An unexpected cause of multiple intra-abdominal abscesses in an HIV-positive patient

This case report describes a female HIV-positive patient diagnosed with pelvic actinomycosis using 16S rRNA gene sequence analysis. Actinomycosis is notoriously difficult to diagnose by microbiological culture. 16S rRNA gene sequence analysis allows rapid definitive diagnosis of actinomycosis and is potentially of great value in a clinical setting. This is the first report of pelvic actinomycosis in an HIV-1 infected patient.

Pelvic actinomycosis mimicking ovarian malignancy: three cases

OBJECTIVE

Three cases of pelvic actinomycosis initially diagnosed as pelvic malignancy and treated surgically are reported.

CASES

The first case was a 38-year-old multiparous woman who was referred to our clinic because of bilateral ovarian solid masses. With the impression of ovarian carcinoma, a laparotomy was performed. During surgery adhesiolysis, total abdominal hysterectomy, bilateral salpingo-oophorectomy, infracolic omentectomy, appendectomy, peritoneal washings, and peritoneal abscess drainage were performed. The second patient was a 37-year-old woman who presented with a left-sided fixed solid mass highly suggestive of pelvic malignancy. Both ureters were found to be dilated with hydronephrosis in the right kidney supporting the diagnosis of retroperitoneal fibrosis. Excision of the mass, colectomy and temporary diverting colostomy and stent insertion to the left ureter were performed. Colostomy repair was performed five months later. On the fifth day postoperatively, fascial necrosis developed so a Bogota-bag was placed on the anterior abdominal wall and left for secondary healing. The third patient was a 51-year-old postmenopausal woman incidentally diagnosed as having a pelvic mass while having been investigated for constipation and nausea. She had had a colostomy one year before and a reanastomosis two months after. Total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. In all cases, histopathologic staining of the specimens revealed chronic inflammation containing actinomycosis abscesses confirmed with microbiologic identification.

CONCLUSION

Pelvic actinomycosis is an uncommon cause of a pelvic mass. However, it should be kept in mind in the differential diagnosis of pelvic masses, especially in the patients with a history of IUD use to avoid an unnecessary extensive surgical procedure.

[Effects of biofeedback and pelvic electric stimulation in treatment of stress urinary incontinence]

OBJECTIVE

To investigate procedures and benefits of using bio-feedback and pelvic electric stimulation in treatment of stress urinary incontinence.

METHODS

Forty-six patients with stress urinary incontinence were included randomly into the study and treated with Stimogyn BIO 2001 treatment equipment. Treatment procedures and benefits were observed.

RESULTS

Among 46 patients, 43 cases achieved improvement with an effective rate of 93%. Nineteen patients in premenopause received 4-30 times treatments with an average of 9.8. Effectiveness time was 1-10 with an average time of 3.6. Twenty-seven patients in postmenopausal period received same treatments with an average of 10. Effectiveness time was 1-10 with an average time of 4.2. Average treating time was 40 minutes. Forty patients had follow-up information, but 6 patients were lost to follow-up. Nine patients were cured, including 3 patients with stress incontinence after hysterectomy. Four patients chose surgical treatment after successful conservative treatment. Three patients recurred. Patients who experienced recurrence were cured or improved after receiving conservative therapy again. Body mass index (BMI) and severity of stress incontinence might have different influences on treating times, but had no influence on the outcomes of treatment (P > 0.05).

CONCLUSIONS

Biofeedback and pelvic electric stimulation could be used to treat stress incontinence. Menopause status, BMI and severity of stress incontinence can not obvious affect the outcomes of biofeedback and pelvic electric stimulation.

Bone infection in cat-scratch disease: A review of the literature

OBJECTIVE

To describe the main features of bone infection associated with Cat-scratch disease (CSD).

METHODS

We searched for articles indexed in the international literature databases by using the following key words: "Bartonella", "bone", "cat-scratch", "osteomyelitis" and "osteolytic".

RESULTS

Cases of 47 patients were reviewed. The median age was 9 years, with an equal sex distribution. Bone pain and fever were the main symptoms. The presence of fever and increased age were more common in patients with bone infection than classically reported in uncomplicated (i.e. nodal) CSD. The vertebral column and pelvic girdle were the most common sites of infection. Radiological examination typically confirmed bone osteolysis. All patients recovered without complications or chronic infection, although they received a various combination antibiotic regimen and duration therapy. The mechanism by which infection might spread to the bone is via the haematogenous route, accounting for most of the disseminated cases and via the lymphatic route, for those with regional limited extension.

CONCLUSIONS

Bone infection is rare but should be considered when bone pain and fever are present in a patient with nodal CSD. The prognosis is good, whatever treatment is given. Thus bone biopsy should be recommended only in a difficult diagnostic setting, when other bacteria or malignant disease are suspected.

[Tuboovaric actinomycosis. A report of a case]

OBJECTIVE

Tuboovaric actinomycosis case report.

PRESENTATION

PATIENT

eighteen-year-old woman using intrauterine devise for the past two years and with a four months old appendicectomy. Initially, a two month old pelvic tumor with acute abdominal pain and fever was identified. A laparotomy was performed with total pelvic tumor section. A week later, postoperatory colonskin fistula appeared requiring surgery. The histopathology report showed tuboovaric actinomycosis. Therefore, sodic penicillin was used to treat the patient until health was recovered.

CONCLUSION

Actinomycosis is characterized by late diagnosis and must be suspected in patients with pelvic tumor exeresis with nonsatisfactory evolution, where intestinal surgery and IUD use are risk factors.

Staphylococcus lugdunensis infection sites: predominance of abscesses in the pelvic girdle region

We used a screening protocol to identify Staphylococcus lugdunensis in clinical specimens with pure or predominant growth of coagulase-negative staphylococci. S. lugdunensis was isolated from 17 patients in a 12-month period and was judged to be the cause of infection in 14 cases. In 13 cases, the patient had a soft-tissue abscess, and in 9 of these, the abscess was located in the pelvic girdle region, which suggests that this may be the natural habitat of S. lugdunensis.

Is the stat Gram stain helpful during percutaneous image-guided fluid drainage?

RATIONALE AND OBJECTIVES

The purpose of this study was to use logistic regression to analyze both Gram stain results and other clinical information to create a decision rule capable of predicting which abdominal or pelvic fluid collections would later prove to be infected and therefore require catheter drainage.

MATERIALS AND METHODS

The authors retrospectively collected Gram stain results and clinical data (postoperative status and antibiotic use) regarding 124 abdominal or pelvic fluid drainage procedures performed between 1991 and 1996. They then analyzed these data by using logistic regression to create an equation that predicted the presence of fluid infection. Finally, they validated this equation by applying it to 39 abdominal or pelvic fluid drainage procedures performed in 1997.

RESULTS

The resulting equation predicted that a fluid collection was likely to be infected if any of the following were present: Gram stain positive for bacteria, Gram stain showing moderate or many white blood cells, and purulent fluid at visual inspection. For the initial data set, the sensitivity of the decision rule was 91%, the specificity was 54%, and the overall accuracy was 77%. For the 1997 data set, the sensitivity of the decision rule was 88%, the specificity was 50%, and the accuracy was 77%.

CONCLUSION

When combined with clinical information, Gram stain results are sensitive but nonspecific in the detection of abdominal or pelvic fluid infection. Use of the decision rule could prevent unnecessary catheter placement in a minority of patients with abdominal or pelvic fluid collections.

Post-therapeutic evolution of serum chlamydial antibody titers in women with acute salpingitis and tubal infertility

OBJECTIVE

To determine if serologic data and, more particularly, antichlamydial immunoglobulin (Ig) M can be used for diagnosis of current chlamydial intrapelvic gynecologic infection.

DESIGN

Forty-two women with acute salpingitis (group A), 131 women with tubal factor infertility (group B), and 98 pregnant women (control group C) were studied.

SETTING

Hôpital Jean Rostand, Sèvres (patients), Laboratories Magenta and Eylau, Paris (serology), Institut Pasteur, Paris (cultures).

INTERVENTIONS

Study groups: endocervical/urethral swabs, pelvic samples; serologic study before and after treatment.

CONTROL GROUP

Serologic study.

MAIN OUTCOME MEASURES

Serum samples were collected from each patient initially and 6 to 9 weeks later; additionally, two to five sequential sera were obtained from 22 (group A) and 25 (group B) patients with positive cultures, evolutive serology, or positive antichlamydial IgM. Sera were tested for antichlamydial IgG by a microimmunofluorescence assay using Chlamydia trachomatis elementary bodies and for IgA and IgM by whole inclusion-fluorescent assay.

RESULTS

Before treatment, there was a correlation between the presence of antichlamydial IgM and positive cervical and/or intrapelvic chlamydia cultures. After treatment, antichlamydial IgM, when initially positive, rapidly disappeared in most subjects; its persistence after 4 months was significantly associated with tubal sequelae in group A patients and persistence of positive intrapelvic chlamydial cultures in group B women.

CONCLUSION

Serologic analysis of women with acute salpingitis or tubal infertility, including antichlamydial IgM, may aid both in the before treatment diagnosis of chlamydial infection and in the follow-up evaluation.

Treatment of recalcitrant actinomycosis with ciprofloxacin

We describe a case of actinomycosis with several unusual features. The patient has been under medical supervision for more than 20 years; the disease has spread in an atypical manner and did not respond to standard therapy. Finally, there has been an unexpected response to a prolonged course of a member of the quinolone group of antibiotics.

[The role of laparoscopy in the evaluation of chronic pelvic pain]

Chronic pelvic pain, defined as cyclic or acyclic pain reported for a minimum of six months, is one of the most common gynecological symptoms and one of the most important in terms of social costs. From January 1987 to December 1991, 127 patients suffering from chronic pelvic pain were submitted to diagnostic laparoscopy at the Department of Obstetrics and Gynecology of the Università Cattolica del Sacro Cuore in Rome. The mean age of the patients was 30 years, ranging from 14 to 46. All patients were submitted to bimanual pelvic examination upon hospital admission, and most of them (No. = 99, 78%) to pelvic ultrasonographic examination. In 117 patients (92%) samples for the isolation of Chlamydia trachomatis in 5-iodo-2-deoxiuridine treated McCoy cell cultures were obtained from the cervix, the endometrium and the cul-de-sac peritoneal fluid. At laparoscopy, in 25 patients (20%) the exam showed normal pelvic anatomy, whereas in 102 patients (80%) some pelvic pathology was found. The most frequent conditions observed were: pelvic adhesions in 55% (No. = 70), endometriosis in 29% of the cases (No. = 37), and other pathologies (non-endometriotic ovarian cysts, hydrosalpinges, myomas, etc.) in 25% of the cases (No. = 32). At the comparison of bimanual examination and laparoscopic findings, out of 71 patients with normal findings at bimanual examination, 75% (No. = 53) were found to have abnormal findings at laparoscopy; out of 55 patients with abnormal bimanual examination, 11% (No. = 6) were found to have normal laparoscopic findings.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary abdominal actinomycosis in a diabetic woman--an intractable disease

Primary abdominal actinomycosis is very unusual. Only five previous cases have been reported in the English literature. We describe the case of a 57-year-old diabetic woman with primary abdominal actinomycosis, refractory to several antimicrobial regimens and surgical procedures. We conclude that primary abdominal actinomycosis in such a diabetic woman is an intractable disease.

Hydatid disease of the pelvis

The clinical and radiological features of five patients with hydatid cyst of the pelvis are presented. The cysts were found in the following sites: the broad ligament, the pararectal soft tissues, the greater omentum, the ala of the sacrum and in the retrovesical space. Hydatid disease should be considered in the differential diagnosis of unusual cystic swellings in the pelvis, particularly in patients who have lived in endemic areas.

Abdominal manifestations of actinomycosis in IUD users

The use of an intrauterine device (IUD) is associated with the presence of actinomyces in the female genital tract. Since IUD use is currently so prevalent, IUD-related pelvic inflammatory disease occasionally spreads to the rest of the abdomen. Two patients with abdominal actinomycosis in association with an IUD illustrate the problem; we review the general problem.

The clinical significance of clindamycin-resistant Bacteroides fragilis

The Bacteroides fragilis group of bacteria are the most numerous microorganisms in the colon and the most common anaerobic isolates from human infections. Although clindamycin hydrochloride is still considered the antibiotic of choice for treatment of infections with these bacteria, resistant strains are becoming more common. To determine the clinical significance of clindamycin-resistant bacteroides, we reviewed the charts of 14 patients with resistant isolates. Clindamycin resistance was a major factor in the clinical course of at least four patients. Three of these did not recover until they were treated with effective antimicrobials. Seven patients had been treated with either erythromycin or clindamycin before isolation of the resistant strain. These observations underscore the importance of antimicrobial sensitivity testing of the B fragilis group and of considering the possibility of resistance when patients infected with Bacteroides fail to respond to clindamycin treatment.

Use of single-agent antimicrobial therapy in the treatment of polymicrobial female pelvic infections

One hundred twenty patients with either postpartum endomyometritis or postgynecologic surgical infections were treated either with ticarcillin, clindamycin, or chloramphenicol. One hundred nine (91%) responded successfully to single-agent antimicrobial therapy. Most of the infections were polymicrobial, involving both aerobic and anaerobic bacteria. Forty patients were treated with ticarcillin, with 90% responding successfully; 48 were treated with chloramphenicol, with 94% responding successfully; and 32 were treated with clindamycin, with 88% responding successfully. Single-agent antimicrobial therapy appears to be appropriate for treating polymicrobial obstetric and gynecologic soft tissue infections.

Intrauterine device-associated actinomycosis simulating pelvic malignancy

We describe pelvic and rectal actinomycosis in a patient with an intrauterine contraceptive device. The presentation was that of an indolent, noninfectious process which mimicked a pelvic malignancy. As in many cases of pelvic actinomycosis, the diagnosis was not suspected preoperatively. Moreover, suppurative disease progressed despite removal of the intrauterine device. In patients who have intrauterine contraceptive devices or who have had them removed recently, abdominal pain, recurrent vaginal bleeding or adnexal masses should prompt a diligent search for potentially pathogenic actinomyces in the genital tract.

Pelvic colonization with Actinomyces in women using intrauterine contraceptive devices

Recent reports suggest a relationship between intrauterine contraceptive device (IUD) use and colonization or infection of the genital tract with Actinomyces species. This prospective, case-controlled study was designed to determine the incidence of colonization or infection with Actinomyces in IUD users. None of 50 control patients and four of 50 study patients (8%) had Actinomyces identified. None of the patients with positive results had symptomatic pelvic infection. Cervical cytology was effective in detecting each of the four study patients with positive results. It appears that the presence of any type of IUD is a major predisposing factor to colonization with Actinomyces.