An Interesting Case Series of Actinomycosis Masquerading as Ovarian Cancer

Introduction Pelvic actinomycosis although rare occurs almost only in women. It may mimic pelvic malignancies, which often makes it difficult to diagnose. Case Series Case 1: A 34-year-old lady with diabetes mellitus was admitted with complaints of abdominal distension and swelling on anterior abdominal wall since 1 month. On examination, patient had pallor. On per abdominal examination, a sinus was noticed over the anterior abdominal wall over left iliac fossa with minimal discharge. Vague abdominopelvic mass was palpated over lower abdomen. MRI abdomen and pelvis showed large solid predominantly T2 hyperintense mass lesion 7.2 x 5.8.5.9 cm seen arising from right ovary infiltrating the right lateral wall with infiltration of mass into the preperitoneal plane CA 125 being 124. Cytology for malignant cells from sinus discharge and ascitic fluid was inconclusive. Image-guided biopsy taken from ovarian mass was also inconclusive. Laparotomy showed right ovarian complex cyst and left simple cyst. Uterus was bulky. Omental nodules, peritoneal nodules and nodules are noticed on serosal surface of rectum. Right ovarian mass was densely adherent and infiltrating the anterior abdominal wall, uterus, appendix and greater omentum. Patient underwent primary cytoreduction and abdominal wall sinus excision en masse. Postoperatively, histopathologic examination was suggestive of actinomycosis. She was treated with penicillin antibiotics and recovered. Case 2: 36-year-old female with diabetes on insulin presented with complaints of lower abdominal pain. On examination, patient was pallor, prognathism and abdomen examination showed 6*4 cm mass on the lower anterior abdominal. Pelvic examination shows large nodule felt on pouch of douglas. Blood investigation shows normal basic parameters, Ca125-30 IU/ml. CT scan of the abdomen demonstrated a 6*5 cm mixed density lesion arising from the left adnexa with dense adhesions to the anterior abdominal wall and multiple nodularities in the omentum. MRI brain-there was mass lesion in suprasellar region s/o pituitary macroadenoma. FNAC from pod nodule and image-guided biopsy was inconclusive. Case was discussed in multidisciplinary meeting and planned for diagnostic laparoscopy. Patient who underwent diagnostic laparoscopy intraoperatively decided to perform primary cytoreduction. Post op histopathology was suggestive of actinomycosis. Patient was started on Inj. penicillin and further evaluated for the pituitary lesion. Conclusions Actinomycosis can masquerade as pelvic malignancy, and a high index of suspicion should be there when biopsy is inconclusive and history of IUD insertion present.