Journal of Postgraduate Medicine
 Open access journal indexed with Index Medicus & ISI's SCI  
Users online: 3611  
Home | Subscribe | Feedback | Login 
About Latest Articles Back-Issues Articlesmenu-bullet Search Instructions Online Submission Subscribe Etcetera Contact
 
  NAVIGATE Here 
  Search
 
  
 RESOURCE Links
 ::  Similar in PUBMED
 ::  Search Pubmed for
 ::  Search in Google Scholar for
 ::  Article in PDF (1,078 KB)
 ::  Citation Manager
 ::  Access Statistics
 ::  Reader Comments
 ::  Email Alert *
 ::  Add to My List *
* Registration required (free) 

  IN THIS Article
 ::  References
 ::  Article Figures

 Article Access Statistics
    Viewed1276    
    Printed45    
    Emailed0    
    PDF Downloaded9    
    Comments [Add]    

Recommend this journal


 


 
  Table of Contents     
CASE SNIPPET
Year : 2023  |  Volume : 69  |  Issue : 1  |  Page : 63-64

Appendiceal actinomycosis presenting as acute appendicitis: A diagnostic and therapeutic challenge


1 Department of General and Minimal Access Surgery, Sir H.N. Reliance Foundation Hospital and Research Centre, Mumbai, Maharashtra, India
2 Department of Laboratory Medicine, Sir H.N. Reliance Foundation Hospital and Research Centre, Mumbai, Maharashtra, India

Date of Submission23-Feb-2022
Date of Decision15-Jul-2022
Date of Acceptance18-Jul-2022
Date of Web Publication19-Dec-2022

Correspondence Address:
Dr. S P Tendulkar
Department of General and Minimal Access Surgery, Sir H.N. Reliance Foundation Hospital and Research Centre, Mumbai, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpgm.jpgm_196_22

Rights and Permissions




How to cite this article:
Tendulkar S P, Jain P A, Mehta M G, George S. Appendiceal actinomycosis presenting as acute appendicitis: A diagnostic and therapeutic challenge. J Postgrad Med 2023;69:63-4

How to cite this URL:
Tendulkar S P, Jain P A, Mehta M G, George S. Appendiceal actinomycosis presenting as acute appendicitis: A diagnostic and therapeutic challenge. J Postgrad Med [serial online] 2023 [cited 2023 Jun 3];69:63-4. Available from: https://www.jpgmonline.com/text.asp?2023/69/1/63/364509




A 31-year-old female presented with complaints of right lower abdominal pain and vomiting for 2 days. Abdominal examination revealed tenderness at McBurney's point. Laboratory findings were normal, except for a white blood cell count of 18,000/mm3 with a neutrophilic predominance and a C-reactive protein level of 2.5 mg/L. Computed tomography (CT) of the abdomen was suggestive of acute retrocecal appendicitis without any regional lymphadenopathy [Figure 1]a and [Figure 1]b. The patient was posted for an emergency appendectomy. Intra-operatively, the appendix was mildly inflamed with thickened mesoappendix. The cecal pole was especially thickened disproportionate to the extent of surrounding inflammation [Figure 1]c and [Figure 1]d. The rest of the small and large intestine was grossly normal. The right colon was mobilized and appendectomy along with excision of the cecal pole was done. The cecal wall was approximated and reinforced with 3–0 polydioxanone suture in two layers. The patient recovered well postoperatively and was discharged subsequently. Histopathological examination showed acute gangrenous appendicitis with clumps of basophilic filamentous bacteria on the mucosal surface and within the mucosa. Special stains showed gram-positive and acid-fast negative filamentous organisms consistent with actinomycosis [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d. Hence, the patient was prescribed intravenous penicillin for 6 weeks followed by oral therapy for 6 months. After 24 months of follow-up, the patient had no postoperative complications or any long-term morbidity.
Figure 1: (a and b) Contrast-enhanced CT Abdomen: Coronal and axial images showing fluid-filled distended [21 mm in diameter] appendix containing two calcific appendicoliths with annular mural thickening and hyperenhancement (arrowed), (c and d) Showing the thickened base of the appendix (arrowed)

Click here to view
Figure 2: (a) Focus of actinomycosis with surrounding inflammatory cells (arrowed, H and E stain, original magnification ×10), (b) Gram-positive actinomycotic colony (arrowed, gram stain, original magnification ×10), (c) Acid-fast negative bacteria (acid-fast stain, original magnification ×10), (d) Focus of actinomycosis with surrounding inflammatory cells (arrowed, H and E stain, original magnification ×100

Click here to view


Actinomycosis is a subacute–chronic bacterial infection affecting the soft tissues and internal organs of the body. The most common pathogen that causes actinomycosis in humans is Actinomyces israelii. These organisms are indigenous to the oral cavity, gastrointestinal tract, and genital tract.[1],[2],[3] Although A. israelii is a non-pathogenic bacterium, mucosal injuries that disrupt the mucosal barriers, like perforated appendicitis, perforated diverticulitis, Crohn's disease, and intestinal perforation due to bone or fishbone, allow the microorganism to reach deep planes, resulting in actinomycotic infections. Involvement of distant organs is possible via the hematogenous spread, leading to the formation of metastatic abscesses in the liver. However, because of the size of the bacterium, it usually does not spread via the lymphatic system; therefore, regional lymphadenopathy is uncommon or develops late.[1],[2] Actinomycosis commonly occurs in three distinct forms that may occasionally overlap; most clinical disease is cervicofacial (50–55%), followed by 20% occurring in the abdominopelvic form and 15% in the thoracic form.[2],[3],[4] Abdominopelvic actinomycosis is associated with longstanding intrauterine devices, trauma, or any abdominal surgery which is associated with a breach in bowel mucosal integrity.[1],[2],[3] Other known predisposing systemic factors include malnutrition, immunosuppression, and acquired immunodeficiency syndrome. The present case did not have any known local or systemic predisposing factors. Abdominopelvic actinomycosis commonly involves the appendix and the terminal ileum (65% of cases).[3],[4] However, the colon, stomach, liver, gallbladder, pancreas, pelvis, and abdominal wall may also be involved.[2],[5],[6] Appendiceal actinomycosis is one of the rare causes of acute appendicitis with an incidence of 0.02–0.06% of all appendicitis cases. CT features of abdominopelvic actinomycosis are nonspecific, which can range from the bowel wall thickening to an infiltrative mass adjacent to the other involved organs.[1],[2] Definite diagnosis of the disease is often made with the intraoperative or postoperative histopathological examination, like in the present case. Preoperative diagnosis is possible in only 10% of the cases, usually following examination of aspiration or biopsy material obtained under CT guidance.[1],[3] Surgical excision remains the mainstay of therapy. The intense desmoplastic reaction, associated with actinomycosis, limits drug penetration and thereby, warrants high-dose long-term antibiotic therapy.[1],[3] The preferred antibiotic treatment includes intravenous high-dose crystalline penicillin G (2–4 weeks) followed by long-term (6–12 months) oral penicillin or semi-synthetic penicillin derivatives. For patients allergic to penicillin, tetracycline, erythromycin, and clindamycin are accepted and efficient alternatives.[3] Abdominopelvic actinomycosis is associated with a high recurrence rate, increased risk of intestinal fistulization, and localized abscess formation, if not detected or treated inadequately, which can result in significant long-term morbidity and delayed healing. In view of anecdotal evidences with regards to its long-term complications and follow-up, the patient was kept under surveillance for 24 months.

Declaration of patient consent

The authors certify that appropriate patient consent was obtained.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 :: References Top

1.
Yardımcı VH, Yardımcı AH. Is appendectomy always adequate for treatment?: Clinical manifestations of isolated actinomycosis in the appendix. Turk J Surg 2018 (in press).  Back to cited text no. 1
    
2.
Lee SY, Kwon HJ, Cho JH, Oh JY, Nam KJ, Lee JH, et al. Actinomycosis of the appendix mimicking appendicealtumor: A case report. World J Gastroenterol 2010;16:395-7.  Back to cited text no. 2
    
3.
Nissotakis C, Sakorafas GH, Koureta T, Revelos K, Kassaras G, Peros G. Actinomycosis of the appendix: Diagnostic and therapeutic considerations. Int J Infect Dis 2008;12:562-4.  Back to cited text no. 3
    
4.
Gómez-Torres GA, Ortega-Gárcia OS, Gutierrez-López EG, Carballido-Murguía CA, Flores-Rios JA, López-Lizarraga CR, et al. A rare case of subacute appendicitis, actinomycosis as the final pathology reports: A case report and literature review. Int J Surg Case Rep 2017;36:46-9.  Back to cited text no. 4
    
5.
Cho IS, Bae SU, Jung HR, Park KS, Jeong WK, Baek SK. Actinomycosis of the appendix mimicking cecaltumor treated by single-port laparoscopic approach. Ann Coloproctol 2021;37:125-8.  Back to cited text no. 5
    
6.
Karateke F, Ozyazıcı S, Menekşe E, Daş K, Ozdoğan M. Unusual presentations of actinomycosis; anterior abdominal wall and appendix: Report of three cases. Balkan Med J 2013;30:315-7.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]



 

Top
Print this article  Email this article
 
Online since 12th February '04
2004 - Journal of Postgraduate Medicine
Official Publication of the Staff Society of the Seth GS Medical College and KEM Hospital, Mumbai, India
Published by Wolters Kluwer - Medknow