Primary hepatic actinomycosis mimicking metastatic liver tumor

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.

Primary liver actinomycosis in a pediatric patient: A case report and literature review

BACKGROUND

Primary hepatic actinomycosis is a rare infection that can be clinically confused with hepatic pyogenic abscesses or neoproliferative processes. Only a few cases of primary hepatic actinomycosis in children have been reported in the English literature.

CASE SUMMARY

We describe a pediatric patient with primary hepatic actinomycosis that involved the base of the right lung and anterior abdominal wall and skin. The patient was diagnosed via histological examination of spontaneously drained material. The patient was successfully treated with an exploratory laparotomy and right posterior segmentectomy of the liver, combined with antibiotic treatment. Following surgery, the patient remains in excellent condition, without evidence of recurrence at the time of drafting this report. To summarize the clinical manifestations, diagnosis, treatment, and outcomes of primary hepatic actinomycosis, 18 case reports in English were reviewed.

CONCLUSION

We conclude that actinomycosis clinically features a chronic onset, nonspecific symptoms, and a primarily histologic diagnosis. Prolonged antibiotic treatment combined with invasive intervention provides a good prognosis.

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.

Severe abdominopelvic actinomycosis with colon perforation and hepatic involvement mimicking advanced sigmoid colon cancer with hepatic metastasis: a case study

BACKGROUND

Actinomycosis is a rare chronic invasive disease caused by Actinomyces spp. Although abdominopelvic actinomycosis, which involves the colon and the pelvic organs extensively, has been frequently reported, abdominopelvic actinomycosis presenting with colon perforation and hepatic involvement concurrently has yet to be reported.

CASE PRESENTATION

A 55-year-old woman presented at the emergency room with squeezing epigastric pain. Palpation of the abdomen revealed a hard mass with no acute peritoneal signs. Vital signs were normal range except for tachycardia. Initial laboratory testing revealed leukocytosis, anemia, elevated C-reactive protein (CRP), hypoalbuminemia; and normal AST/ALT and BUN/creatinine. CT scan of the abdomen-pelvis revealed a microperforations of the sigmoid colon, abscess in the left lower quadrant and hepatic lesion. Furthermore, there was a large infiltrating conglomerated mass invading the urinary bladder, left adnexa, sigmoid, left inguinal canal and left pelvic wall area. Ultrasound revealed an intra-uterine device (IUD). All these findings initially raised a suspicion of malignancy such as advanced cancer of the colon with liver metastasis. Despite the rarity of the disease, actinomycosis were not excluded because of the IUD found on ultrasound. Parenteral antibiotics and percutaneous drainage of abdomen abscess as well as fasting with total parental nutrition were prescribed for sigmoid perforation and abscess. After 10 days of conservative treatment, no remarkable change was detected in conglomerated mass invading pelvis. Furthermore, the finding of newly developed mechanical small bowel obstruction warranted surgery. Exploratory laparotomy was performed for the removal of perforated colon, obstructive small bowel and organs involved and postoperative histology confirmed a diagnosis of colonic actinomycosis. The patient made an uneventful recovery and was started on a 6-month course of penicillin.

CONCLUSIONS

Abdominopelvic actinomycosis presenting with colon perforation and hepatic involvement is extremely rare; however, it is clinically similar to advanced colon cancer with liver metastasis, therefore, complicating the preoperative diagnosis. A diagnosis of abdominopelvic actinomycosis should be considered in patients with a history of IUD and chronic abdominal pain, along with an abdominal mass or cutaneous abscess. If surgery is indicated, preoperative empirical antibiotic therapy for actinomycosis and frozen biopsy during surgery may be considered.

Hepatic Actinomycosis

Actinomycosis is a rare disorder caused by an anaerobic gram-positive bacillus (Actinomyces), predominantly by the Actinomyces israelii species. Only 20% of cases show an abdominal manifestation, the appendix and ileocecal valve being the most frequent locations. Definitive diagnosis is based on microbiological cultures, microscopy or macroscopy examination. Nevertheless, histological examination of the percutaneous biopsy and blood microbiological cultures are rarely positives. Preoperative diagnosis is hampered by the lack of specific clinical and imaging manifestations, which often mimic malignancy. The rate of preoperative diagnosis is less than 10%, however, the outcome is excellent, with a low mortality rate. The authors describe the case of a patient who was diagnosed with primary hepatic actinomycosis only by a histological examination of the surgical specimen of left hepatectomy extended to segments V and VIII, for suspected malignant lesion. This case demonstrates the difficulties in diagnosing hepatic actinomycosis.

Identification of a novel 16S rRNA gene variant of Actinomyces funkei from six patients with purulent infections

Little is known about the clinical significance and laboratory diagnosis of Actinomyces funkei. In this report we describe six clinical cases where A. funkei was isolated from purulent, polymicrobial infections. Conventional identification procedures were compared with molecular methods including matrix-assisted laser desorption/ionization time-of-flight mass spectrometry technique. Analysis of the full 16S rRNA gene sequence of the six investigated strains revealed differences from the A. funkei type strain. DNA-DNA hybridization showed that the clinical strains represent a novel 16S rRNA gene variant within the species of A. funkei.