Adnexal Mass II

This is a continuation of the case yesterday. We cleared the patient from an infection standpoint to go to the operating room. The gynecologic oncology team did an exploratory laparotomy, opening up her pelvis where they found frank purulent exudate, which is very suggestive of infection. They then took out her ovary which had areas of necrosis. The gynecology attending stated that it looked much more consistent with infection than cancer, and then he became concerned that it was tuberculosis. They called us intraoperatively and though we did not think it was TB, we alerted infection control and asked all the operating room staff to put on N-95 masks.

They sent the ovary off to pathology. Several days later, we were called and told that they had an answer. After rounds, we all went down to pathology, a part of the hospital I had never tread. There, we looked at slides under a multi-headed microscope where we saw many histiocytes and filamentous, gram-positive, anaerobic bacteria. Indeed, this was actinomyces.

Actinomycosis most often occurs in the cervicofacial region, but abdominal actinomyces, usually involving the appendix and ileocecal region, is well described. The classic description is an infection that spreads contiguously, ignoring tissue planes. We also noted possibly sulfur granules. There have been many reports of an association with IUD use. Abdominal actinomyces is easily confused with Crohn's disease, tuberculosis, and carcinoma, and most often, the diagnosis is made post-operatively after a laparotomy for a suspected carcinoma. Treatment is penicillin.