Diagnosis of hepatic actinomycosis by fine-needle aspiration

A 60-Year Literature Review on Hepatic Actinomycosis

Hepatic actinomycosis (HA) is a rare infection with an indolent course, atypical clinical manifestations, nonspecific laboratory and imaging findings, and challenging diagnosis. We describe a case of a 35-year-old female who developed HA 2 weeks after gastrectomy. In addition, we analyzed clinical characteristics and outcome of 157 additional cases of HA identified in a 60-year literature review. Patients with HA were predominantly male (57%) and more than one-half were between 40 and 70 years of age. The infection was cryptogenic in 80.8% of cases. Risk factors for HA were identified in 63.1% of the patients. Clinical presentation included fever (57.7%), abdominal pain (52.1%), weight loss (45.1%), anorexia (27.5%), fatigue and chills (12.7% each), and malaise (12%) over a 2.35 ± 3.5 months period. Leukocytosis, elevated alkaline phosphatase, erythrocyte sedimentation rate, and C-reactive protein were the most frequent laboratory findings. Radiologic imaging revealed that the right lobe was more frequently affected (62.5%) with a single lesion found in two-thirds of cases. Diagnosis was achieved by histopathologic examination in 70.6% of cases. Cultures yielded Actinomyces in 45 instances, with A. israelii being the most frequent species. Less than one-half of the patients were treated only with antibiotics, while the others received combined medical and surgical treatment. The median duration of antibiotic therapy was 135 days. The presence of multiple lesions or solid tumor-like lesions (without liquefaction) was significantly associated with medical therapy alone. The outcome was favorable in most cases (94%). Although rarely encountered, HA should be considered in patients with a chronic or subacute inflammatory process of the liver to promptly diagnose and treat.

Abdominal actinomycosis

Abdominal actinomycosis has been recognised for over 150 years yet remains largely unknown to most clinicians. It's varied presentations are usually considered to represent malignancy rather than an infective process - and was once described as 'the most misdiagnosed disease'. Actinomyces are gram positive bacilli of the Actinomycetales genus, and A. israelii is responsible for the majority of human disease. They are normal commensal inhabitants of the human bronchial and gastrointestinal tracts and seem to only cause pathological infection after preceding mucosal breakdown. Patients who have undergone appendicectomy, have had a missed perforated appendicitis or women with a history of intrauterine contraceptive device use are at an increased risk. Florid abscess formation with fistulation, abundant granulation and dense surrounding fibrosis are common. Diagnosis prior to, or even during, surgery is rare and the findings are usually mistaken for acute inflammatory pathologies or malignancy. The treatment of choice is prolonged antibiotic therapy, usually with penicillin to which the organisms remain exquisitely sensitive, although delayed recurrence is possible. This review outlines the historical background of actinomyceal infection and considers the epidemiology, pathophysiology and clinical features of abdominal actinomycosis.

Hepatic actinomycosis: an overview of salient features and outcome of therapy

A 34-y-old African-American male developed Actinomyces liver abscess 8 months after appendectomy. Review of the English language literature revealed 56 additional cases of hepatic actinomycosis. Affected patients were typically immunocompetent, had a wide age range (4-86 y) and were predominantly male (70.2%). Infection was frequently (80.7%) cryptogenic, presenting with fever (83.3%), abdominal pain (74.5%) and weight loss (50.9%) over a 3.7 +/- 5.1 month period. The most common radiographic finding was a single hypodense mass/abscess (68.4%). Extension to surrounding tissues was evident in 19 cases (33.3%). Diagnosis was usually accomplished microscopically and culture was often (33.3%) negative. Infection was often (35.2%) mixed, usually with anaerobic bacteria. A surgical or percutaneous approach was diagnostic in 29/35 (82.9%) and 24/33 (72.7%) cases, respectively. The overall mortality rate was 8.8%; it was 10.7% with medical therapy alone and 4.0% using a combined medical/intervention approach (p = 0.6). In conclusion, hepatic actinomycosis is a rare subacute infection that may mimic neoplasm. It is usually cryptogenic, is more common among immunocompetent individuals and male subjects and is highly responsive to medical therapy.

Gastrointestinal actinomycosis: an unusual presentation with obstructive uropathy: report of a case and review of the literature

A 55-year-old female patient is described who had recurrent retroperitoneal infections without an apparent focus. After a protracted period of illness the infection proved to be caused by actinomycosis. An unusual feature of the inflammatory process consisted of obstruction of the ureters, ultimately resulting in destruction of the left kidney. Hydronephrosis resulting from inflammatory fibrosis has not been reported in the literature before.

Diagnosis of infectious diseases: a cytopathologist's perspective

This review explores the role of the cytopathology laboratory in the detection and presumptive identification of microorganisms. Sample procurement by exfoliation, abrasion, and aspiration techniques, as well as a variety of cytopreparatory and staining methods, is reviewed. Emphasis is placed on the utility of fine-needle aspiration as a rapid, safe, and cost-effective diagnositic procedure. The role of rapid interpretation and specimen triage is also discussed. Cytomorphologic features and staining characteristics are presented for a spectrum of microorganisms potentially encountered in the cytopathology laboratory. Pitfalls in diagnosis and the usefulness of special stains and ancillary techniques are also evaluated. The importance of communication, collaboration, and clinical correlation is stressed.

Ultrasound-guided transvaginal aspiration in the management of actinomyces pelvic abscess

BACKGROUND

Increasing reports of intrauterine device (IUD)-related abdominopelvic actinomycosis have been described recently. Surgical therapy has been the usual treatment when tubo-ovarian abscess is identified.

CASE

A 38-year-old woman suffering from Actinomyces pelvic abscess unresponsive to medical treatment underwent transvaginal ultrasound-guided needle aspiration. It resulted in marked improvement and avoided surgical treatment.

CONCLUSION

Transvaginal needle aspiration of Actinomyces pelvic abscess may be an alternative to surgical therapy, thereby allowing the preservation of pelvic organs.

Actinomycosis in fine needle aspiration cytology

Four cases of actinomycosis were diagnosed by fine needle aspiration (FNA) cytology and eight more cases were detected during a review of FNA smears reported as inflammatory. The age of these 12 cases ranged from 20 to 61 years with a median of 35 years. The male to female ratio was 3:1. The common regions of involvement were cervicofacial in seven cases (58.3%), thoracic in three (25.0%) and abdominal in two (16.7%). Four of the seven cervicofacial cases presented with intra-oral masses; the thoracic lesions were pulmonary in location, and the abdominal lesions presented as bowel masses. The possibility of actinomycosis was not considered clinically in any case. The main reason for missed cytodiagnosis in two thirds of the cases appeared to be observer error. It is suggested that when the aspiration smear from a mass is found to be an inflammatory exudate rich in neutrophils, special efforts must be made to look for this microorganism.