Background: Increasing reports of intrauterine device (IUD)-related abdominopelvic actinomycosis
have been described recently. Surgical therapy has been the usual treatment when tubo-ovarian
abscess is identified

Anteby, Eyal Y.

Hanoch, Josef

Laufer, Neri

Rahav, Galiya

Shimonovitz, Shlomo

Yagel, Simcha

Infectious Diseases in Obstetrics & Gynecology

English

PubMed

Anteby, Eyal Y

Yagel, Simeha

Digital Commons@Becker

Washington University School of MedicineDigital Commons@BeckerOpen Access Publications1996Ultrasound-guided transvaginal aspiration in themanagement of actinomyces pelvic abscessEyal Y. AntebyWashington University School of Medicine in St. LouisGaliya RahavHadassah University HospitalJosef HanochHadassah University HospitalShlomo ShimonovitzHadassah University HospitalSimeha YagelHadassah University HospitalSee next page for additional authorsFollow this and additional works at: https://digitalcommons.wustl.edu/open_access_pubsPart of the Medicine and Health Sciences CommonsThis Open Access Publication is brought to you for free and open access by Digital Commons@Becker. It has been accepted for inclusion in OpenAccess Publications by an authorized administrator of Digital Commons@Becker. For more information, please contact engeszer@wustl.edu.Recommended CitationAnteby, Eyal Y.; Rahav, Galiya; Hanoch, Josef; Shimonovitz, Shlomo; Yagel, Simeha; and Laufer, Neri, ,"Ultrasound-guidedtransvaginal aspiration in the management of actinomyces pelvic abscess." Infectious Diseases in Obstetrics and Gynecology.,.298-300. (1996).https://digitalcommons.wustl.edu/open_access_pubs/998AuthorsEyal Y. Anteby, Galiya Rahav, Josef Hanoch, Shlomo Shimonovitz, Simeha Yagel, and Neri LauferThis open access publication is available at Digital Commons@Becker: https://digitalcommons.wustl.edu/open_access_pubs/998Infectious Diseases in Obstetrics and Gynecology 4:298-300 (1996)(C) 1997 Wiley-Liss, Inc.Ultrasound-Guided Transvaginal Aspiration in theManagement of Actinomyces Pelvic AbscessEyal Y. Anteby,* Galiya Rahav,2 Josef Hanoch, 1Shlomo Shimonovitz, 1 Simeha Yagel, and Neri Laufer1Department of Obstetrics and Gynecology Hadassah University Hospital, MT. Scopus,Jerusalem, IsradeDepartment of Microbiology, Hadassah University Hospital, Mt. Scopus, Jerusalem, IsraelABSTRACTBackground: Increasing reports of intrauterine device (IUD)-related abdominopelvic actinomycosishave been described recently. Surgical therapy has been the usual treatment when tubo-ovarianabscess is identified.Case: A 38-year-old woman suffering from Actinomyces pelvic abscess unresponsive to medicaltreatment underwent transvaginal ultrasound-guided needle aspiration. It resulted in marked im-provement and avoided surgical treatment.Conclusion: Transvaginal needle aspiration ofActinomyces pelvic abscess may be an alternative tosurgical therapy, thereby allowing the preservation of pelvic organs. Infect. Dis. Obstet. Gynecol.4:298-300, 1996. (C) 1997 Wilcy-Iiss, Inc.KEY WORDSactinomycosis; abscess; aspiration; ultrasoundgram-positive anaerobic or mi-croacrophilic rods, are normal inhabitants ofthe oropharynx and the bowel. The clinical syn-drome of pelvic actinomycosis in association withthe "modern" intrauterine device (IUD) was firstreported by Henderson.z Since then, several casereports have described pelvic actinomycosis in pa-tients with IUDs. The disease rarely occurs unlessthe IUD has been in place for at least 2 years, andthe risk seems to increase with time. The presen-tation is typically indolent, often delaying the di-agnosis. Endomctritis and tubo-ovarian abscess arcusually the earliest forms of pelvic actinomyco-sis.4’ The disease can spread locally and involvethe ureters, bladder, and the rectum.6 Extension tothe abdominal wall, small bowel, and pelvic bonesand distant hematogcnous dissemination may oc-cur. 7-9 An initial diagnosis of ovarian or uterine tu-mot is frequently considered, leading to unneces-sary extensive surgery. Actinomycotic pelvic ab-scess is treated initially by large doses ofintravenously administered penicillin. Surgical in-tervention was necessitated in the majority of thecases previously described.CASE REPORTA 38-year-old woman presented to the emergencyroom with high fever, chills, and lower abdominalpain. Her medical history was unremarkablc. Shehad had 3 normal pregnancies and term deliveries,2 miscarriages, and induced abortion. She hadused a multiload copper IUD for the previous 4years. For 2 weeks prior to her admission she hadsuffered from lower abdominal pain. On admission,she had fever of 40C, pulse 94/rain, and bloodpressure 120/70 mm Hg. Her abdomen was dif-fusely tender. On her vaginal examination, the*Correspondence to: Eyal Y. Anteby, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology,Washington University, Box 8064, 4911 Barnes Hospital Plaza, St. Louis, MO 63110.Received 13 December 1996Obstetrical Case Report Accepted 13 November 1996ACTINOMYCES PELVIC ABSCESS ANTEBYET AL.Fig. I. Transvaginal sonogram of the actinomycosis pelvicabscesses.uterus was extremely tender. A painful mass, 10 cmin diameter, was felt in the pouch of Douglas. TheIUD was removed. Pus exuding from the cervixwas sent for culture. It showed methicillin-sensitive Staphylococcus aureus. Blood and urine cul-tures were sterile. The erythrocyte sedimentationrate was 150 mm/h, hemoglobin 10.8 g%, and whiteblood cell count 17,700 with a shift to the left. Anultrasound (US) scan showed an 11 cm, scmicysticmass containing both of her ovaries in the pouch ofDouglas (Fig. 1). The right ovary contained a 5 x 5cm hyperechogenic cystic structure consistent withan abscess, and the left ovary contained severalloculi, 1-2 cm in diameter. The patient was treatedwith intravenous amoxicillin-clavulanate (1 g x3/day), gentamicin (80 mg x 3/day), and doxycy-cline (100 mg x 2/day). After 5 days of antibiotictreatment the patient remained febrile, with tem-peratures reaching over 38.5C. She continued tosuffer from abdominal pain and the pelvic and USexamination findings were similar to those on heradmission. Therefore, a transvaginal US-guidedneedle aspiration was performed. One hundredtwenty milliliters of pus was drained from the largeright ovarian abscess and 30 ml from several leftovarian loculi. A Gram stain revealed many poly-morphonuclear cells with branching gram-positivefilaments. Her culture grew Actinomyces israelii. Fol-lowing the drainage, her fever subsided and theabdominal pain disappeared. She was treated withintravenous penicillin for 2 weeks, followed by oralamoxicillin for 2 months. The pelvic abscess de-creased to 6 cm 2 weeks after drainage and finallydisappeared.DISCUSSIONPelvic actinomycosis may be a serious, possiblylife-threatening disease. Ninety-two cases of acti-nomycotic pelvic abscesses were reviewed recentlyby Fiorino.1 The average age of the patients was37 years, and the IUDs had been in place for anaverage of8 years. The most common complaintswere abdominal pain and weight loss. A physicalexamination was usually uninformative. Uni- or bi-lateral tubo-ovarian abscesses were present in 90%of the cases, with other organs often involved bythe inflammatory process. In the remaining pa-tients, the abscesses involved the bowel, bladder,retroperitoneum, or abdominal wall. Hysterectomywith uni- or bilateral salpingo-oophorectomy wasperformed in the majority of the patients. One ofthe major concerns in treating actinomycosis is thepossibility of surgical complication, due to the ex-tensive tissue damage and absence of the usualsurgical planes, which characterize the disease.Therefore, the treatment of choice is high-dose in-travenous penicillin (18-24 million units) for a pro-longed time (2-6 weeks), followed by oral therapyfor 6-12 months.1 Yet, in most of the cases, theinability to diagnose the disease preoperatively andthe unresponsiveness of the patients to the initialmedical treatment lead to high rates of surgical in-terventions, usually hysterectomy and salpingo-oophorectomy. Fistula formation may also compli-cate the postoperative course. As a large percent-age of women presenting with IUD-relatedactinomycosis pelvic abscesses are 40 years oryounger, this standard surgical treatment can leavethem sterile. Reports of prolonged medical therapyalone curing extensive actinomycosis bring the useof ablative surgical therapy into question. Fur-thermore, percutaneous aspiration, or drainage ofperiappendicular,z hepatic, 1" or epigastric14 acti-nomycosis has been reported, offering an addi-tional therapy option. This method can also be ofvalue in the diagnosis and treatment of womenwith actinomycosis pelvic abscess. However, its usein the management of these cases has not beenreported.Transvaginal aspiration of pelvic abscesses andfluid collections caused by other microorganismshas been reported previously, ls-s In these cases,the diagnosis of pelvic abscess was made by thecharacteristic symptoms and physical examination,INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY 299ACTINOMYCES PELVIC ABSCESS ANTEBY ETAL.combined with the appearance of a complex cysticmass on transvaginal US. Transvaginal needle as-piration yielded 35-150 ml of purulent fluid, withpositive bacteriologic cultures being observed in60-80% of the patients. Escherichia coli was the iso-lated microorganism in the majority of the patients.Other bacteria included K/ebsidla, S. aureus, Strep-tococcus c hemolyticus, and Acinetobacter. Completeevacuation of the abscesses was usually achieved.No complications were related to the procedure,and full clinical improvement was reported by allauthors.In the presented case, transvaginal US-guidedneedle aspiration combined with antibiotic treat-ment was a safe and simple method of treatingactinomycosis pelvic abscess. We suggest thatwhen a patient with IUD-associated pelvic actino-mycosis does not respond to medical therapy,transvaginal US-guided aspiration should be con-sidered. Surgical treatment can be reserved forthose cases who do not improve following thetransvaginal drainage.REFERENCES1. Evans DTP: Actinomyces isradii in the female genitaltract: A review. Genitourin Med 69:54-59, 1993.2. Henderson SR: Pelvic actinomycosis associated with anintrauterine device. Obstet Gynecol 41:726-732, 1973.3. Chatwani A, Amin-Hanjani S: Incidense of actinomyco-sis associated with intrauterine device. J Reprod Med39(8):585-587, 1994.4. Burkman R, Schlesselman S, McCafrrey L, et al.: Therelation of genital tract actinomycetes and the develop-ment of pelvic inflammatory disease. Am J Obstet Gy-necol 143:585-589, 1982.5. Anteby E, Milwidsky A, Goshen R, Ben-Chetrit A, RonM: IUD associated abdominopelvic actinomycosis.Harefua 121:150-153, 1991.6. Muller Hozner E, Ruth NR, Abfalter E, et al.: IUDassociated pelvic actinomycosis: A report of 5 cases. IntJ Gynecol Pathol 14(1):70-74, 1995.7. Shurbaji MS, Gupta PK, Newman MM: Hepatic acti-nomycosis diagnosed by fine needle aspiration. Acta Cy-tol 31:751-755, 1982.8. de la Monte SM, Gupta PK, White CL III: SystemicActinomyces infection. A potential complication of intra-uterine contraceptive device. JAMA 248:1876-1877,1982.9. McBride WJ, Hill DR, Gordon DL: Chest wall actino-mycosis in association with the use of an intrauterinedevice. Aust NZJ Surg 65(2):141-143, 1995.10. Fiorino AS: Intrauterine contraceptive device-associated actinomycotic abscess and Actinomyces detec-tion on cervical smear. Obstet Gynecol 87:142-149,1996.11. Schleck W, Gelfand M, Alper B, et al.: medical man-agement of visceral actinomycosis. South Med J 76:921-922, 1983.12. Goldway S, Abbitt P, Wattf B: Case report: Percutane-ous drainage of periappendiceal actinomycosis. Clin Ra-diol 44:422-424, 1991.13. Grander JK, Houn H-YD: Diagnosis of hepatic actino-mycosis by fine-needle aspiration. Diagn Cytopathol 7:95-97, 1991.14. O’Connor KF, Bagg MN, Croley MR, Schabel SI: Pelvicactinomycosis associated with intrauterine devices. Ra-diology 170:559-560, 1989.15. Aboulghar MA, Mansour RT, Serour GI, Sattat MA,Awad MM, Amin Y: Transvaginal ultrasonic needleguided aspiration of pelvic inflammatory cystic massesbefore ovulation induction for in vitro fertilization. Fer-til Steril 53:311-314, 1990.16. Aboulghar MA, Mansour RT, Serour GI: Ultrasono-graphically guided transvaginal aspiration of tubo-ovarian abscesses and pyosalpinges: An optional treat-ment for acute pelvic inflammatory disease. Am J Ob-stet Gynecol 172:1501-1503, 1995.17. Teisala K, Heinonen PK, Punnonen R: Transvaginalultrasound in the diagnosis and treatment of tubo-ovarian abscess. Br J Obstet Gynaecol 97:178-180, 1990.18. Van Sonnenverg E, D’Agustino HB, Casola G, et al.: USguided transvaginal drainage of pelvic abscesses andfluid collections. Radiology 181:53-56, 1991.300 INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY

Ultrasound-guided transvaginal aspiration in the management of actinomyces pelvic abscess

Crossref

Actinomyces isradii in the female genital tract: A review.

al.: medical management of visceral actinomycosis.

Amin-Hanjani S: Incidense of actinomycosis associated with intrauterine device.

Case report: Percutaneous drainage of periappendiceal actinomycosis.

DL: Chest wall actinomycosis in association with the use of an intrauterine device.

Houn H-YD: Diagnosis of hepatic actinomycosis by fine-needle aspiration.

Intrauterine contraceptive deviceassociated actinomycotic abscess and Actinomyces detection on cervical smear.

IUD associated abdominopelvic actinomycosis.

IUD associated pelvic actinomycosis: A report of 5 cases.

MM: Hepatic actinomycosis diagnosed by fine needle aspiration.

Pelvic actinomycosis associated with an intrauterine device.

Pelvic actinomycosis associated with intrauterine devices. Radiology 170:559-560,

Serour GI: Ultrasonographically guided transvaginal aspiration of tuboovarian abscesses and pyosalpinges: An optional treatment for acute pelvic inflammatory disease.

The relation of genital tract actinomycetes and the development of pelvic inflammatory disease.

Transvaginal ultrasonic needle guided aspiration of pelvic inflammatory cystic masses before ovulation induction for in vitro fertilization. Fertil Steril 53:311-314,

Transvaginal ultrasound in the diagnosis and treatment of tuboovarian abscess.

US guided transvaginal drainage of pelvic abscesses and fluid collections. Radiology 181:53-56,

White CL III: Systemic Actinomyces infection. A potential complication of intrauterine contraceptive device.

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Ultrasound-guided Transvaginal Aspiration in the Management of Actinomyces Pelvic Abscess

Ultrasound-guided Transvaginal Aspiration in the Management of Actinomyces Pelvic Abscess

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