The use of an intrauterine device (IUD) is associated with the presence of actinomyces in the female genital tract. Since IUD use is currently so prevalent, IUD-related pelvic inflammatory disease occasionally spreads to the rest of the abdomen. Two patients with abdominal actinomycosis in association with an IUD illustrate the problem; we review the general problem.
PIP: 2 case reports are presented of IUN wearers with advanced actinomycotic disease. In both women there was extensive involvement of the bowel and in 1 woman deposits in the liver. The discussion covers the objectives of making a preoperative diagonsis, initiating antibiotic therapy, and potentially obviating or limiting surgical intervention. A 44-year old black woman complained of gradually increasing abdominal girth, weight loss, weakness, and pedal edema. Her last menstrual period had been 5 months prior to admission. She had an IUD in place for 11 years and was sexually inactive. She was a cachectic woman with a temperature of 100 degrees Farenheit, bilateral inguinal adenopathy, and 1+ pedal edema. Barium studies revealed an IUD in the right side of the pelvis and a large soft tissue mass pressing upon and intimately adherent to the sigmoid colon. At laparotomy, mumerous adhesions were encountered and a large cavitated mass was found to occupy the entire left side of the pelvis. Fistulas extended from it to both the sigmoid colon and the small bowel. Frozen sections revealed fibrosis and inflammaion with confluent granulomas. Gram stains of the exudate showed sulfur granules suggesting atinomycotic infection. A total hysterectomy and bilateral salpingo-oophorectomy were performed and the intestinal fistuals were repaired. Examination of the resected specimens showed a Majzlin Spring IUD imbeded in the endometrium and myometrium. In the immediate postoperative period, the patient was treated with high dose intravenous antibiotic therapy and on discharge she was continued on oral penicillin. The 2nd case, a previously healthy 53 year old white woman gave a 2 month history of intermittent lower adbominal pain, cramping and alternating diarrhea and constipation. Her last menstrual period had been 6 months earlier and she claimed to have forgotten about a Dalkon Shield IUD which had been in place for 20 years. AT laparotomy, a firm infiltrating mass was found to involve the uterus, left fallopian tube, sigmoid colon, and pelvic side walls. Gross pathologic examination demonstrated extensive acute and chronic inflammation and granulation of the left fallopian tube, uterus, and sigmoid colon. The sigmoid showed thickening of musculas layers, reactive fibrosis in the submucosa, subserosa, and mesentery, and areas of formation of small sinus tracts and/or abscesses. A single sulfur granule was found within the lumen of the left fallopian tube. Gram stain of this demonstrated the characteristic filamentous nature of actinomyces. After surgery, Cefoxitan was continued and intravenous penicillin was added. Both patients were postmenopausal and had forgotten about their IUDs. Millions of women with IUDs are know to be asymptomatic carriers of actinomycosis by virtue of the appearance of the bacillus on routine Pap smears. Most of these women are still menstruating. Possibly cyclical menstrual flow is something of a cleansing mechanism protecting these women from actinomycotic infection.