Unusual presentation of more common disease/injury BMJ Case Rep: first published as 10.1136/bcr-2018-229017 on 28 August 2019. Downloaded from Case report Tube-ovarian abscess caused by Rothia aeria Yusuke Taira, Yoichi Aoki Obstetrics and Gynecology, SUMMARY Subsequent gynaecological examination demon- University of the Ryukyus, Rothia aeria is a gram-positive amorphous bacillus and strated right lower abdominal tenderness with no Nishihara, Japan was discovered in the Russian space station ’Mir’ in rebound or cervical tenderness. 1997. It shows phylogenetic similarity to Actinomyces Her vital signs were as follows: body tempera- Correspondence to israelii, and as determined using 16 s ribosomal RNA ture, 38.1°C; blood pressure 112/58 mm Hg and Dr Yusuke Taira, h115474@ med. u- ryukyu. ac. jp gene analysis R. aeria is classified as a bacteria of heart rate, 86 beats/min. the genus Actinomyces. It was found to colonise in Vaginal speculum examination revealed a normal Accepted 19 July 2019 the human oral cavity, and there are some infectious discharge and normal vaginal portion of the cervix. reports but none specifies gynaecological infection. A Transvaginal ultrasound examination identi- 57-year-old woman, who had been continuously using fied multiple cystic masses in the right adnexa intrauterine contraceptive device, presented with fever (38×45 mm) and no ascites in the Douglas fossa, and lower abdominal pain. She was suspected tube- with normal uterus and left adnexa. ovarian abscess caused by A. israelii, but the uterine MRI revealed multiple cystic tumours with cavity culture revealed R. aeria infection. Considering contrast effect and thickening of the right adnexa surgical treatment, conservative treatment by intravenous wall (figure 1). benzylpenicillin and subsequently oral ampicillin for 6 months improved the abscess, and she has no recurrence TREATMENT for over 1 year. First, we administered cefmetazole (2 g/day) and clindamycin (1800 mg/day) intravenously according to the treatment protocol or severe pelvic perito- BACKGROUND nitis. On day 7 of hospitalisation, the antibiotics Rothia aeria, of the genus Actinomyces, was discov- were switched to ampicillin/sulbactam (12 g/day), ered in the Russian space station ‘Mir’ and was which are used for treating Actinomyces and anaer- found to colonise in the oral cavity.1 There are some obic infections, as an Actinomyces infection was infectious reports caused by R. aeria, but none spec- suspected based on the uterine cavity culture results. ifies gynaecological infection. To the best of our On day 12 of hospitalisation, R. aeria was detected http://casereports.bmj.com/ knowledge, this is the first report of a gynaecolog- in the same culture (figure 2), and thus the antibi- ical infection caused by R. aeria.2–4 otics were switched to benzylpenicillin (24 000 U/ day) according to previous reports on R. aeria infec- tion treatment.2–4 The benzylpenicillin treatment CASE PRESENTATION improved her fever and inflammation; therefore, A 57-year-old woman presented with fever and this conservative treatment was further continued. lower abdominal pain. She had been continuously After 6 weeks of intravenous benzylpenicillin using intrauterine contraceptive device (IUCD) for administration, the patient was discharged with 20 years without undergoing medical examina- a prescription for oral ampicillin (1500 mg/day). tion. She has been experiencing abnormal vaginal on September 23, 2021 by guest. Protected copyright. After 6 months of treatment with oral ampicillin, discharge for the past 1 year. Before admitting in her abdominal tenderness disappeared (figure 3). our hospital, she underwent medical examination in an internal medicine clinic and was administered levofloxacin to treat acute cystitis but her symptoms OUTCOME AND FOLLOW-UP did not improve. Subsequently, in another gynae- After 6 months of ampicillin therapy pelvic MRI cological clinic, she underwent transvaginal ultra- and transvaginal ultrasound revealed a complete sound examination that revealed a right adnexa response, and there was no recurrence for over tumour. She was then admitted in our hospital for 1 year. careful examination and treatment with a suspicion of tube-ovarian abscess, after the removal of her DISCUSSION IUCD. © BMJ Publishing Group R. aeria was isolated from the air of the Russian Limited 2019. Re-use permitted under CC BY-NC. No space station ‘Mir’; it is a gram-positive amorphous commercial re-use. See rights INVESTIGATIONS bacillus that was isolated in 2004. Unlike Actino- and permissions. Published Initial examination at our hospital revealed myces israelii, a gram-positive amorphous bacillus, by BMJ. the following results: white blood cell count, R. aeria grows aerobically. However, as it shows 9 To cite: Taira Y, Aoki Y. BMJ 15.7×10 /L ; haemoglobin level, 11.2 g/L; platelet phylogenetic similarity to A. israelii, as determined 9 Case Rep 2019;12:e229017. count, 36.3×10 /L ; procalcitonin level, 0.051 ng/ using 16 s ribosomal RNA gene analysis and as it doi:10.1136/bcr-2018- mL and C reactive protein (CRP) level, 31.91 mg/ is also a gram-positive amorphous bacillus, R. aeria 229017 dL. is classified as a bacteria of the genus Actinomyces. Taira Y, Aoki Y. BMJ Case Rep 2019;12:e229017. doi:10.1136/bcr-2018-229017 1 Unusual presentation of more common disease/injury BMJ Case Rep: first published as 10.1136/bcr-2018-229017 on 28 August 2019. Downloaded from Figure 1 Images obtained at the first examination. Transvaginal ultrasound examination identified multiple cystic masses in the right adnexa. MRI revealed multiple cystic tumours with contrast effect and thickening of the right adnexal wall. (A) Transvaginal ultrasound, (B) MRI T2-weighted image and (C) MRI fat suppression gadolinium contrast T1-weighted image. Gram-positive amorphous bacilli are classified into six genera: Molecular approaches such as mass spectrometry and DNA Corynebacterium, Propionibacterium, Eubacterium, Actino- sequencing are considered to diagnose accurately the infections myces, Bifidobacterium and Rothia. Furthermore, Rothia is clas- caused by R. aeria. sified into R. aeria (Li et al, 20041), Rothia amarae (Fan et al, Furthermore, Tsuzukibashi et al15 reported oral Rothia species 20025), Rothia dentocariosa (Onishi, 19496; Georg and Brown, selective medium as a new culture medium for the isolation and 19677), Rothia endophytica (Xiong et al, 20138), Rothia muci- possible easy detection of Rothia species from the oral cavity. laginosa (Collins et al, 2000), Rothia nasimurium (Collins et al, There are no comprehensive data on the drug susceptibility 9 10 2000 ) and Rothia terrae (Chou et al, 2008 ). of R. aeria; therefore, we selected antibiotics based on previous R. aeria is considered to reside in the oral cavity and pharynx, case reports. Tarumoto et al2 reported on R. aeria-induced similar to other Actinomyces species. Previously, Rothia had been infectious endocarditis and that it was susceptible to most 2 3 3 reported to cause infective endocarditis, neonatal bacteremias antibiotics except clindamycin and vancomycin. Monju et al 4 and respiratory infections in compromised hosts as opportu- reported that ampicillin and cefotaxime were active against nistic infections. Additionally, airway infection and haematoge- neonatal sepsis caused by R. aeria. Using drug susceptibility nous dissemination by intrinsic infection were reported to be the tests, R. aeria demonstrated good sensitivity against most 3 4 infection routes. antibiotics except for clindamycin. Hiyamuta4 reported on a However, there are no reports on gynaecological infections respiratory infection caused by R. aeria that was successfully caused by R. aeria. In this case R. aeria was not detected in the treated with benzylpenicillin. They found no reports of drug oral cavity, and the patient had no history of steroid administra- resistance, and similar to Actinomyces, R. aeria’s sensitivity to http://casereports.bmj.com/ tion or immunodeficiency from HIV infection. benzylpenicillin was good. Generally, Actinomyces infection in the gynaecological organs Tube-ovarian abscess was treated by the conservative admin- manifests as chronic pyogenic granuloma caused by Actinomyces istration of antibiotics, considering the timing of surgical israelii. Intrauterine devices are a known risk factor for such 11 intervention. After removal of the IUCD, which was consid- infections . ered to be the cause of infection in this case, and after initi- However, the long-term use of intrauterine devices is only the ating antibiotic therapy, leucocyte count, CRP level and fever common risk factor for Actinomyces infection in gynaecological gradually decreased, and the patient’s entire body condition organs. The transanal and transperineal infectious routes are improved. Therefore, surgical intervention was deemed inessen- believed to be responsible with regard to such infections. tial. However, there was a possibility of reducing the duration The causative bacterium in this case was identified using mass of antibiotic treatment by surgical intervention, and we should on September 23, 2021 by guest. Protected copyright. spectrophotometry (VITEK MS, Sysmex bioMérieux), and the have made an effort to reduce the risk of incidence of antibiot- bacterial DNA sequence was confirmed using ABI PRISM 310 ic-resistant bacteria, considering injury to other organs due to Genetic Analyzer. Actinomyces infection is difficult to detect strong adhesions. based on bacterial culture tests12;