Figure 1.
Contrast-enhanced computed tomography (CT) revealed roughening and thickening of the sigmoid colon and upper rectum walls, with luminal narrowing and uneven enhancement. In conjunction with laboratory examination (RBC 2.95 × 1012/L, Hb 80 g/L, WBC 12.3 × 109/L, CRP 53.44 mg/L, CEA 1.73 ng/mL, AFP3.64 ng/mL, CA125 19.2 U/mL, CA19-9 8.83 U/mL), CT indicated possible inflammatory lesions with pelvic lymph node enlargement.
Figure 1.
Contrast-enhanced computed tomography (CT) revealed roughening and thickening of the sigmoid colon and upper rectum walls, with luminal narrowing and uneven enhancement. In conjunction with laboratory examination (RBC 2.95 × 1012/L, Hb 80 g/L, WBC 12.3 × 109/L, CRP 53.44 mg/L, CEA 1.73 ng/mL, AFP3.64 ng/mL, CA125 19.2 U/mL, CA19-9 8.83 U/mL), CT indicated possible inflammatory lesions with pelvic lymph node enlargement.
Figure 2.
Positron emission tomography–computed tomography (PET-CT) reveals an irregular high-density mass in the pelvic mesentery, forming a ‘C’ shape enveloping the sigmoid colon from the right, with unclear demarcation from the sigmoid colon and markedly increased FDG uptake. FDG can be used as an important indicator to distinguish benign and malignant lesions by reflecting the level of glucose metabolism in the lesion, but it does not have absolute specificity. Tuberculosis and inflammatory lesions can also show increased FDG. There may be chronic granulation tissue hyperplasia near actinomycete abscesses or sinuses, and the infiltration of various inflammatory cells, tissue cells, and fibroblasts, resulting in high uptake of 18F-FDG.
Figure 2.
Positron emission tomography–computed tomography (PET-CT) reveals an irregular high-density mass in the pelvic mesentery, forming a ‘C’ shape enveloping the sigmoid colon from the right, with unclear demarcation from the sigmoid colon and markedly increased FDG uptake. FDG can be used as an important indicator to distinguish benign and malignant lesions by reflecting the level of glucose metabolism in the lesion, but it does not have absolute specificity. Tuberculosis and inflammatory lesions can also show increased FDG. There may be chronic granulation tissue hyperplasia near actinomycete abscesses or sinuses, and the infiltration of various inflammatory cells, tissue cells, and fibroblasts, resulting in high uptake of 18F-FDG.
Figure 3.
The preoperative ultrasound detection of pelvic mass: (A) ultrasound detection of a mass of about 8.8 × 4.4 × 4.8 cm in the right adnexa, with abundant blood flow signals, RI: 0.65. (B) The mass is not clearly demarcated from the rectum, sigmoid colon, and sacroiliac ligament. (C) Ultrasound shows thickening and decreased echo of the intestinal wall behind the uterus, with abundant blood flow. (D) Multiple enlarged lymph nodes in the bilateral iliac fossa. (E) A copper-bearing intrauterine contraceptive device, in the normal position. (F) The size and shape of the left ovary are acceptable.
Figure 3.
The preoperative ultrasound detection of pelvic mass: (A) ultrasound detection of a mass of about 8.8 × 4.4 × 4.8 cm in the right adnexa, with abundant blood flow signals, RI: 0.65. (B) The mass is not clearly demarcated from the rectum, sigmoid colon, and sacroiliac ligament. (C) Ultrasound shows thickening and decreased echo of the intestinal wall behind the uterus, with abundant blood flow. (D) Multiple enlarged lymph nodes in the bilateral iliac fossa. (E) A copper-bearing intrauterine contraceptive device, in the normal position. (F) The size and shape of the left ovary are acceptable.
Figure 4.
(
A) A gradual reduction in the mass. (
B) The eventual resolution of the mass, confirming a diagnosis of Actinomyces infection. Pelvic actinomycosis, a rare subacute to chronic granulomatous disease, constitutes approximately 3% of all actinomycosis cases [
1]. Long-term IUD placement can lead to endometrial damage, facilitating the invasion of Actinomyces into the subendometrial layer. This invasion often extends to the fallopian tubes and ovaries, where Actinomyces secrete protein hydrolases that can exert a malignancy-like invasive effect and provoke an infection-like inflammatory response [
2]. The clinical and imaging features of pelvic actinomycosis are not distinct, making its diagnosis challenging. Preoperative diagnosis is accurate in less than 10% of cases [
3]. Although the imaging characteristics of pelvic actinomycosis are not unique, they also have some similar features with other diseases [
2,
4]. CT may reveal a thick-walled cystic or solid mass with heterogeneous enhancement. Ultrasound typically shows cystic–solid mixed echoes with abundant blood flow signals. In the early stages, the disease may present as an isolated mass. As the disease progresses, the mass enlarges, invading and compressing adjacent organs, and becomes increasingly irregular in shape and poorly demarcated from surrounding structures, complicating preoperative diagnosis. The affected intestinal wall may exhibit echogenic signs of inflammation due to invasion. The urinary tract can also demonstrate fluid dilatation due to compression and obstruction. On PET/CT, the mass often displays high fluorodeoxyglucose (FDG) uptake. Reflecting on this case, the localization of the lesion posed significant challenges. The copious inflammatory exudate and extensive adhesions within the pelvis obscured clear demarcation on tomographic images. Consequently, based on the patient’s prolonged gastrointestinal symptoms, both CT and PET-CT erroneously suggested an intestinal tract and mesentery origin. In contrast, ultrasonography, employing real-time scanning through various modalities and perspectives, accurately localized the lesion to the right adnexal region. Qualitatively, differentiating this disease from ovarian malignancy and pelvic tuberculosis is exceptionally challenging. Continuous differentiation throughout the course of the disease is imperative, especially considering the high failure rate (up to 50%) of Actinomyces cultures [
1]. This necessitates extreme caution in postoperative pathological differentiation. Patients with ovarian cancer, predominantly older women, typically present with abdominal pain, distension, and cachexia, often lacking symptoms like chills and high fever. These cases are characterized by a marked elevation in CA125 levels. Unlike the extensive adhesions and sinus tract formation in the late stage of actinomycosis, larger ovarian tumors on imaging are often accompanied by significant abdominal or pelvic effusions and extensive lymphadenopathy. In this case, real-time dynamic ultrasound provided distinct advantages in determining the origin of the mass, assessing the extent of pelvic adhesions, and evaluating the involvement of surrounding tissues. It was also preferred for post-surgical efficacy assessment, playing a pivotal role throughout the diagnostic and treatment process.
Figure 4.
(
A) A gradual reduction in the mass. (
B) The eventual resolution of the mass, confirming a diagnosis of Actinomyces infection. Pelvic actinomycosis, a rare subacute to chronic granulomatous disease, constitutes approximately 3% of all actinomycosis cases [
1]. Long-term IUD placement can lead to endometrial damage, facilitating the invasion of Actinomyces into the subendometrial layer. This invasion often extends to the fallopian tubes and ovaries, where Actinomyces secrete protein hydrolases that can exert a malignancy-like invasive effect and provoke an infection-like inflammatory response [
2]. The clinical and imaging features of pelvic actinomycosis are not distinct, making its diagnosis challenging. Preoperative diagnosis is accurate in less than 10% of cases [
3]. Although the imaging characteristics of pelvic actinomycosis are not unique, they also have some similar features with other diseases [
2,
4]. CT may reveal a thick-walled cystic or solid mass with heterogeneous enhancement. Ultrasound typically shows cystic–solid mixed echoes with abundant blood flow signals. In the early stages, the disease may present as an isolated mass. As the disease progresses, the mass enlarges, invading and compressing adjacent organs, and becomes increasingly irregular in shape and poorly demarcated from surrounding structures, complicating preoperative diagnosis. The affected intestinal wall may exhibit echogenic signs of inflammation due to invasion. The urinary tract can also demonstrate fluid dilatation due to compression and obstruction. On PET/CT, the mass often displays high fluorodeoxyglucose (FDG) uptake. Reflecting on this case, the localization of the lesion posed significant challenges. The copious inflammatory exudate and extensive adhesions within the pelvis obscured clear demarcation on tomographic images. Consequently, based on the patient’s prolonged gastrointestinal symptoms, both CT and PET-CT erroneously suggested an intestinal tract and mesentery origin. In contrast, ultrasonography, employing real-time scanning through various modalities and perspectives, accurately localized the lesion to the right adnexal region. Qualitatively, differentiating this disease from ovarian malignancy and pelvic tuberculosis is exceptionally challenging. Continuous differentiation throughout the course of the disease is imperative, especially considering the high failure rate (up to 50%) of Actinomyces cultures [
1]. This necessitates extreme caution in postoperative pathological differentiation. Patients with ovarian cancer, predominantly older women, typically present with abdominal pain, distension, and cachexia, often lacking symptoms like chills and high fever. These cases are characterized by a marked elevation in CA125 levels. Unlike the extensive adhesions and sinus tract formation in the late stage of actinomycosis, larger ovarian tumors on imaging are often accompanied by significant abdominal or pelvic effusions and extensive lymphadenopathy. In this case, real-time dynamic ultrasound provided distinct advantages in determining the origin of the mass, assessing the extent of pelvic adhesions, and evaluating the involvement of surrounding tissues. It was also preferred for post-surgical efficacy assessment, playing a pivotal role throughout the diagnostic and treatment process.
![Diagnostics 14 01923 g004]()
Author Contributions
Conceptualization, L.H. and W.X.; methodology, L.H.; validation, L.H. and W.X.; formal analysis, L.H.; investigation, L.H.; resources, L.H.; data curation, L.H.; writing—original draft preparation, L.H.; writing—review and editing, W.X.; visualization, L.H.; supervision, W.X.; project administration, W.X.; funding acquisition, W.X. All authors have read and agreed to the published version of the manuscript.
Funding
This research was funded by the Key Research and Development Project of the Science and Technology Department of Sichuan Province, grant number [2021YFS0381]. And The APC was funded by the Key Research and Development Project of the Science and Technology Department of Sichuan Province.
Informed Consent Statement
Written informed consent has been obtained from the patient(s) to publish this paper.
Data Availability Statement
No new data were created or analyzed in this study. Data sharing is not applicable to this article.
Conflicts of Interest
The authors declare no conflicts of interest.
References
- Adhlakha, B.; Khageshan, A.P.; Pradhan, S.; Singh, A.K. Pelvic actinomycosis mimicking an advanced ovarian carcinoma: A rare case report with review of literature. Int. Surg. J. 2021, 8, 2199–2202. [Google Scholar] [CrossRef]
- García-García, A.; Ramírez-Durán, N.; Sandoval-Trujillo, H.; Romero-Figueroa MD, S. Pelvic actinomycosis: A confusing diagnosis. Int. J. Surg. Case Rep. 2021, 86, 106387. [Google Scholar]
- Jones, P.; Ho, C.; Juliebø, S.Ø.; Hawary, A. Pelvic actinomycosis: A forgotten cause of pelvic pain. Br. J. Hosp. Med. 2020, 81, 1–8. [Google Scholar] [CrossRef]
- Xie, W.; Qi, L.; Huang, S. Misdiagnosis of actinomycetes liver abscess with ~(18)F-FDG PET/CT imaging: A case report. Chin. J. Med. Imaging 2020, 28, 790–791. [Google Scholar]
| Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. |
© 2024 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).