A childhood case of primary hepatic actinomycosis presenting with cutaneous fistula

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.

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.

Abdominal Actinomycosis in Children: A Case Report and Literature Review

Abdominal actinomycosis is an uncommon pediatric infection that often manifests with a tumor-like lesion. We describe a previously healthy 11-year-old girl who presented with right lower quadrant abdominal pain and drainage. Computed tomography scan showed an abdominal wall mass. Surgical debridement cultures grew Actinomyces meyeri. Literature review identified 18 additional pediatric cases since 1964 that we have summarized.

Dermatologic disorders and the liver

Chronic liver disease is associated with several cutaneous manifestations. Although many of these changes are nonspecific, some are associated with distinct liver diseases and correlate with the severity of hepatic pathology. Often the first clue to a liver disease is manifested through skin. Although cirrhosis is associated with spider nevi and palmar erythema, disorders can result in noncirrhotic cutaneous manifestations. It is important for physicians to be familiar with the spectrum of these manifestations, to recognize, help detect, and treat the underlying hepatic disease. This article reviews the medical literature and discusses the spectrum of dermatologic manifestations of liver disorders and their pathogenesis, significance, and treatment.

Case report: actinomycosis of the appendix--an unusual cause of acute appendicitis in children

Abdominal actinomycosis in children is a rare disease, which is occasionally found on histologic examination after an operation for acute appendicitis. Because of its nonspecific clinical and radiological signs and symptoms and low prevalence, the diagnosis is hardly ever made before the patient undergoes an operation and tissue is available for pathologic evaluation. When the diagnosis is made, the patient should be treated with the appropriate long-term antibiotics. With antibiotic therapy, the prognosis is favorable. We describe a 13-year-old girl who presented with acute appendicitis and was found to have abdominal actinomycosis after undergoing open appendectomy, which was treated successfully with penicillin and piperacillin-tazobactam.

Actinomyces in chronic granulomatous disease: an emerging and unanticipated pathogen

BACKGROUND

Chronic granulomatous disease (CGD) is a rare inherited disease of the phagocyte NADPH oxidase system that causes defective production of toxic oxygen metabolites, impaired bacterial and fungal killing, and recurrent life-threatening infections, mostly by catalase-producing organisms. We report for the first time, to our knowledge, chronic infections with Actinomyces species in 10 patients with CGD. Actinomycosis is a chronic granulomatous condition that commonly manifests as cervicofacial, pulmonary, or abdominal disease, caused by slowly progressive infection with oral and gastrointestinal commensal Actinomyces species. Treatment of actinomycosis is usually simple in immunocompetent individuals, requiring long-term, high-dose intravenous penicillin, but is more complicated in those with CGD because of delayed diagnosis and an increased risk of chronic invasive or debilitating disease.

METHODS

Actinomyces was identified by culture, staining, 16S ribosomal DNA polymerase chain reaction, and/or a complement fixation test in 10 patients with CGD.

RESULTS

All 10 patients presented with a history of fever and elevated inflammatory signs without evident focus. Diagnosis was delayed and clinical course severe and protracted despite high-dose intravenous antibiotic therapy and/or surgery. These results suggest an unrecognized and unanticipated susceptibility to weakly pathogenic Actinomyces species in patients with CGD because these are catalase-negative organisms previously thought to be nonpathogenic in CGD.

CONCLUSIONS

Actinomycosis should be vigorously sought and promptly treated in patients with CGD presenting with uncommon and prolonged clinical signs of infection. Actinomycosis is a catalase-negative infection important to consider in CGD.

Post varicella hepatic actinomycosis in a 5-year-old girl mimicking acute abdomen

Actinomycosis is an indolent, slowly progressive infection caused by gram-positive, anaerobic or microaerophilic bacteria. Hepatic involvement is rare and generally secondary to abdominal or thoracic actinomycosis. Hepatic actinomycosis in children may mimic a wide variety of diseases and thus make the diagnosis much more challenging. Here, we report a 5-year-old girl with apparently primary hepatic actinomycosis mimicking acute abdomen 2 weeks after varicella. The diagnosis was made by ultrasonic guided fine needle aspiration biopsy of a hypoechoic lesion of 3.5 cm diameter in the liver showing sulfur granules surrounded by neutrophils. Hepatic actinomycosis should be taken into account when evaluating acute abdomen symptoms in children.

Huge pelvic mass, cutaneous and vaginal fistulas, and bilateral hydronephrosis: a rare presentation of actinomycosis with a good response to conservative treatment and with long-term sequelae of renal atrophy and hydronephrosis

OBJECTIVE

Actinomycosis with an extended pelvic abscess is an uncommon condition, which usually occurs coincident with the presence of an intrauterine contraceptive device (IUD) in the uterine cavity. The clinical picture of pelvic actinomycosis may vary between individuals, is often accompanied by complications, and is frequently misdiagnosed. Here, we report a case of pelvic actinomycosis, presenting as a huge pelvic mass and complicated by a vaginal fistula, a cutaneous fistula, and bilateral hydronephrosis, and we discuss the diagnosis and management of this patient.

CASE REPORT

A 35-year-old woman was referred to our hospital with a huge pelvic complex mass and progressively worsening low abdominal pain. The tumor workup, which included a computed tomography (CT) scan, revealed an extended pelvic abscess and bilateral hydronephrosis. Both cutaneous and vaginal fistulas were also noted. Endometrial curettage and biopsies of the skin and vaginal lesions confirmed the diagnosis of actinomycosis. The patient underwent conservative treatment and recovered well, although the skin lesion only healed after 12 weeks of oral antibiotic treatment. At the 1-year follow-up, a CT scan showed sequelae including a mildly atrophic left kidney and left hydronephrosis.

CONCLUSION

In patients presenting with a pelvic mass and an IUD in the uterine cavity, the diagnosis of actinomycosis should be seriously considered. A detailed workup, including a CT scan, endometrial curettage and biopsies where possible, should be performed before surgery. Once diagnosis has been confirmed, conservative medical treatment should be attempted before considering laparotomy, to reduce the risk of complications. Despite successful treatment with antibiotics, long-term sequelae such as hydronephrosis and renal atrophy are possible in cases of extended pelvic actinomycosis.

Actinomycosis: a differential diagnosis for appendicitis. A case report and review of the literature

Actinomyces is a genus of gram-positive anaerobic or microaerophilic bacteria that colonize the upper respiratory and gastrointestinal tracts and the female genital tract. These organisms cause disseminated disease in the mouth, the respiratory system, and rarely in the gastrointestinal tract. The diseases produced by Actinomyces species result from the disruption of the barriers that allow the dissemination of the bacteria through the surrounding tissues. The appendix is often a nidus of Actinomyces infection, but a prompt diagnosis cannot be made without the results of histologic examination of the appendix. The treatment of choice for actinomycosis of the appendix is the high-dose parenteral administration of penicillin G for 2 weeks immediately after the diagnosis has been made and continued oral treatment with that agent for at least the next 6 months. We present the case of a 13-year-old adolescent boy with actinomycosis of the appendix that was identified by histologic examination after appendectomy.