Introduction
Actinomycesis a gram-positive filamentous bacteria that colonizes the mouth, carious teeth, tonsils, nose, throat, gastrointestinal tract, and urogenital tract and is a part of normal flora. These organisms usually do not cross the mucosal barrier. However, when an injury or a break in the mucosal barrier occurs, they become opportunistic pathogens and become an infection known as actinomycosis. About six species can cause diseases in humans, of which
Actinomyces israelii is the most common. The infection can also occur in the chest, abdomen, pelvis, and other body parts. It is a rare subacute to chronic infection and can be challenging to diagnose. Actinomyces organisms are highly sensitive to Penicillin. Actinomycosis is seen more in males (especially between 40 and 50 years) than in females, and its prevalence is higher in areas with low socioeconomic status. Actinomyces infection can also affect women with certain types of intrauterine device (IUD). However, the clinical presentation of Actinomyces infection mainly depends on the site of infection.
What Is IUD- Associated Actinomyces Infection?
Human infection with Actinomyces species was first described in thoracic, cervicofacial, and abdominal abscesses during the 19th century. Actinomyces organisms are anaerobic, non-acid-fast, gram-positive, and slow-growing bacilli that can colonize the female genital tract and present in polymicrobial pelvic abscesses. These characteristics make it challenging to identify the organism during routine culture techniques. Actinomyces is called so because, during the 19th century, investigators initially characterized the organism as a fungus due to the formation of large radiating colonies. Intrauterine device (IUD)- associated actinomyces infection is a rare condition that may occur in women using IUDs for a long duration.
The bacteria can spread to the fallopian tubes or uterus from an intrauterine device that has been in place for many years, causing various symptoms. It is well documented in various case reports, but it is not possible to quantify the risk during IUD use. However, approximately seven percent of women using an intrauterine device may find Actinomyces-like organisms during a Pap smear test.
What Are the Symptoms of IUD- Associated Actinomyces Infection?
The usual manifestations of IUD-associated actinomyces infection are similar to those in women with an IUD and mild pelvic inflammatory disease (PID). It can also mimic symptoms of certain gynecological malignant tumors, uterine myoma (noncancerous growths from the uterus), or adenomyosis (the lining of the uterus grows into the uterine wall). Some of the signs and symptoms of IUD-associated Actinomyces infection include pelvic tenderness or lower abdominal pain, fever, back pain, bleeding, vaginal discharge, chills, sweats, weight loss, and an increase in leukocyte count. These features demand a test called Papanicolaou-stained cervicovaginal smear to detect the presence of Actinomyces. In some cases, the clinical features can be mild compared to the extent of abscess formation and mistaken for malignancy.
Another important characteristic feature of actinomycosis is an indurated area of small, multiple communicating abscesses surrounded by granulation tissue. These lesions form sinus tracts communicating with the skin, producing a purulent discharge containing sulfur granules and indicating tissue reaction to infection. A localized form of actinomycosis infection is usually associated with pelvic or lower abdominal pain and vaginal discharge. In contrast, a generalized form can spread through the bloodstream to the liver, kidneys, ureters, and other pelvic organs.
What Are the Complications of IUD-Associated Actinomyces Infection?
If left untreated, IUD-associated Actinomyces infection can cause an abscess or scar tissue formation in the fallopian tubes or ovaries, leading to fistulas (an abnormal connection between the organ or a blood vessel) in between these organs. It can also disseminate to the uterine tubes, lead to salpingitis (inflammation of the fallopian tubes), and subsequently destroy the ovarian tissues. Studies have also reported that organs like the urinary bladder, urethra, colon, and iliac fossa can also be affected in some severe cases.
How Is IUD-Associated Actinomyces Infection Diagnosed?
IUD-associated Actinomyces infection is diagnosed using various techniques because culturing Actinomyces species can be challenging.
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The signs and symptoms of the condition are initially considered, and other possibilities, such as abdominal infection, abscess, vaginitis, etc., are ruled out. The affected area is palpated to detect any hard mass, and a gynecological exam is performed to check for inflammation, yellowish secretions, bleeding, or any visible damage to the mucous membrane.
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Laboratory studies are also recommended to determine leukocytosis, high sedimentation rate, erythropenia, C-reactive protein, and cancer antigens.
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Diagnostic tests such as X-rays, ultrasound, laparoscopy, computed tomography (CT scan), or magnetic resonance imaging (MRI) can be recommended to observe the affected area.
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Histological examination, such as a biopsy, is also performed by obtaining the cervicovaginal cells by a Papanicolaou smear test to confirm the diagnosis. These studies demonstrate inflammatory changes, granulomatous and suppurative nature, sulfur granules, and connective tissue proliferation. Pap tests may lack specificity in some cases; hence, other diagnostic approaches, such as immunofluorescent staining of smears, can be used to confirm the Pap results.
How Is IUD-Associated Actinomyces Infection Managed?
The usual treatment for IUD-associated Actinomyces infection involves high and prolonged doses of Penicillin G or Amoxicillin for four to six weeks, followed by oral Penicillin V for a few weeks or months, depending on the severity of the infection. Clindamycin, Erythromycin, or Tetracycline are alternatives for Penicillin allergy patients. It is also observed that Actinomyces species are also sensitive to drugs such as Ciprofloxacin, third-generation Cephalosporins, Trimethoprim-Sulfamethoxazole, and Rifampicin. Eliminating the injured tissues and surgical drainage are also necessary measures employed along with antimicrobial therapy.
Small abscesses are aspirated, large ones are drained, and fistulas are surgically excised.
In some severe cases or extensive pelvic diseases, removal of the intrauterine device with hysterectomy or salpingo-oophorectomy can be recommended. However, Actinomyces can be an incidental finding on a Pap test in females with IUD but without any symptoms; hence, they may not require antimicrobial treatment or intrauterine device removal.
Conclusion
Actinomycosis is an opportunistic, slowly progressive bacterial infection caused by Actinomyces israelii or Actinomyces urogenitalis, organisms commonly found in the nose, mouth, throat, and gastrointestinal tract. It is widely accepted to be a part of the normal flora but can be pathogenic if it crosses the mucosal barrier in case of an injury. It can spread to the uterus in women with an intrauterine device that has been in place for many years. This can cause severe pelvic pain, fever, back pain, bleeding and vaginal discharge. Medications, surgical drainage, and removal of the IUD usually manage it. Therefore, healthcare professionals must educate women choosing an intrauterine device for contraception that there can be a low risk of post-insertion infection with Actinomyces organisms in the future.
