A case of pelvic actinomycosis is described which occurred in association with the use of an intrauterine device (IUD). Initially medical management alone was used, but surgical intervention was necessitated for multiple pelvic abscesses. We would strongly recommend that any IUD be removed should it be associated with actinomyces on genital smears and/or culture. If sepsis is also apparent, IUD removal with use of long-term antibiotics is required.
PIP: In Australia, a 31-year old IUD user with 3 children came to the Royal Women's Hospital in Melbourne, Victoria, for elective laparoscopic sterilization. Cytological examination of a Pap smear revealed actinomyces-like organisms (ALO), yet she had no symptoms. Her physician removed the IUD during tubal occlusion 2 months later, at which time she was febrile. She received 2 g intravenous (IV) cefoxitin. The physician applied a clip to the right tube, but not to the left tube due to dense adhesions around a small ruptured tubo-ovarian abscess. Aspirate culture indicated Actinomyces israelii and Fusobacterium rusii. No. A israelii grew from the removed cultures IUD, however. Histological examination of the curettings revealed proliferative endometrium with IUD effect and ALO-like microcolonies. After the operation, she received IV amoxycillin and rectal metronidazole. Upon a positive Actinomyces culture, she received IV crystalline penicillin and metronidazole. This treatment did not resolve her anorexia, fever, and pelvic infection signs. She received 4 units of blood. Ultrasound showed 4 complex masses near the ovaries and too the right of the fundus. Her physician did a laparotomy to drain the abscesses. Extensive adhesions made the bowel dilate and mat together and to the abdominal wall. The physician removed the left xanthomatous salpinigitic tube. Postoperatively, she underwent nasogastric suction, administration of IV fluids via a central line, a blood/plasma transfusion, and gentamicin. After developing a chest infection, she received IV cefotaxime. 7 days later she no longer had a fever, took oral fluids, and was ambulatory. She took oral penicillin and probenecid. 2 months later, she suffered lower abdominal and adnexal tenderness. Ultrasound revealed a mass near the left tubal stump and a mass near the right ovary. Over the next few weeks the left mass disappeared, but the other mass grew. The physician aspirated hemoserous fluid. They switched to doxycycline over 4 months. 12 months after the initial operation, she had no symptoms and no pelvic abnormalities.