Hepatic actinomycosis: Report of one case and analysis of 32 previously reported cases

A rare case report of liver masses caused by Actinomyces species

Actinomycosis is a rare infection caused by Actinomyces spp. Of all actinomycosis infections, only 5% of Hepatic Actinomycosis (HA) infection has been reported. This disease is often misdiagnosed as a malignancy. This case report presents a 45-year-old woman with diabetes, initially suspected of intrahepatic cholangiocarcinoma, but after careful tissue staining, we found the results supported HA infection.

The role of Actinomyces spp. and related organisms in cervicofacial infections: Pathomechanism, diagnosis and therapeutic aspects

Members of the Actinomyces genus and Actinomyces-like organisms (ALOs; namely Actinotignum, Arcanobacterium, Schaalia and Varibaculum) are Gram-positive, non-spore-forming rods that are commensal members of the human oral cavity, gastrointestinal tract, female genital tract and skin microbiota. Cervicofacial actinomycosis or "lumpy jaw syndrome" - the chronic, suppurative granulomatous disease caused by Actinomyces spp. And ALOs - is characterized by an initially slow and unspecific disease-presentation, which often mimics other pathologies, followed by the formation of painful abscesses and severe tissue destruction. Actinomycosis has been described as a rare disease, however, reliable epidemiological data are lacking. In addition, there is increasing awareness regarding the role of Actinomyces spp. in the development of osteoradionecrosis and medication-related osteonecrosis of the jaw. The aim of this narrative review is to succinctly summarize the current advances regarding the microbiological, clinical, diagnostic and therapeutic aspects of cervicofacial actinomycosis, in addition to the roles of Actinomyces species and ALOs as members of the oral microbiota and in dental biofilm, in other dental infections (caries, root canal infection, periapical infection, periodontitis) and osteonecrosis of the jaw, in the context of recent taxonomic changes affecting the genus. Our paper aims to be a blueprint for dentists, other physicians, microbiologists and researchers regarding the multifaceted field of cervicofacial actinomycosis.

Primary Hepatic Actinomycosis Mimicking Neuroendocrine Tumor

INTRODUCTION

The Actinomyces species is a fastidious, gram-positive, non-spore-forming bacteria that thrive in microareophilic and anaerobic conditions. Infection in the liver, an organ rarely affected by this pathogen, is presumed to be caused by hematogenous spread through the portal vein from a mucosal injury or other abdominal injury or a focus of infection.

CASE DESCRIPTION

 A 60-year-old male patient has a mass lesion of 15 × 10 cm in the left lobe on computed tomography. A tru-cut biopsy was performed with USG, and fragmented tissue pieces were obtained. In histopathological examination, these samples were reported as tumors with neuroendocrine differentiation. The biopsy sample contains a large amount of tumor neighborhood, and tumoral area is quite small. And, therefore, a clear diagnosis could not be found. A mass lesion with mildly increased Ga 68 DOTATATE uptake was observed in the left lobe of the liver (SUVmax value 3.8) and was interpreted in favor of the primary neuroendocrine tumor of the liver.

DISCUSSION

Actinomyces cases are very rare and their diagnosis is usually delayed due to its slow and insidious course, and lack of specific clinical and radiological findings. It is difficult to make a correct diagnosis even in microbiological examinations and biopsy materials obtained in the presence of imaging methods. It can mimic tumors of abdominopelvic structures.

CONCLUSION

Actinomyces should be kept in mind in cases with liver masses accompanied by previous abdominal surgery, abdominal trauma, high fever, and leukocytosis.

Hepatic actinomycosis after total pancreatectomy: A case report

Introduction and importance

Hepatic actinomycosis (HA) is a rare infection mimicking a malignancy. HA after total pancreatectomy for a pancreatic tumor has not been reported.

Case presentation

A 70-year-old woman with a history of gastrectomy and sigmoidectomy for benign lesions, underwent a total pancreatectomy for a non-invasive, intraductal papillary mucinous carcinoma (IPMC). She required partial resection of the transverse colon due to insufficient blood flow and had an anastomotic failure. Four months later, she developed a fever and effusion from the upper abdominal midline incision. No bacteria were cultured from the effusion. Contrast-enhanced computed tomography demonstrated an 80-mm iso-vascular liver mass. A slightly high-signal intensity on T2-weighted magnetic resonance imaging was demonstrated. Positron emission tomography (PET) showed a standardized uptake value of 11.9 at the liver mass. The percutaneous liver biopsy did not establish a diagnosis. Because a malignancy could not be ruled out, an exploratory laparotomy was performed. A tissue sample revealed aggregates of branched filamentous microorganisms; actinomycosis was diagnosed. Oral amoxicillin for 4 months resolved the mass.

Clinical discussion

This patient had several causative factors for HA, including multiple surgical procedures involving the gastrointestinal tract, reconstruction of the biliary tract, anastomotic failure of the transverse colon, and diabetes mellitus following total pancreatectomy. Based on the past treatment history for IPMC and PET findings mimicking a malignancy, a laparotomy was performed to biopsy the lesion. Typically, penicillin is recommended for >6 months.

Conclusion

A rare case of HA mimicking a malignancy after a total pancreatectomy for IPMC is presented.

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Hepatic actinomycosis (HA) is a rare infection mimicking a malignancy.

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A total pancreatectomy and gastrointestinal surgeries were the causable factors.

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Typically, penicillin therapy is recommended for over 6 months.

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Surgical exploration was important avoiding unnecessary hepatectomy.

Primary liver actinomycosis in a pediatric patient: A case report and literature review

BACKGROUND

Primary hepatic actinomycosis is a rare infection that can be clinically confused with hepatic pyogenic abscesses or neoproliferative processes. Only a few cases of primary hepatic actinomycosis in children have been reported in the English literature.

CASE SUMMARY

We describe a pediatric patient with primary hepatic actinomycosis that involved the base of the right lung and anterior abdominal wall and skin. The patient was diagnosed via histological examination of spontaneously drained material. The patient was successfully treated with an exploratory laparotomy and right posterior segmentectomy of the liver, combined with antibiotic treatment. Following surgery, the patient remains in excellent condition, without evidence of recurrence at the time of drafting this report. To summarize the clinical manifestations, diagnosis, treatment, and outcomes of primary hepatic actinomycosis, 18 case reports in English were reviewed.

CONCLUSION

We conclude that actinomycosis clinically features a chronic onset, nonspecific symptoms, and a primarily histologic diagnosis. Prolonged antibiotic treatment combined with invasive intervention provides a good prognosis.

Clinical features of actinomycosis: A 20-year experience of a single institute in Southern China

BACKGROUND

Actinomycosis is a rare indolent infectious disease with nonspecific clinical presentations that delay diagnosis. Although actinomycosis is thought to be more prevalent in developing countries, data from developing countries are scarce. This study aimed to profile actinomycosis in developing countries and identify how it differed from profiles of developed countries.

METHODS

Patients fulfilling the inclusion criteria for actinomycosis from Nanfang Hospital in southern China between January 1999 and December 2018 were retrospectively analyzed. We described clinical characteristics, diagnostic procedures, differential diagnosis, and management of actinomycosis of clinical significance.

RESULTS

Thirty‑one patients were included in this study. The disease was diagnosed predominately in the orocervicofacial (n = 14), cardiothoracic (n = 11), abdominopelvic (n = 5), and soft tissue (n = 1) regions. Diagnosis was obtained by either histopathology (n = 29, 94%) or microbiology (n = 2, 6%). Only one-third of patients presented with general symptoms, such as fever and weight loss. Ten were lost during follow-up, and the median duration of antibiotic use was 93.5 days (interquartile range 28-300), whereas the median follow-up time was 34 months (interquartile range 9-132). Ten patients receiving complete resection of the lesion were cured without postoperative use of antibiotics. Only one patient relapsed during the follow-up period.

CONCLUSIONS

Actinomycosis is a rare disease even in developing countries, and both misdiagnosis and missed diagnosis are common. Diagnosis was often delayed and was obtained postoperatively from histopathology in developing countries. Hence, clinicians should be aware of this disease in patients with high risk factors. In the future, specific molecular methods may help to improve early diagnosis and treatment.

A systematic review of case reports of hepatic actinomycosis

Background

Hepatic Actinomycosis (HA) is one of the infections that causes disorders in patients when diagnosed untimely and inappropriately.

Methods

Case reports on HA in patients published between 2000 and April 2020 were gathered by carrying out a structured search through PubMed/Medline.

Results

Through a survey of the Medline database, 130 studies were identified and then, 64 cases with HA were included in the final analysis. Asia had the largest share of cases with 37.5% (24 reports), followed by Europe and the Americas. Affected patients were predominantly males (64%) and the overall mortality rate was 1% with only one male patient in his 50 s dying. Nearly all patients (92%) were immunocompetent. However, in four patients, the use of immunosuppressive medication led to depression of the immune system. Most of the patients (80%) experienced complications. In terms of the complications, the most frequent ones were previous history of abdominal surgery (32%) and foreign bodies in the abdominopelvic region (20%). Actinomyces israelii was the most common pathogen isolated from patients. Abdominal pain (66%), fever (62%), weight loss (48%), night sweat, malaise, and anorexia (14%) over about 3.1 months were the most frequently reported clinical symptoms. Extension to one or more surrounding organs was evident in 18 patients (28%). Histopathologic examination confirmed infection in 67% of the patients and samples obtained from liver puncture biopsy (32%) were most frequently used in diagnosis. Surgery or puncture drainage + anti-infection was the most common method to treat patients and penicillin, Amoxicillin, Doxycycline, and ampicillin were the most frequently used drugs to control infection.

Conclusion

HA should be considered in patients with a subacute or chronic inflammatory process of the liver. With accurate and timely diagnosis of infection, extensive surgery can be prevented.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-021-01821-5.

Metabolic Effects of Oxytocin

There is growing evidence that oxytocin (OXT), a hypothalamic hormone well recognized for its effects in inducing parturition and lactation, has important metabolic effects in both sexes. The purpose of this review is to summarize the physiologic effects of OXT on metabolism and to explore its therapeutic potential for metabolic disorders. In model systems, OXT promotes weight loss by decreasing energy intake. Pair-feeding studies suggest that OXT-induced weight loss may also be partly due to increased energy expenditure and/or lipolysis. In humans, OXT appears to modulate both homeostatic and reward-driven food intake, although the observed response depends on nutrient milieu (eg, obese vs. nonobese), clinical characteristics (eg, sex), and experimental paradigm. In animal models, OXT is anabolic to muscle and bone, which is consistent with OXT-induced weight loss occurring primarily via fat loss. In some human observational studies, circulating OXT concentrations are also positively associated with lean mass and bone mineral density. The impact of exogenous OXT on human obesity is the focus of ongoing investigation. Future randomized, placebo-controlled clinical trials in humans should include rigorous, standardized, and detailed assessments of adherence, adverse effects, pharmacokinetics/pharmacodynamics, and efficacy in the diverse populations that may benefit from OXT, in particular those in whom hypothalamic OXT signaling may be abnormal or impaired (eg, individuals with Sim1 deficiency, Prader-Willi syndrome, or craniopharyngioma). Future studies will also have the opportunity to investigate the characteristics of new OXT mimetic peptides and the obligation to consider long-term effects, especially when OXT is given to children and adolescents. (Endocrine Reviews XX: XX - XX, 2020).

Hepatic Actinomycosis in a Patient With Retained Common Bile Duct Stent

Primary hepatic actinomycosis is rare, with less than 100 cases reported in English literature. Most of these cases are cryptogenic. We describe a 35-year-old woman who presented with a retained common bile duct stent for 6 years and found to have a hepatic mass with altered perfusion and enhancement, and minimal degree of washout on enhanced cross-sectional imaging. Fine-needle aspiration revealed presence of filamentous bacteria morphologically consistent with Actinomyces species. This report is a demonstration of a rare instance in which a retained biliary stent led to primary hepatic actinomycosis.

Severe abdominopelvic actinomycosis with colon perforation and hepatic involvement mimicking advanced sigmoid colon cancer with hepatic metastasis: a case study

BACKGROUND

Actinomycosis is a rare chronic invasive disease caused by Actinomyces spp. Although abdominopelvic actinomycosis, which involves the colon and the pelvic organs extensively, has been frequently reported, abdominopelvic actinomycosis presenting with colon perforation and hepatic involvement concurrently has yet to be reported.

CASE PRESENTATION

A 55-year-old woman presented at the emergency room with squeezing epigastric pain. Palpation of the abdomen revealed a hard mass with no acute peritoneal signs. Vital signs were normal range except for tachycardia. Initial laboratory testing revealed leukocytosis, anemia, elevated C-reactive protein (CRP), hypoalbuminemia; and normal AST/ALT and BUN/creatinine. CT scan of the abdomen-pelvis revealed a microperforations of the sigmoid colon, abscess in the left lower quadrant and hepatic lesion. Furthermore, there was a large infiltrating conglomerated mass invading the urinary bladder, left adnexa, sigmoid, left inguinal canal and left pelvic wall area. Ultrasound revealed an intra-uterine device (IUD). All these findings initially raised a suspicion of malignancy such as advanced cancer of the colon with liver metastasis. Despite the rarity of the disease, actinomycosis were not excluded because of the IUD found on ultrasound. Parenteral antibiotics and percutaneous drainage of abdomen abscess as well as fasting with total parental nutrition were prescribed for sigmoid perforation and abscess. After 10 days of conservative treatment, no remarkable change was detected in conglomerated mass invading pelvis. Furthermore, the finding of newly developed mechanical small bowel obstruction warranted surgery. Exploratory laparotomy was performed for the removal of perforated colon, obstructive small bowel and organs involved and postoperative histology confirmed a diagnosis of colonic actinomycosis. The patient made an uneventful recovery and was started on a 6-month course of penicillin.

CONCLUSIONS

Abdominopelvic actinomycosis presenting with colon perforation and hepatic involvement is extremely rare; however, it is clinically similar to advanced colon cancer with liver metastasis, therefore, complicating the preoperative diagnosis. A diagnosis of abdominopelvic actinomycosis should be considered in patients with a history of IUD and chronic abdominal pain, along with an abdominal mass or cutaneous abscess. If surgery is indicated, preoperative empirical antibiotic therapy for actinomycosis and frozen biopsy during surgery may be considered.

Hepatic actinomycosis with immunoglobulin G4-related liver disease: A case report

RATIONALE

Immunoglobulin (Ig)G4-related pseudotumors of the liver are very rare diseases that are difficult to distinguish from malignant tumors. They can be usually improved by steroid therapy. Actinomycosis is a chronic, suppurative, granulomatous infection, for which immune suppression is a predisposing factor. It can also mimic malignant tumors.

PATIENT CONCERNS

A 67-year-old man presented with mild abdominal discomfort and a 5-kg weight loss for 3 months. Initially, he visited another hospital and was treated with antibiotics under the assumption of a liver abscess. Symptom was not resolved.

DIAGNOSES

He diagnosed as having an IgG4-related pseudotumor of the right lobe of the liver after liver biopsy. Despite 2 months of steroid therapy, the liver mass was aggravated and invaded the right lung, as observed on follow-up computed tomography scan.

INTERVENTIONS

We performed en bloc resection of the tumor under the assumption that it was a malignant tumor.

OUTCOMES

The pathology of the tumor was revealed as actinomycotic colonies and IgG4-positive plasma cells of the liver. He recovered well and was discharged with ursodeoxycholic acid tablet for 14 days. After 3 months, he underwent postoperative follow-up CT and there was no remarkable finding in remnant left hepatic lobe.

LESSONS

Hepatic actinomycosis and IgG4-related pseudotumors of the liver are both difficult to diagnose. As in our patient, combined diseases are more difficult to diagnose and to determine the optimal treatment. Since immunosuppression therapy of autoimmune diseases can cause and aggravate infection, management must be approached carefully. We can learn that various possibilities must be considered before diagnosing and treating a hepatic mass.

Immunohistochemistry and Special Stains in Medical Liver Pathology

Histochemical and immunostains are routinely used to evaluate medical liver biopsy specimens. The use of these special stains allows the identification of more clinically important information than is available on hematoxylin and eosin stains alone. These special stains are important for evaluating active and chronic injury and for establishing a specific diagnosis. The skillful use of these stains greatly improves patient care. Information on the use of special stains can be scattered in different sources, making the information hard to access. In this article, the use of special stains in medical liver biopsies is concisely reviewed.

Actinomyces-induced inflammatory myofibroblastic tumor of the colon: A rare cause of an abdominal mass: Akbulut et al. inflammatory myofibroblastictumor due to actinomyces spp

INTRODUCTION

Inflammatory myofibroblastic tumors (IMFTs) are neoplastic lesions that are either benign or have low-grade malignancy potential. Although the etiopathogenesis is not entirely clear, many factors play a role in their development, including trauma, autoimmune disorders, and infectious and inflammatory processes. However, IMFTs caused by Actinomyces spp. infection are rare, with a limited number of cases reported in the literature.

PRESENTATION OF CASE

A 30-year-old woman was admitted to our clinic with abdominal pain and a palpable abdominal mass. Contrast-enhanced computed tomography revealed a tumoral lesion (11×10×7cm) in the right colon. A right hemicolectomy and ileocolic anastomosis were performed, during which almost complete obstruction of the lumen by the 7.5×7.0×5.0cm tumor was observed. Histopathology and immunohistochemical findings revealed that the tumor was consistent with an IMFT that developed from an Actinomyces infection. The patient was then placed on amoxicillin and doxycycline therapy.

CONCLUSION

This case demonstrates that the development of IMFT secondary to actinomycosis is difficult to predict in the preoperative period. Once an exact diagnosis is confirmed by histopathologic examination, affected patients should receive prolonged antibiotherapy.