Infectious Disease Reports 2014; volume 6:5157

Renal hemorrhagic actinomy- increased to 12 g/dL after 2 units packed red blood cells. Creatinine was 0.6 mg/dL. Correspondence: Marcela C. Smid, Department of cotic abscess in pregnancy Tuberculin skin test was negative. Urology and Obstetrics and Gynecology, Division of Maternal medical oncology consultations were obtained. Fetal Medicine, University of North Carolina at 1,2 2 Marcela C. Smid, Neha R. Bhardwaj, She was managed with nil per os (NPO) status, Chapel Hill School of Medicine, 3010 Old Clinic Laura M. Di Giovanni,2 Scott Eggener,3 analgesics, and additional two units of packed Building, CB #7516, Chapel Hill, NC 27599-7516, Micaela Della Torre2 red blood cells after her hemoglobin decreased USA. Tel.+1.919.966.4103 - Fax: +1.919.966.6377. 1 to 8.8 g/dL over four days. Department of Obstetrics and Gynecology, E-mail: [email protected] Division of Maternal Fetal Medicine, A non-contrast magnetic resonance imaging University of North Carolina at Chapel Hill (MRI) of the abdomen and pelvis was obtained Key words: actinomyces, abscess, pregnancy com- School of Medicine, NC; 2Department of to further characterize the mass and to identify plication, kidney. any possible renal vasculature anomalies. MRI Obstetrics and Gynecology, Chicago Lying showed an 11.2×7.7 cm right renal mass (Figure Acknowledgments: we would thank Dr. David in Hospital, University of Chicago Medicine, 1). She developed preterm contractions and Grimes for his assistance in the preparation of 3 IL; Section of Urology, University of received nifedipine and a betamethasone course this manuscript. Chicago Medicine, IL, USA for fetal lung maturity. Her cervical exam remained unchanged. An ultrasound-guided Contributions: the authors contributed equally. right kidney biopsy of medulla and cortex revealed mild to moderate patchy interstitial Conflict of interests: the authors declare no potential conflict of interests. Abstract inflammation with no evidence of malignancy. Immunochemical staining for kappa and lambda Received for publication: 5 November 2013. Actinomyces israelii is a gram-positive, fila- light chain and periodic acid Schiff staining Revision received: 29 January 2014. mentous anaerobic bacteria colonizing the oral demonstrated lymphoplasmacytic infiltrate, Accepted for publication: 4 February 2014. and gastrointestinal tracts. Retroperi toneal indicating acute interstitial nephritis, however actinomycotic abscess is uncommon and its rare renal function was normal. Differential diagno- This work is licensed under a Creative Commons presentation as a hemorrhagic mass may be sis based on pathological studies included onlyAttribution NonCommercial 3.0 License (CC BY- NC 3.0). confused with malignancy. We present a case of and interstitial inflammation this unusual infection complicating pregnancy. secondary to unbiopsied renal mass with less ©Copyright M.C. Smid et al., 2014 Increased awareness of actinomycotic abscess likely possibility of renal carcinoma, lymphoma Licensee PAGEPress, Italy in the differential diagnosis of renal mass con- and metanephric adenoma. Given the useinconclu- Infectious Disease Reports 2014; 6:5157 cerning for malignancy is critical to early recog- sive biopsy with no indication of malignancy, doi:10.4081/idr.2014.5157 nition and treatment of this rare infection and stable hemodynamic status and advanced gesta- most importantly, avoidance of unnecessary sur- tion, the multi-disciplinary team recommended fluid collections were treated with percutaneous gical intervention. expectant management with close monitoring drains inserted by . She for mass size change and hemodynamic status. was started on piperacillin/ tazobactam then On hospital day 19, patient was discharged switched to amoxicillin/clavulanate for six home. Interval MRIs showed stable size of the Case Report months. Subsequent computerized tomography mass throughout her pregnancy. At 35 weeks (CT) imaging showed complete resolution of gestation, the patient was admitted for preterm mass. A 20-year-old Puerto Rican woman, G2P0101, labor. She underwent a vacuum assisted vaginal was referred to us at 24 weeks gestation for eval- delivery of a 2595-gram male infant. Placenta uation of an 11 cm right upper quadrant mass pathology showed mature third trimester pla- and anemia. She reported a history of cholelithi- centa without evidence of inflammation or Discussion asis, childhood seizure disorder, left upper infection. The presumptive diagnosis of the extremity embolectomy and a laparoscopic mass was angiomyolipoma with as Actinomyces israelii as the cause of renal appendectomy in prior pregnancy at six weeks there are many reports of ruptured angiomy- gestation, although operative Non-commercial and imaging olipoma with hemorrhage in the obstetric litera- mass is rare and can be associated with severe 5 records were unavailable. Her previous delivery ture;1-4 the plan was to repeat the MRI study six sequelae. We are aware of one published case of was a Cesarean section. She had no history of weeks post-partum. retroperitoneal bleeding associated with this 6 poor dentition or intrauterine device (IUD) use. Twelve days after delivery, the patient type of abscess. The source of actinomycotic One month before admission to our hospital, she returned with fever, right flank and leuko- infection is often unknown. In the gynecological reported fatigue, 25 pound weight loss over six cytosis of 19.7 K/UL. She was taken to the oper- literature, cases of IUD associated with pelvic months, and severe right-sided pain. At another ating room where she underwent a right renal actinomyces infections mimicking malignancy hospital, she underwent right upper quadrant exploration, resection of retroperitoneal mass have been reported and in one case with renal and renal ultrasound revealing stones and and partial nephrectomy. The pathology report failure.7,8 However, our patient did not have any sludge in the gallbladder. Ultrasound noted an revealed xanthogranulomatous pyelonephritis history of IUD use. Neither pelvic nor renal 8×9×11 cm hemorrhagic mass in the right renal with occasional clusters of actinomyces infec- actinomycosis has been reported in the obstetric subcapsular area extending to the right tion (Figure 2). Her operation was complicated literature. It is unlikely that the actinomycotic diaphragm. At this time, differential diagnosis by an unsuspected duodenal necessitat- infection played a role in her preterm delivery as included angiomyolipoma with hemorrhagic ing exploratory laparotomy and repair two days the placenta and membranes showed now evi- rupture, renal carcinoma, lymphoma, later. Pathology from resection of duodenal mass dence of infection. Her strongest risk factor for metanephric adenoma and renal/pelvic tubercu- showed abscess, granulation tissue and xan- preterm delivery was her previous preterm deliv- losis. Chest radiograph was within normal lim- thogranulomatous inflammation without evi- ery.9 Interestingly, the patient did have a laparo- its. Her hemoglobin was initially 7 g/dL and dence of actinomycotic infection. Multiple pelvic scopic appendectomy in her pregnancy two years

[Infectious Disease Reports 2014; 6:5157] [page 7] Case Report

Figure 2. High power view Hematoxylin and Eosin stain of abscess: sulfur granules of actinomyces colonies with dense lym- phocytic infiltrate. Figure 1. Non-contrast magnetic resonance imaging of abdomen and pelvis: heterogeneous mass 11.2×7.7 cm arising from right MA, et al. A new form of presentation of kidney extending to liver edge, splenomegaly with spleen meas- renal actinomycosis: renal tumor with uring 15.2 cm and mild right hydronephrosis. retroperitoneal bleeding. Arch Esp Urol 2006;59:756-9. 7. Marret H, Wagner N, Ouldamer L, et al. prior to presentation. Actinomyces has been cautioned by our experience and include actino- Pelvic actinomycosis: just think of it. associated with appendicitis in case reports and mycosis on the differential of hemorrhagic renal Gynecol Obstet Fertil 2010;38:307-12. may have been the initial source of peri-nephric mass in the pregnant and non-pregnant patient. 8. Ugezuonly CH, Kelly I, Walker F, Stratton JF. A infection.10-12 Splenomegaly, which was present case of pelvic actinomycosis with bilateral in our case, and actinomycotic infection has hydronephrosis and renal failure associated been associated with splenic rupture.13 Dental with prolonged intrauterine contraceptive caries may be a possible source of spread to per- Conclusions systems use. J Obstet Gynaecol 2012; inephric structures,14 however our patient had use 32:403-4. no known dental disease. Consideration of actinomycotic infection in 9. Goldenberg RL, Culhane JF, Iams JD, The initial diagnosis of actinomycotic abscess the differential diagnosis of renal or pelvic mass Romero R. Epidemiology and causes of PTB. is difficult and presentation as pelvic or renal with fevers and weight loss is important as Lancet 2008;371:75-84. 10. Mumme T, Peiper C, Biesterfeld S, mass is often confused with renal or gynecolog- recognition may avoid laparotomy, hasten treat- Schumpelick V. Acute retrocecal appendici- ical malignancy.5,14-16 We recognize that pre- ment with antibiotics, and decrease intraopera- tis caused by an Actinomyces israelii mixed operative diagnosis is difficult given non-specif- tive complication from distorted tissue planes.16 infection. Zentralbl Chir 2001;126:632-10. ic findings and low index of suspicion. On initial We hope that our experience increases aware- 11. Yi iter M, Kiyici H, Arda IS, Hiçsönmez A. biopsy, we found only dense fibrotic tissue with- ness of actinomycotic renal infection in the ğ Actinomycosis: a differential diagnosis for out sulfur granules. Clinicians should be aware obstetric and general population. appendicitis. A case report and review of the that actinomyoctic abscesses are characterized literature. J Pediatr Surg 2007;42:E23-6. by slow growth, abscess formation ignoring nor- 12. Lee SY, Kwon HJ, Cho JH, et al. 17 mal tissue planes and dense fibrosis. The Actinomycosis of the appendix mimicking absence of sulfur granules on biopsy does not References appendiceal tumor: a case report. World J exclude actinomycotic infection as these Gastroenterol 2010;16:395-7. abscesses form centrally with surrounding neu- 1. Wang HB, Yeh CL, Hsu KF. Spontaneous 13. Sperling, RL, R Heredia, WJ Gillesby, et al. trophils. The presence of dense fibroticNon-commercial tissue on rupture renal angiomyolipoma with hemor- Rupture of the spleen secondary to biopsy may be the only clue to the true diagno- rhagic . Intern Med 2009;48:1111-2. Actinomycosis. Arch Surg 1967;94:344-8. sis. Even intra-operatively, multiple biopsies of 2. Lopater J, Hartung O, Bretelle F, Bastide C. 14. Akhan SE, Dogan Y, Akhan S, et al. Pelvic the abscess may be necessary to obtain a sample Management of angiomyolipoma vena cava actinomycosis mimicking ovarian malig- showing sulfur granules and increased vigilance thrombus during pregnancy. Obstet nancy: three cases. Eur J Gynaecol Oncol should be taken as normal tissues planes may be Gynecol. 2011;117:440-3. 2008;29:294-7. distorted.18 When accurately diagnosed, actino- 3. Kontos S, Politis V, Fokitis I, et al. Rapture of 15. Pusiol T, Morichetti D, Pedrazzani C, Ricci F. myces infection has an excellent response with renal angiomyolipoma during pregnancy: a Abdominal-pelvic actinomycosis mimicking intravenous penicillin for 4-6 weeks followed by case report. Cases J 2008;1:245. malignant neoplasm. Infect Dis Obstet oral penicillin for or amoxicillin for 6-12 months. 4. Koh JL, Lee YH, Kang CY, Lin CN. Gynecol 2011;2011:747059. Erythromycin or clindamycin are acceptable Simultaneous cesarean section and radical 16. Dieckmann KP, Henke RP, Ovenbeck R. alternatives for penicillin allergic patient. nephrectomy for angiomyolipoma with Renal actinomycosis mimicking renal carci- Tetracylin is also acceptable for the non-preg- spontaneous bleeding during pregnancy: a noma. Eur Urol 2001;39:357-9. nant patient. case report. J Reprod Med 2007;52:338-40. 17. Smego RA Jr, Foglia G. Actinomycosis. Clin Due to low index of suspicion for actinomy- 5. Horino T, Yamamoto M, Morita M, et al. Infect Dis 1998;26:1255-61. cotic infection and patient’s clinical instability at Renal actinomycosis mimicking renal 18. Khalaff H, Srigley JR, Klotz LH. Recognition post-partum presentation, definitive diagnosis tumor: case report. South Med J 2004;97: of renal actinomycosis: nephrectomy can be was not obtained prior to surgical procedure. 316-8. avoided. Report of a case. Can J Surg However, we hope that other clinicians will be 6. Monzón A, Alvarez Múgica M, Seco Navedo 1995;38:77-9. [page 8] [Infectious Disease Reports 2014; 6:5157]