Article

Actinomycosis of the sigmoid colon: A case report

Antonio Privitera, Charanjit Singh Milkhu, Vivek Datta, Alastair Windsor, Charles Richard Cohen, Department of Surgery, University College London Hospitals, London NW1 2BU, United Kingdom.
World journal of gastrointestinal surgery 11/2009; 1(1):62-4. DOI: 10.4240/wjgs.v1.i1.62
Source: PubMed

ABSTRACT

Abdominal actinomycosis is a chronic suppurative infection caused by Actinomyces species. The ileo-cecal region is most commonly affected, while the left side of the colon is more rarely involved. The infection has a tendency to infiltrate adjacent tissues and is therefore rarely confined to a single organ. Presentation may vary from non specific symptoms and signs to an acute abdomen. A computed tomography scan is helpful in identifying the inflammatory process and the organs involved. It also allows visual guidance for percutaneous drainage of abscesses, thus aiding diagnosis. Culture is difficult because of the anaerobic character and slow growth of actinomycetes. Colonoscopy is usually normal, but may shows signs of external compression. Preoperative diagnosis is rare and is established only in less than 10% of cases. In uncomplicated disease, high dose antibiotic therapy is the mainstay of treatment. Surgery is often performed because of a difficulty in diagnosis. Surgery and antibiotics are required in the case of complicated disease. Combined medical and surgical treatment achieves a cure in about 90% of cases. The authors report a case of sigmoid actinomycosis where diagnosis was made from the histology, and a review of the literature is presented.

CASE REPORT
Actinomycosis of the sigmoid colon: A case report
Antonio Privitera, Charanjit Singh Milkhu, Vivek Datta, Manuel Rodriguez-Justo, Alastair Windsor,
Charles Richard Cohen
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doi:10.4240/wjgs.v1.i1.62
World J Gastrointest Surg 2009 November 30; 1(1): 62-64
ISSN 1948-9366 (online)
© 2009 Baishideng. All rights reserved.
November 30, 2009
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Volume 1
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Number 1
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Antonio Privitera, Charanjit Singh Milkhu, Vivek Datta,
Alastair Windsor, Charles Richard Cohen,
Department of
Surgery, University College London Hospitals, London NW1
2BU, United Kingdom
Manuel Rodriguez-Justo,
Histopathology Department, Royal
Free & University College Medical School, Rockefeller Building,
London WC1E 6JJ, United Kingdom
Author contributions:
All authors have participated in the
perioperative treatment of the patient, diagnosis and follow-up.
Correspondence to: Dr. Antonio Privitera, MD, PhD, MRCS,
Department of Surgery, University College London Hospitals,
London NW1 2BU, United Kingdom. privitera@hotmail.com
Telephone:
+44-759-5423060
Fax:
+44-120-6742030
Received:
July 15, 2009
Revised:
September 15, 2009
Accepted:
September 22, 2009
Published online:
November 30, 2009
Abstract
Abdominal actinomycosis is a chronic suppurative
infection caused by
Actinomyces
species. The ileo-cecal
region is most commonly affected, while the left side of
the colon is more rarely involved. The infection has a
tendency to inltrate adjacent tissues and is therefore
rarely confined to a single organ. Presentation may
vary from non specic symptoms and signs to an acute
abdomen. A computed tomography scan is helpful in
identifying the inflammatory process and the organs
involved. It also allows visual guidance for percutaneous
drainage of abscesses, thus aiding diagnosis. Culture
is difficult because of the anaerobic character and
slow growth of actinomycetes. Colonoscopy is usually
normal, but may shows signs of external compression.
Preoperative diagnosis is rare and is established
only in less than 10% of cases. In uncomplicated
disease, high dose antibiotic therapy is the mainstay
of treatment. Surgery is often performed because of
a difficulty in diagnosis. Surgery and antibiotics are
required in the case of complicated disease. Combined
medical and surgical treatment achieves a cure in about
90% of cases. The authors report a case of sigmoid
actinomycosis where diagnosis was made from the
histology, and a review of the literature is presented.
© 2009 Baishideng. All rights reserved.
Key words:
Abdominal pain; Actinomycosis; Gram-
positive bacteria; Sigmoid colon; Sulfur
Peer reviewers:
Walter E Longo, Professor, Department of
Surgery, Yale University School of Medicine, 205 Cedar Street,
New Haven, CT 06510, United States; Sri P Misra, Professor,
Gastroenterology, Moti Lal Nehru Medical College, Allahabad
211001, India
Privitera A, Milkhu CS, Datta V, Rodriguez-Justo M, Windsor A,
Cohen CR. Actinomycosis of the sigmoid colon: A case report.
World J Gastrointest Surg
2009; 1(1): 62-64 Available from:
URL: http://www.wjgnet.com/1948-9366/full/v1/i1/62.htm
DOI: http://dx.doi.org/10.4240/wjgs.v1.i1.62
INTRODUCTION
Actinomycosis is a chronic suppurative infection which
spreads to contiguous tissues and has the tendency to
form external sinuses that may drain characteristic sulfur
granules composed of a matrix of calcium phosphate,
colonies of actinomycetes, cellular debris and associated
organisms
[1]
. The most common pathogen in humans
is
Actinomyces Israelii
, named after Israel who was first
to describe the microorganism in a human autopsy
specimen
[2]
. This is a gram-positive, non-spore forming
anaerobic bacterium which is a commensal in the mucosa
of the oral cavity and upper gastrointestinal tract, but able
to cause opportunistic infections
[1]
.
Cervicofacial actinomycosis is the most common
clinical form, comprising up to 60% of cases. Abdominal
actinomycosis is rare and reported only in about 20% of
cases
[3]
.
The authors report a case of actinomycosis of the
sigmoid colon and review the literature.
CASE REPORT
A 67-year-old African-Caribbean lady presented with
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Privitera A
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. Sigmoid actinomycosis causing abdominal pain
a 3-mo history of altered bowel habits associated with
worsening right iliac fossa pain and nausea. Past medical
history showed hypertension, depression and a left-sided
stroke. Her surgical history revealed a cesarean section
at the age of 25. On examination she was dehydrated,
pyrexic (38.2
) and tachycardic (118 beats/min). The
abdomen was tender with guarding in the right iliac
fossa, and obstructive bowel sounds were heard. Blood
tests showed a microcytic anemia (hemoglobin 9.3 g/dL)
and a high white cell count (20 000/mm
3
). A rapid sickle
cell test performed prior to the procedure was negative.
A computed tomography (CT) scan of the abdomen
and pelvis was performed and this showed a 6.5 cm ×
7.7 cm inammatory mass in the right iliac fossa involving
the sigmoid colon which contained a few diverticulae. No
free air was noted. The patient was resuscitated, transfused
with 2 units of blood and was commenced on broad
spectrum antibiotics. At laparotomy, an abscessed mass of
the sigmoid colon was found. This involved a loop of small
bowel and infiltration of the uterus, fallopian tubes and
ovaries. A Hartmanns procedure was carried out (Figure 1).
Histology showed an inflammatory mass with abscess
formation arising from outside the bowel with the mucosa
being well dened and unremarkable. The bowel wall was
fibrotic and edematous with a few diverticulae, but no
evidence of perforation. Numerous lymphoid aggregates,
some with reactive germinal centers were present within
the submucosa. Extensive pericolic necrosis containing
numerous bacterial colonies of
Actinomyces
species
were noted (Figures 2 and 3). A diagnosis of sigmoid
actinomycosis was made. The patient made an uneventful
recovery and was started on a 6-mo course of penicillin. At
1-year follow-up she was well and free from disease.
DISCUSSION
Actinomycetes are normally not capable of invading
the intact intestinal mucosa. However, under certain
circumstances deeper invasion occurs. Predisposing factors
include immunosuppression (HIV, diabetes), surgical trauma,
appendicitis, diverticulitis, bowel perforation, foreign bodies
and neoplasia
[3-5]
. The bacterium is found in up to 25% of
cervical smears performed on women with an intrauterine
device and this may explain a higher incidence of infection in
these patients
[6-9]
. No predisposing factors are noted in about
50% of cases
[10]
.
Once outside the intestine, the infection usually spreads
locally with only a rare incidence of hematogenous or
lymphatic spread
[11]
.
The ileo-cecal region is most commonly involved
[12]
. The
left side of the colon is rarely reported to be affected
[3,13-20]
.
Hepatic involvement accounts for 5%-15% of cases and
is often associated with multiple small abscesses
[21]
. Other
reported sites include the stomach, gallbladder, pancreas,
small bowel, anorectal region, pelvis and abdominal wall
[3,5]
.
Involvement of retroperitoneal organs may result from
hematogenous dissemination or direct extension
[22,23]
.
Abdominal actinomycosis usually presents as a slowly
growing mass which may be associated with altered bowel
habits, nausea, vomiting and cramping pain. Constitutional
symptoms are common and include anorexia, weight loss,
fever and night sweats. Mild to moderate leukocytosis is
often noted
[3,11,12]
. Occasionally, the disease may be latent
for years and manifest itself in the form of multiple
sinuses, stulae, bowel stricture or hydronephrosis
[4,5,23]
.
A preoperative diagnosis is rarely considered and is
established only in less than 10% of cases. The nature
of the organism is generally identified from a surgically
resected specimen, culture from abscesses or at autopsy
[3,18]
.
Radiographic evidence is usually non
specic. Barium
studies may show signs of external bowel compression
with a tapered narrowing of the lumen, but complete
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Figure 1 Surgical specimen: Sigmoid colon mass (80 mm × 30 mm) with
abscess formation.
Figure 2 Histology: A colony of Actinomyces is seen within the pericolonic
inammatory tissue.
Figure 3 Gram-positive staining of an Actinomyces colony.
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obstruction is rarely seen
[6]
. Colonoscopy is usually not
useful in diagnosis as the disease is of extramucosal origin.
However, endoscopy is important to exclude colitis or
neoplastic disease and may reveal luminal narrowing or
stiffness. Occasionally, nodules with central umbilication are
noted and these are related to bowel wall brosis as a result
of chronic inammation
[19]
.
A CT scan is helpful in identifying the inflammatory
mass and the organs involved. Bowel thickening and
inflammatory changes which cross fascial planes and
involve multiple compartments are usually seen. CT-guided
drainage of abscesses may also lead to identification of
the microorganism
[19]
. Sulfur granules can be observed in
the purulent material in 50% of cases, but these are not
pathognomonic for the disease. In fact,
Nocardia, Streptomyces
,
and some
Staphylococci
can produce comparable granules
[24]
.
Culture is difcult because of the anaerobic characteristics
and slow growth of
Actinomyces
. Laboratory tests may reveal
a normocytic, normochromic anemia, leukocytosis and an
elevated erythrocyte sedimentation rate
[25]
.
Gastrointestinal actinomycosis resembles other chronic
inflammatory bowel diseases such as tuberculosis and
Crohns disease, particularly when stula or sinus tracts are
present. Also, bowel malignancy, diverticulitis, appendicitis
and amebiasis are part of the differential diagnosis
[3]
. If a
diagnosis can be made without surgery and the disease is
uncomplicated, the treatment of choice is an antibiotic.
High-dose penicillin is the standard treatment, although
cephalosporin is often used as it can be administered on a
less frequent dosing schedule. Other effective antibiotics
include tetracycline, erythromycin, chloramphenicol,
clindamycin and imipenem
[3,26-28]
. There is still controversy
regarding the dosage and duration of antibiotic treatment.
However, a long course for a period of at least 6 mo
or until disappearance or stabilization of the lesions is
recommended, in consideration of the low penetration
in the fibrotic area and the tendency of the disease to
recur
[5,18]
. Surgical treatment is often required because of
difculty in diagnosis or in combination with antibiotics in
the presence of extensive disease, necrosis, abscess, stricture
or persisting sinuses and fistulae. Combined medical and
surgical treatment achieves a cure in about 90% of cases
[19]
.
In conclusion, abdominal actinomycosis is to be
considered in the differential diagnosis of an abdominal
mass. Predisposing factors, imaging, blood tests and
microbiology studies may aid diagnosis. Medical treatment
should be tried rst in uncomplicated cases and surgery
limited to dealing with complications or persistent disease.
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Privitera A
et al
. Sigmoid actinomycosis causing abdominal pain
November 30, 2009
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