UNILATERAL ACTINOMYCOTIC TUBO-OVARIAN ABSCESS COMPLICATED WITH CEREBRITIS – A CASE REPORT

Abstract

Background: Tuboovarian abscess is a serious complication of pelvic inflammatory disease. Pelvic ac- tinomycosis may correlate with long term use of intra-uterine device (IUD), but is uncom- mon cause of inflammation, except in postmenopausal IUD users.1, 2 Tuboovarian abscess complicated with cerebritis is relatively uncommon condition.

Methods: We present a rare case of a 56-years-old woman with IUD, developing tuboovarian abscess that complicated with cerebritis. Twenty days before admittance to the Gynecologic clinic, she complained of fatigue and nausea, anorexia, vomiting and diarrhea. After an initial improvement for 5 days her symptoms recurred, profounded with sweating and fever up to 40 °C, leg weakness and walking difficulties, and weight loss. In that condition she was presented to our emergency room. There was no history of chronic disease. The patient had an IUD for the past 30 years. On physical examination the abdomen was tender, but without signs of peritoneal irritation. Laboratory studies revealed elevated CRP (107 mg/L), ESR (65mm/h) and normal number of leukocytes (7.8 × 109/L). Ultrasound showed 8x4 cm left infraumbilical septated mass suspect for tubo-ovarian abscess.. She was hospitalized, IUD was removed and Metronidazol, Ciprofloxacin and Gentamycin were started parenterally. Tumor markers were negative. On the next day she developed neurologic symptoms with blindness and left-hemiparesis. MR angiography and CT of the head revealed local brain edema, suspect for cerebritis. Although the laboratory findings of inflammation were de- creasing, we changed the antimicrobial therapy with Cefotaxime and Kloksacilin (Orbenin) instead of Metronidazol and Ciprofloxacin because of better blood-brain barrier transport. Cerebrospinal fluid tests for HSV, neurotropic viruses, malignant cells, TBC, echinoccocus, toxoplasmosis, cysticercosis, pathogenic bacteria, fungi, TILR2, and TNF alfa were nega- tive. A brain biopsy was preformed and no pathologic changes were found, except a group of beta amyloides. Rectoscopy ruled out malignancy. Because of enlargement of the brain edema Mannitol and Dexamethazon were added in the therapeutic regimen. Temporar- ily stabilizing the increment of brain edema, we performed exploratory laparotomy that revealed a left retroperitoneal abscess infiltrating the sigmoid colon and left parameters. Left fallopian tube and ovary were modified in a solid tumor. A total hysterectomy with bilateral salpingoophorectomy with Hartmann resection of sigmoid colon was performed. After operation general inhalation anesthesia was initiated at Central Intensive care unit (CIT). Control brain CT showed diffuse bilateral brain edema. Brain biopsy was performed and the histology results were negative. Vancomycin and Ceftriakson were added in therapy for 15 days. After this therapy, CT revealed a decrease in the brain edema and isolated bilateral hypodense parietoocipital formations and a right frontal paramedial hypodense formation. The patient was kept sedated and intubated. Approximately one month later a try of awaking the patient from general anesthesia was unsuccessful. Our neurologic team proposed either a repeat of the brain lesion biopsy or intrathecal empiric antimicrobial therapy. On the next day, before performing either of proposed procedures, the patient completely awaked and was contactable but with left-sided hemiparesis. According to the hystologic and microbyologic findings the patient was transferred to Intensive Care unit of our Department where Imipenem was started, and later transferred to Infectology for further treatment. Approximately one year after the hospitalization, long-term use of intravenous antibiotics and rehabilitation, the patient fully recovered with minimal consequences of brain damage.

Results: Hystologically the removed left-sided mass was a tuboovarian abscess with actinomycotic colonies. On microbiologic examination Enterococcus faecium, Bacteroides capillosus and Anaerobic gram negative bacilli were isolated, sensitive to Metronidazol, Clindamycin, Imipenem and Amoksicilin with Clavulonic Acid. The definite diagnosis was tuboovarian abscess caused by actinomyces complicated with etiologically undeterminated cerebritis.

Conclusions: Tuboovarian abscess in a postmenopausal woman as a cause for brain inflammation or abscess is an absolute rarity. Actinomyces species are not generally considered as a part of the normal vaginal flora but rather are associated with the presence of a foreign body, most often an IUD. It is a chronic supurative infection, with a tendency to form abscess. Pelvic actinomycosis is a rare bacterial disease in women (3). It is difficult to diagnose because of the non specific clinical symptoms and imaging findings. Treatment is not standardized and depends on the clinical form. Medical therapy is based on long-term Penicillin G (4). The prognosis of correctly treated pelvic actinomycosis is generally good (3, 4). Experiences with the infection of the CNS by Actinomyces showed that it is potentially fatal (5) and should be considered in those patients with cerebral abscesses or cerebral infection as evident from our case.