title: Huge pelvic mass, cutaneous and vaginal fistulas, and bilateral hydronephrosis: a rare presentation of actinomycosis with a good response to conservative treatment and with long-term sequelae of renal atrophy and hydronephrosis.
abstract: OBJECTIVE
  Actinomycosis with an extended pelvic abscess is an uncommon condition, which usually occurs coincident with the presence of an intrauterine contraceptive device (IUD) in the uterine cavity. The clinical picture of pelvic actinomycosis may vary between individuals, is often accompanied by complications, and is frequently misdiagnosed. Here, we report a case of pelvic actinomycosis, presenting as a huge pelvic mass and complicated by a vaginal fistula, a cutaneous fistula, and bilateral hydronephrosis, and we discuss the diagnosis and management of this patient.
  
  
  METHODS
  A 35-year-old woman was referred to our hospital with a huge pelvic complex mass and progressively worsening low abdominal pain. The tumor workup, which included a computed tomography (CT) scan, revealed an extended pelvic abscess and bilateral hydronephrosis. Both cutaneous and vaginal fistulas were also noted. Endometrial curettage and biopsies of the skin and vaginal lesions confirmed the diagnosis of actinomycosis. The patient underwent conservative treatment and recovered well, although the skin lesion only healed after 12 weeks of oral antibiotic treatment. At the 1-year follow-up, a CT scan showed sequelae including a mildly atrophic left kidney and left hydronephrosis.
  
  
  CONCLUSIONS
  In patients presenting with a pelvic mass and an IUD in the uterine cavity, the diagnosis of actinomycosis should be seriously considered. A detailed workup, including a CT scan, endometrial curettage and biopsies where possible, should be performed before surgery. Once diagnosis has been confirmed, conservative medical treatment should be attempted before considering laparotomy, to reduce the risk of complications. Despite successful treatment with antibiotics, long-term sequelae such as hydronephrosis and renal atrophy are possible in cases of extended pelvic actinomycosis.
authors.affiliation: Department of Obstetrics and Gynecology, Hsin Chu Mackay Memorial Hospital, Hsinchu, Taiwan.
authors.forename: Pu-Tsui
authors.initials: PT
authors.lastname: Wang
authors.forename: Shey-Chiang
authors.initials: SC
authors.lastname: Su
authors.forename: Fang-Yu
authors.initials: FY
authors.lastname: Hung
authors.forename: Shun-Long
authors.initials: SL
authors.lastname: Weng
authors.forename: Chih-Ping
authors.initials: CP
authors.lastname: Chen
mesh_terms: D000196:Actinomycosis / Q000150:complications*; D000328:Adult; D019980:Amoxicillin-Potassium Clavulanate Combination / Q000008:administration & dosage; D001284:Atrophy; D017577:Cutaneous Fistula / Q000000981:diagnostic imaging / Q000382:microbiology*; D005260:Female; D006801:Humans; D006869:Hydronephrosis / Q000382:microbiology*; D007434:Intrauterine Devices / Q000382:microbiology; D007668:Kidney / Q000473:pathology*; D010406:Penicillins / Q000008:administration & dosage; D014057:Tomography, X-Ray Computed; D014624:Vaginal Fistula / Q000000981:diagnostic imaging / Q000382:microbiology*
chemical_list: D010406:Penicillins; D019980:Amoxicillin-Potassium Clavulanate Combination