Actinomyces bacteremia in association with tubo-ovarian abscesses and hysteroscopic sterilization.

BACKGROUND: Actinomyces infection is well-documented in intrauterine devices but has not been previously associated with hysteroscopic sterilization using coil inserts. Additionally, abscesses associated with these implants have been observed in few cases. CASE: A 31-year-old multiparous woman with a history of hysteroscopic sterilization with coil inserts 18 months previously presented with several weeks of pelvic pain. Despite percutaneous drainage of intra-abdominal abscesses, her pain and fevers persisted. Blood cultures were positive for Actinomyces infection, and exploratory laparotomy demonstrated abscesses at both coil sites. CONCLUSION: When a causative organism cannot be identified or the when patient does not respond to standard antibiotic therapy, Actinomyces infection should be considered because prolonged antibiotic therapy is necessary.

Actinomyces urogenitalis bacteremia and tubo-ovarian abscess after an in vitro fertilization (IVF) procedure.

We describe the first case of bacteremia due to Actinomyces urogenitalis. Bacteremia was secondary to a tubo-ovarian abscess following transvaginal oocyte retrieval. Identification was established by matrix-assisted desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) and confirmed by 16S rRNA gene sequencing. A. urogenitalis should be considered as a potential causative agent of infection after gynecological procedures.

Abdominal and pelvic coccidioidomycosis.

Coccidioidomycosis is a fungal infection endemic to the Southwestern United States that has a clinical presentation resembling community-acquired pneumonia. Disease occurs after inhalation of airborne arthroconidia. Dissemination to a variety of organ systems via hematogenous spread from a primary pulmonary focus may then occur. Coccidioidomycosis rarely involves the abdominal cavity. The authors review the spectrum of abdominal and pelvic presentations of coccidioidomycosis and report 6 unusual cases, including acute appendicitis, hepatitis and adnexal masses. Pathologists played a critical role in the diagnosis of these presentations by recognizing spherules in tissue. In only 2 of the cases were Coccidioides species cultured.

[Tuberculous peritonitis in peritoneal dialysis]. / Peritonitis tuberculosa en diálisis peritoneal.

We report a patient in Automatic Peritoneal Dialysis (APD) with tuberculous peritonitis by possible peritoneal infection due to the proximity between fallopian tube and the left ovary, a peritoneal liquid culture was constantly negative. The patient presented a bad clinic evolution. Her only medical history was hypercalcemia six months before developing a peritonitis and occasionally nausea and vomits To confirm the diagnosis it was needed a peritoneal biopsy by means of a laparoscopy with a removal of the peritoneal catheter and left anexectomy. Now, the patient is asintomatic in daily home hemodialysis.

Salmonella: the pelvic masquerader.

Salmonella sp is a significant cause of morbidity and mortality. Although commonly infecting the gastrointestinal system, other presentations are not unheard of. Salmonella is an unlikely and an unusual cause of genital tract infection. We describe a woman with suspected pelvic inflammatory disease eventually confirmed as Salmonella O C2 infection.

Ovarian and vesical actinomycosis: a case report and literature review.

We present a patient with a tubo-ovarian abscess pathologically confirmed to be actinomycosis in a 44-year-old woman with an intrauterine device (IUD). An ultrasound showed that the IUD was imposed on an apparently degenerated myoma. A pelvic MRI was performed to differentiate the uterine findings from a sarcoma. The MRI showed a heterogeneous pelvic mass and a bladder mass suggesting chronic inflammation caused by an organism such as actinomycosis. An exploratory laparotomy was performed, which revealed a right tubo-ovarian mass with abscess formation as well as a bladder mass. A subtotal hysterectomy, right salpingoophorectomy, partial cystectomy, and appendectomy were performed in addition to drainage of the abscess. Histopathological examination revealed a tubo-ovarian abscess and a bladder mass with colonies of actinomycoses.

Pasteurella multocida bacteremia and tuboovarian abscess.

BACKGROUND: Tuboovarian abscess is commonly associated with sexually transmitted pathogens. We report a tuboovarian abscess caused by a rare pathogen, Pasteurella multocida, which was managed conservatively. CASE: A 50-year-old sexually inactive woman presented with suprapubic pain and fever. Cat scratches were seen on her hand. Ultrasonography showed a 7.9-cm complex cystic adnexal structure. Her fever persisted despite broad-spectrum parenteral antibiotics. After placement of a transvaginal drain, the patient defervesced, and her pain improved. Both blood cultures and cyst aspirates grew Pasteurella multocida. CONCLUSION: Tuboovarian abscess secondary to rare pathogens must be considered in the differential diagnosis of acute febrile pelvic illness in a non-sexually active woman. Minimally invasive drainage procedures may avoid surgery in patients failing initial antibiotic therapy.

Chlamydia trachomatis antibody titres by enzyme-linked immunosorbent assay are useful in predicting severity of adnexal adhesion.

The aim of this study was to investigate the relationship between chlamydia infection and adnexal adhesion. A total of 131 infertile women who were otherwise asymptomatic underwent chlamydia antibody testing and laparoscopy. These women had additional infertility factors. Serum concentration of anti-Chlamydia trachomatis immunoglobulins G and A were determined prospectively by means of an enzyme-linked immunosorbent assay (ELISA). Results were compared with the tubal patency and severity of adnexal adhesion. Sensitivity, specificity, positive and negative predictive value, and likelihood ratios of anti-C.trachomatis antibody titres for the presence of adnexal adhesion were calculated. Patients who were positive for chlamydia antibody had a significantly higher incidence of tubal occlusion than those who were negative (47.1 versus 25.0%). Adnexal adhesion scores were significantly higher in the patients who were positive for chlamydia antibody than those in patients who were negative (17.1 versus 8.5). Adnexal adhesion scores were significantly correlated with anti-chlamydia antibody titre by ELISA [immunoglobulin (Ig) G: r = 0.60, Ig A: r = 0.61]. As the antibody titre by ELISA rose, the specificity, positive predictive value and the positive likelihood ratio all increased. In conclusion, C.trachomatis antibody testing is a simple and inexpensive means of predicting pelvic damage and laparoscopic examination may be recommended for patients with high anti-C.trachomatis antibody titres by ELISA.

Laparoscopic management of adnexal abscesses: consequences for fertility.

OBJECTIVE: To study fertility of patients with adnexal abscesses treated by laparoscopy, antibiotic therapy, and second-look laparoscopy. DESIGN: A retrospective clinical study. SETTING: Department of Obstetrics Gynecology and Reproductive Medicine, University of Auvergne, University Hospital of Clermont Ferrand, France. PATIENT(S): Thirty-nine patients treated for adnexal abscesses between January 1983 and December 1992. INTERVENTION(S): Laparoscopic drainage of adnexal abscesses was performed in all patients; 35 patients underwent a second laparoscopy 3 to 6 months later. MAIN OUTCOME MEASURE(S): Immediate and long-term clinical results, anatomical data obtained at second-look laparoscopy, spontaneous fertility. RESULT(S): No immediate reoperation was necessary within the first 2 months after the initial laparoscopic surgery. At second-look laparoscopy, an adhesiolysis was necessary in all cases. A distal tuboplasty was performed in 17 patients and 6 patients were referred to IVF-ET. Subsequently, 12 of 19 patients not using any contraception obtained a spontaneous intrauterine pregnancy (63%). CONCLUSION(S): This study confirms that laparoscopic surgery is a safe and efficient technique for treating adnexal abscesses. Anatomical results observed at second-look laparoscopy suggest that this second surgical step is essential for patients desiring future pregnancy.

Recognition of tubo-ovarian abscess in adolescents with pelvic inflammatory disease.

PURPOSE: Ultrasonography of the pelvis is commonly used to diagnose tubo-ovarian abscess (TOA) in patients with pelvic inflammatory disease (PID). Our objective was to determine whether the clinical features of PID differ in adolescents with and without TOA. METHODS: A retrospective design was used to derive and validate a clinical model differentiating adolescents with PID who did and did not have TOA. The study population consisted of hospitalized adolescents with a discharge diagnosis of PID. Of the 208 patients discharged from January 1, 1990, to July 31, 1993, 87 (42%) met published criteria for PID and comprised the derivation set. Of the 63 patients from August 1, 1993, to June 24, 1994, 30 (48%) met criteria and comprised the validation set. All patients had pelvic ultrasonography performed during hospitalization. The ultrasonography records were reviewed retrospectively for TOA, ovarian and uterine size, clarity of tissue planes, and endometrial or cul-de-sac fluid. Medical records were reviewed for sociodemographic characteristics, medical and sexual history, physical examination, laboratory results, and hospital course. RESULTS: TOA was present in 17% of the derivation set and 20% of the validation set. A six-variable model developed on the derivation set performed best in differentiating the TOA and non-TOA groups: last menstrual period > 18 days prior to admission (60% and 17%), previous PID (53% and 22%), palpable adnexal mass (13% and 3%), white blood cell count > or = 10,500/microliters (33% and 64%), erythrocyte sedimentation rate > 15 mm/h (33% and 64%), and heart rate > 90/min (40% and 78%). In the derivation and validation sets, the model correctly identified 78 and 83% of the TOA groups and 88 and 77% of the non-TOA groups. The area under the receiver operating characteristic curve of the model was 0.92 in the derivation set and 0.87 in the validation set. CONCLUSIONS: We conclude that clinical characteristics help identify adolescents with acute PID who have TOA. These patients may have fewer signs of acute illness than those without TOA and may develop symptoms later in the menstrual cycle.

Progress in the management of tuboovarian abscesses.

The last 20 years have witnessed remarkable improvements in the treatment of tuboovarian abscesses. Gone are the days of significant mortality associated with ruptured and unruptured TOAs. Broad-spectrum antibiotics have enabled patients to be treated solely with medical therapy, avoiding the need for surgery. Operative intervention is still necessary in 25% of cases of unruptured TOAs, but the combination of conservative surgical procedures, such as unilateral salpingo-oophorectomy, and broad-spectrum antimicrobial agent therapy have reduced the need for total abdominal hysterectomy with bilateral salpingo-oophorectomy greatly. Although fertility after TOAs is compromised significantly, new advances in reproductive technology, including in vitro fertilization and donor egg transplantation, represent reproductive options for these women. Percutaneous drainage and laparoscopic treatment of TOAs are becoming popular treatment options, but prospective studies urgently are needed to assess their efficacy.

[Gynecologic and obstetric infections caused by aerobic bacteria]. / Infecciones ginecoobstétricas por bacterias anaerobias.

The anaerobic bacteria (AB) are between the most numerous microorganisms (mo) that constitute the flora of the female genital tract, so they can participate in the etiology of obstetric and gynecologic infections (OGI). The objective of this study was to investigate the frequency of AB isolations and the clinical characteristics of the anaerobic infections (AI) in patients of the National Institute of Perinatology, from January 1st, 1988 to May 31, 1991. AB were isolated from 117 patients who developed 163 infections; 167 anaerobic and 83 aerobic bacteria were recovered from these infections. The 99.2% were obstetric patients. The 85.5% of the isolations of AB were done from patients with endometritis, and 8.5% from postsurgical wound abscesses. Most of the AI were polymicrobial with a mean of 2.1 mo by infection. Peptostreptococcus, Clostridium and Bacteroids were the AB most frequent recovered. The majority of the patients had resolution of the infection within the first 5 days of antimicrobial treatment. There was no mortality in this group. We concluded that the AB have an important role in the etiology of OGI, then it is necessary that the treatment of these infections include antibiotics that cover AB.

[Isolation of Chlamydia trachomatis from the endometrium and endometritis. Apropos of a series of 42 patients]. / Isolement de Chlamydia trachomatis dans l'endomètre et endométrite. A propos d'une série de 42 patientes.

Most studies have been concerned with recovering Chlamydia trachomatis (CT) from the endocervix on the one hand and from the adnexae on the other hand and consider its relationship to infection of the upper genital tract. Our work is concerned with the endometrium. 42 women were examined: 22 of them had salpingitis (group I), 14 were considered possibly to have endometritis with a risk of infection with CT, or had cervicitis (group II), and 6 were in the control group (group III). Samples were taken from the endometrium that had been removed for histological examination and for searching for CT in cultures. These samples were taken routinely at the initial examination and then again 10 and/or 40 days later for women in groups I and II. These latter were all treated systemically with cyclines. A high incidence of endometrial infection with CT was found (17%). The recovery of CT from the endometrium was correlated with the presence of an intra-uterine device, with purulent discharge, with evidence of CT in the cervix, and with anti-chlamydia serology higher than or equal to 1/128. CT infection of the endometrium gave late lesions of endometritis which persisted in spite of the antibiotic therapy that had been given.

Actinomycosis of the female genital tract.

Four cases of actinomycosis involving the uterus and adnexal structures are reported. In 2 cases the infection was transmitted from a ruptured appendix. Ascending actinomycosis involving the endometrium and resulting in adnexal abscesses was associated with the use of an IUD in 2 patients. This infection should be suspected in any patient who develops a pelvic abscess with an IUD in place. Culture and histologic examination of tissue removed with the IUD may be a means of early diagnosis. The nature of these infections became apparent only after serious complications developed. Each patient required several surgical procedures. The diagnosis remained unsuspected until repeated laboratory examinations detected the fungus. The difficulty encountered identifying Actinomyces israeli indicates the infection is often undetected. Gallium scans were helpful in localizing occult abscesses in 2 patients.

PIP: 4 cases of actinomycosis, treated at the University of Virginia Hospital, involved the uterus and adnexal structures. 2 cases were the result of a transferred infection from a ruptured appendix. Ascending actinomycosis involved the endometrium and resulted in adnexal abcesses for 2 patients in which infection was associated with the use of an IUD. A means of early diagnosis might be through examination of tissue removed with an IUD. The nature of these infections becomes apparent only after serious complications develop. Patients required several surgical procedures. The diagnosis may remain undetected through repeated examination in the laboratory. This difficulty in detecting Actinomyces israeli indicates that the infection may often be undetected. Gallium scans were helpful in localizing occult abscesses i n 2 patients.

Actinomycosis infections associated with intrauterine contraceptive devices.

A series of 10 instances of genital actinomycosis infection complicating the use of intrauterine contraceptive devices is recorded and its pathogenesis described. The likelihood is suggested that this complication is more frequent than is generally appreciated. A pathway of infection extending upward from the patient's anus, across the perineum, and up the vagina and cervix is suggested as the route of infection. The traumatizing effect of the device and a previously existing or intercurrent infection as additional contributing factors to the development of actinomycotic infection in the female genitalia is also postulated.