally much higher [3],[4] . Ileocaecal region resulting from appendiceal perforation is most frequently affected although stomach, duodenum, gallbladder, colon, anorectal area and pelvic organs can also be involved [4],[10],[12] . The liver is the primary site of infection in 15% of abdominal actinomycosis [13].

Actinomycosis is one of the great imitators in clinical practice, particularly when it occurs in abdominal Cavity [11] . Non specific nature of presentation such as abdominal pain, occasional fever, anorexia, weight loss and abdominal mass can easily mislead clinicians to an incorrect diagnosis. Whilst reviewing literature, one is struck by the frequency with which actinomycotic lesions are diagnosed to be a neoplasm [2],[3],[8],[10],[14] . Our patients presented with a similar nonspecific symptoms of chronic illness, with weight loss, abdominal mass (Case 1), mass lesion on ultrasonography and CT scan which led us to a similar conclusion, that these patients have neoplasm. There are no specific radiological signs of gastrointestinal actinomycosis. Ultrasonography, CT scan, MRI and angiography may fail to distinguish between liver actinomycosis and hepatocellular carcinoma [15]. Gallium 67 scan shows increased uptake in liver actinomycosis, which is similar to pyogenic liver abscess and malignancy of liver [16] . However, when patients present with superficial lesions, with pus discharging sinuses that contains sulfur granules or accessible to biopsy, diagnosis can be established preoperatively. Percutaneous liver aspiration or endoscopic biopsy may help in establishing the diagnosis in some patients [5],[8] . Anaerobic culture from these aspirate may establish the diagnosis [10] . In our patients, attempts to establish a preoperative diagnosis by liver aspiration and endoscopic biopsy were unrewarding. Anaerobic culture was not obtained in these patients because the diagnosis was not suspected.

Actinomycosis is a fully curable disease. A prolonged course of antibiotics is usually required for cure. Most authorities recommend high-dose intravenous penicillin G followed by oral penicillin for three months. Ampicillin, tetracycline, piperacillin, erythromycin and minocycline have also been advocated for therapy [3],[8],[10] .

In conclusion, the diagnosis of abdominal actinomycosis is difficult due to its rarity and specific presentation. It would be considered in the differential diagnosis of abdominal mass. In a suspected mass, a preoperative fine needle aspiration and anaerobic culture can establish the diagnosis. Increased awareness of this entity will help in raising the index of suspicion and possibility of preoperative diagnosis.


   Acknowledgement Top


We would like to thank Corazon L. Rivera for her assistance in typing this manuscript.

 
   References Top

1.Stringer MD, Cameron AEP. Abdominal actinomycosis: A forgotten Disease. Br J Hosp. Med 1987; 38: 125-7.  Back to cited text no. 1    
2.Thompson JR, Watt SR, Thompson WC. Actinomycetoma masquerading as an abdominal neoplasm. Dis Colon Rectum 1982;25:368-70.  Back to cited text no. 2    
3.Noda S, Soybel DI, Sampson BA, De Camp MM. Broncholithiasis and thoracoabdominal actinomycosis from dropped gallstones. Ann thorac Surg 1998; 65: 1465-7.  Back to cited text no. 3    
4.Fisher AM, Harvey JC. Actinomycosis: some concepts of therapy and prognosis. Postgrad Med 1956; 19-32.  Back to cited text no. 4    
5.Piper MH, Schaberg DR, Ross JM, Shartsis JM, Orzechowski RW. Endoscopic detecion and therapy of colonic actinomycosis. Am J Gastroenterol 1992,87:1040-2.  Back to cited text no. 5  [PUBMED]  
6.Deshmukh N, Heaney SJ. Actinomycosis at multiple colonic sites. Am J. Gastroentrol 1986; 81:1212-14.  Back to cited text no. 6    
7.Gingold BS, Fazio VW. Abdominal Actinomycosis: A complication of colonic perforation. Dis Colon Rectum 1978; 21:374-6.  Back to cited text no. 7  [PUBMED]  
8.Sugano S, Matuda T, Suzuki T, Makino H, Linuma M, Ishii K, Ohe K, Mogami K. Hepatic actinomycosis: Case report and review of literature in Japan. J. Gastroenterol 1997; 32: 672-6.  Back to cited text no. 8    
9.Cheng YF, Hung CF, Liu YH, Ng KK, Tasai CC.. Hepatic actinomycosis with portal vein occlusion. Gastrointest Radiol 1989; 14: 268-70.  Back to cited text no. 9    
10.Kawahara M, Kawahara K, Goto T, Yamamoto S, Fuchinoue S, Matsumoto T. Abdominal actinomycosis misdiagnosed as a secondary bladder tumor: A case report. Int J Urol 1998; 5: 498-500.  Back to cited text no. 10  [PUBMED]  
11.Davies M, Keddie NC. Abdominal actinomycosis. Br J Surg 1973; 60:18-22.  Back to cited text no. 11  [PUBMED]  
12.Brewer NS, Spencer RJ, Nicolas DR. primary anorectal actinomycosis, JAMA 1974; 228: 1397-400.  Back to cited text no. 12    
13.Lee JD, Kim PG, Jo HJ, Park DH. Seo EJ. A case of primary hepatic actinomycosis, J Korean Med Sci 1993; 8: 385-9.  Back to cited text no. 13    
14.Higaki S, Matsura S, Awaya N, Mitani N, Tada M, Okita K. A case of colonic actinomycosis difficult to distinguish from advanced colonic carcinoma. Endoscopy 1995; 27: 712.  Back to cited text no. 14    
15.Kasano Y, Tanimura H, Yamaue H, Hayashido M, Umano Y. Hepatic actinomycosis infiltrating the diaphragm and right hung. Am J Gastroenterol 1996; 91: 2418-20.  Back to cited text no. 15  [PUBMED]  
16.Chandarlapty SK, Dusol MJr, E Edwards R, Pereiras RJr, Clark R, Schiff ER.. 67 Gallium accumulation in hepatic actinomycosis. Gasteroenterology 1975; 69: 752-5.  Back to cited text no. 16    

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Correspondence Address:
Mohammed Khurshid Alam
Department of Surgery, King Khalid University Hospital, P. 0. Box 7805, Riyadh 11472
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


PMID: 19861765

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