Hepatic actinomycosis mimicking an isolated tumor recurrence

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.

18F-FDG PET/CT of Hepatosplenic Actinomycosis After Laparoscopic Cystojejunostomy for Pancreatic Pseudocyst

ABSTRACT

We report the 18F-FDG PET/CT appearance of abdominal actinomycosis in a 48-year-old immunocompetent woman with a history of laparoscopic cystojejunostomy for pancreatic pseudocyst previously. 18F-FDG PET/CT demonstrated multiple hypermetabolism in the liver, spleen, cystojejunostomy anastomosis, greater omentum, and umbilical region. Actinomycosis was verified by biopsy. Hepatosplenic actinomycosis secondary to cystojejunostomy is extremely rare and easily to be misdiagnosed. PET/CT is helpful for auxiliary diagnosis, guiding biopsy, and exploring the extent of the disease.

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.

Cytopathology of Hepatobiliary-Related Actinomycosis

BACKGROUND

The clinical diagnosis of hepatobiliary-related actinomycosis can be challenging owing to its rarity and variable presentation. Moreover, actinomycotic pseudotumors may mimic malignancy and result in unnecessary surgical resection. Herein, we present the clinical and cytopathological features of 3 cases with hepatobiliary-related actinomycosis.

CASES

The first patient was a 73-year-old man who presented with an exophytic liver lesion. The second patient was a 78-year-old woman who presented with a biliary stricture. The third patient was an 88-year-old woman with a right flank mass extending to the liver. The aspirate smears in these 3 cases demonstrated 'cotton ball' clusters of filamentous microorganisms and abscesses. The cell blocks of 2 of the patients showed sulfur granules with peripheral filamentous microorganisms positive with a Gram stain but negative with an acid fast stain, consistent with Actinomyces species. All patients were elderly and shared a past surgical history of laparoscopic cholecystectomy.

CONCLUSION

These cases demonstrate the complementary role of cytology in the diagnosis of hepatobiliary actinomycosis. A cytologic diagnosis of actinomycosis is minimally invasive and quick. It can prompt proper culture medium selection and avoid unnecessary or extensive surgery. Based on our experience, laparoscopic cholecystectomy may be a precipitating factor for the subsequent development of hepatobiliary-related actinomycosis.

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.

Hepatic actinomycosis: Report of one case and analysis of 32 previously reported cases

Hepatic actinomycosis is rare, with few published cases. There are no characteristic clinical manifestations, and computed tomography (CT) shows mainly low-density images, making clinical diagnosis difficult, and leading to frequent misdiagnosis as primary liver cancer, metastatic liver cancer or liver abscess. Diagnosis normally requires examination of both the aetiology and pathology. This article reports one male patient aged 55 who was hospitalized because of repeated upper abdominal pain for more than 2 mo. He exhibited no chills, fever or yellow staining of the skin and sclera, and examination revealed no positive signs. The routine blood results were: haemoglobin 110 g/L, normal numbers of leukocytes and neutral leukocytes, serum albumin 32 g/L, negative serum hepatitis B markers and hepatitis C antibodies, normal tumour markers (alpha-fetoprotein and carcinoembryonic antigen). An abdominal CT scan revealed an 11.2 cm × 5.8 cm × 7.4 cm mass with an unclear edge in the left liver lobe. The patient was diagnosed as having primary liver cancer, and left lobe resection was performed. The postoperative pathological examination found multifocal actinomycetes in the hepatic parenchyma, which was accompanied by chronic suppurative inflammation. A focal abscess had formed, and large doses of sodium penicillin were administered postoperatively as anti-infective therapy. This article also reviews 32 cases reported in the English literature, with the aim of determining the clinical features and treatment characteristics of this disease, and providing a reference for its diagnosis and treatment.

Refractory primary hepatic actinomycosis with direct infiltration to the diaphragm and thorax: the usefulness of contrast-enhanced ultrasonography

An 80-year-old man was admitted to our hospital with a diagnosis of primary hepatic actinomycosis determined based on a percutaneous aspiration biopsy. The abscesses and state of liquefaction were easily and effectively visualized on contrast-enhanced ultrasonography. Ampicillin/sulbactam was administered; however, lesions of hepatic actinomycosis suddenly infiltrated the diaphragm and right thorax six months later. A drainage tube was inserted into the right thoracic space, and the pleural effusion gradually decreased. The patient received continuous antibiotic therapy for nearly two years and remained free of hepatic actinomycosis on follow-up more than one year later.

Actinomycosis of cecum associated with entamoeba infection mimicking perforated colon cancer

Actinomycosis is a granulomatous disease caused by Actinomyces that mimics other intra-abdominal pathologies especially neoplasms. Correct diagnosis can be rarely established before radical surgery. On the other hand Entamoeba infection affects a considerable number of people worldwide. To our knowledge only one case has been reported to be affected by both organisms. We report a man who has been operated for a mass in the cecum mimicking a perforated colon cancer. Abdominal CT revealed a mass with features of an invading neoplasm. After radical surgery, definitive pathology revealed that the mass was due to actinomycosis associated with Entamoeba infection. The postoperative period was uneventful and the patient was on long-course antibiotherapy. It is important to consider actinomycosis especially in patients with intra-abdominal masses with unusual aggressiveness to prevent unnecessary surgery. However, surgery can be unavoidable especially in the presence of complicated disease or high index of suspicion for malignancy.