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Case Report
Revised

Case Report: Acute large bowel obstruction with actinomycosis of the sigmoid colon mimicking neoplasm

[version 2; peer review: 2 approved]
PUBLISHED 29 Aug 2024
Author details Author details
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Abstract

Introduction

Actinomycosis is an uncommon inflammatory bacterial disease caused by Actinomyces species, especially Actinomyces Israeli. Abdominopelvic forms are relatively rare and may involve the colon as a solid mass, mimicking a malignant tumor.

Case presentation

A 68-year-old Tunisian man, with a history of diabetes, hypertension, penicillin allergy, and renal failure, presented to the emergency department with abdominal pain, vomiting, and bowel obstruction. CT scan showed an acute intestinal obstruction upstream with obstructive tissular mass at the sigmoid colon. Emergency surgery revealed a sigmoid mass and a pre-perforative cecum. Total colectomy was performed, with ileostomy and distal end closure. Histological examination confirmed Actinomyces infection. The patient was then placed on long-term doxycycline and Bactrim, with no recurrence over a 9-month follow-up period.

Conclusion

Abdominal actinomycosis, though rare, presents diagnostic challenges. It can be mistaken for malignancy, leading to unnecessary surgery in non-complicated cases, since it is effectively treated by antibiotics. In complicated cases, a combined approach involving both surgery and antibiotic therapy is necessary until the infection is completely eradicated.

Keywords

Abdominal actinomycosis, actinomyces, acute intestinal obstruction, antibiotic therapy, surgery.

Revised Amendments from Version 1

We added that the patient is not an alcohol or tobacco user.
We also added Serum HbA1c level at admission.
We added that there are no immunosuppressive factors other than diabetes mellitus.
We made a grammatical correction by replacing “we underwent” with “the patient underwent”.
We corrected a mistake in the abstract, replacing “subtotal colectomy” with “total colectomy”.

See the authors' detailed response to the review by Mhasisielie Zumu and Dr Arun RS
See the authors' detailed response to the review by Prajwal Dahal

Introduction

Actinomycosis is an uncommon inflammatory bacterial disease caused by Actinomyces Israeli, a Gram-positive anaerobic bacterium typically found in the digestive and genital tracts. This condition is often mistaken for a tumor or presents as an inflammatory mass. It can also lead to the formation of abscesses.1 The progression is slow and insidious, with local inflammation extending across different organs without confinement to a single one.2 Actinomyces typically colonizes the oral cavity, bronchi, gastrointestinal and female genital tracts. In the gut, it preferentially involves the stagnated zones, notably the caecum, the appendix, and the sigmoid colon. Clinical manifestations and radiological findings are nonspecific.3 Since acute and complicated forms require early treatment, most forms are diagnosed postoperatively. In this case report, we present a rare occurrence of colonic actinomycosis mimicking neoplasm and causing acute large bowel obstruction.

Case presentation

A 68-year-old non-smoking non-alcoholic Tunisian man, with a history of diabetes, hypertension, penicillin allergy, and renal failure, with no prior surgical history, presented to the emergency department with abdominal pain, vomiting, and bowel obstruction. The patient reported a similar symptomatology over the last two months, which resolved spontaneously. He also complained of chronic abdominal discomfort. On examination, he was hemodynamically stable. There was no fever. The abdominal examination revealed a distended and resonant abdomen, tender throughout, with a palpable mass in the left iliac fossa. The laboratory tests were normal, except for a previously known renal failure. Serum HbA1c level was 6%. We followed up with an abdominal CT scan without contrast, which revealed an acute intestinal obstruction upstream of a suspected obstructive tissue process at the sigmoid colon, with associated satellite lymph nodes and a dilated cecum measuring 12 cm (Figure 1). Emergency surgery was decided after a brief resuscitation. Exploration of the abdomen by midline laparotomy revealed a mass in the sigmoid loop, measuring 7 cm along its major axis, adherent to the omentum, the parietal peritoneum, and the posterior wall, with dilation of the entire upstream colonic frame. The cecum was dilated to 13 cm with a weakened, pre-perforative wall. The patient underwent a total colectomy with ileostomy and distal end closure (Figure 2). The postoperative recovery was uneventful. Gross pathologic examination of the surgical specimen revealed a stenosing lesion of the sigmoid colon with ulcerated surface mucosa. Histological examination showed acute inflammatory reaction and abscess formations surrounding clumps of short branching basophilic filaments stained with PAS (Periodic Acid Schiff). Dense fibrosis was associated. There was no granulomatous inflammation (Figures 3, 4). Actinomyces infection of the sigmoid colon was confirmed. The patient was then placed on long-term doxycycline and Bactrim. Upon follow-up, he was seen regularly for 9 months. No recurrence has been diagnosed. The restoration of bowel continuity was postponed until completing a full year of antibiotic therapy.

dc3f2dda-9023-4df9-9ebe-eadff0b41a94_figure1.gif

Figure 1. Abdominal CT scan showing acute intestinal obstruction with an obstructive tissular mass at the sigmoid colon (red asterixis).

dc3f2dda-9023-4df9-9ebe-eadff0b41a94_figure2.gif

Figure 2. Total colectomy specimen with a 7 cm obstructive solid mass of the sigmoid colon (white arrow).

dc3f2dda-9023-4df9-9ebe-eadff0b41a94_figure3.gif

Figure 3. Histological examination: Colonic actinomycosis with spherical cluster of actinomyces and a suppurative inflammation at the periphery (H&E ×200).

dc3f2dda-9023-4df9-9ebe-eadff0b41a94_figure4.gif

Figure 4. Densely packed filamentous bacteria arranged in clusters surrounded by polymorphic inflammatory cells (PAS Stain ×200).

Discussion

Actinomycosis is a rare granulomatous inflammation caused by Actinomyces species, especially Actinomyces Israeli, gram-positive anaerobic bacteria that are part of the normal human flora, colonizing the oral, digestive, and urogenital tracts.4,5

Actinomyces species have low virulence potential and require mucosal barrier disruption. This can occur after surgery, trauma, or in the presence of a foreign body, or in immunosuppression situations.6

All tissues may be infected, and we can distinguish four types of pre-ponderant infections, cervicofacial 50 to 60%, thoracic 15%, abdominopelvic 20%, and rarely disseminated disease.7

Actinomycosis commonly occurs between the ages of 20 and 60 years old and affects men three times more than women.8 Nevertheless, its incidence in women is increasing, associated with the rising use of intrauterine devices, reaching 75% of patients with pelvic actinomycosis in some studies.8

Abdominopelvic forms can mimic malignant tumors due to their chronic evolution. They have no specific clinical presentation and patients can consult for various symptoms such as chronic abdominal pain, abdominal mass, nausea, vomiting, anorexia, weight loss, and bleeding.9

This explains that it can evolve insidiously and manifest as a voluminous mass at the time of diagnosis.

Our case described an unusual presentation of abdominopelvic actinomycosis characterized by large bowel obstruction occurring in a 75-year-old patient with no risk factors cited above, except diabetes mellitus. It was due to a pseudotumoral sigmoid mass with a pre-perforative cecum.

Differential diagnoses in patients presenting with abdominal forms include appendicitis, diverticulitis, inflammatory bowel disease, tuberculosis, and bowel malignancies.10

Being a chronic suppuration, abdominal actinomycosis leads to the formation of multiple adjacent abscesses and to a large inflammatory reaction that can potentially invade neighboring tissues, appearing as a locally advanced tumor.6,10

In addition, being able to spread through hematogenous ways, actinomycosis may cause distant infections, mimicking distant metastasis.10

The management of abdominopelvic actinomycosis depends on its presentation.

The diagnosis can be suspected on CT scan findings, and confirmed after undergoing CT-guided puncture where Actinomyces species can be identified.

In such cases, the patient will undergo long-term antibiotherapy, such as parenteral penicillin G, followed by oral penicillin V or amoxicillin for up to 12 months. Alternative antibiotics like Tetracycline, Erythromycin or Clindamycin can be given in patients with penicillin allergy.

Generally, the prognosis is favorable and treatment efficacy is verified through ultrasonography or computer tomography.8,11,12

However, in most cases, actinomycosis is only diagnosed postoperatively. Indeed, confusion with a malignant mass, or manifestation in complicated forms, as in our observation, often leads to primary surgery.

According to the literature, actinomycosis involving the colon and presenting as acute abdomen or acute large bowel obstruction is rarely reported.

A review of the literature was conducted using the PubMed Database. We used “actinomycosis”, “colon”, “intestinal obstruction”, and “acute abdomen” as keywords. We excluded articles that reported extrinsic invasion of the colon, non-complicated colonic actinomycosis treated with antibiotics, and manuscripts not written in English.

A total of 15 articles were found between 1980 and 2024.

The most commonly affected colonic segments were the ascending colon and the transverse colon. In almost all reported cases, emergency surgery was performed and the diagnosis was made postoperatively. All patients received prolonged antibiotic therapy after surgery, with no reported recurrence.

In only one case, as detailed by Lin et al.,13 the diagnosis was made through endoscopic biopsy conducted during an episode of acute infectious colitis, suspected to be caused by actinomycosis infection. The patient was successfully treated with antibiotics and did not require surgery.

The details are summarized in Table 1.

Table 1. Literature review (1980-2024) of complicated colonic actinomycosis cases.

YearAuthorAgeM/FSizeLocalizationPresentation/ComplicationDiagnosisTreatment
2024Our case68M7 cmSigmoid colonAcute large bowel obstructionPostoperative anatomopathological examinationSurgery + antibiotic therapy
2023Lyew et al.1448F7.7 × 4.8 × 4.5 cmTransverse colon, small bowel, abdominal wallAbdominal pain, epigastric massPostoperative anatomopathological examinationSurgery + antibiotic therapy
2021Pamathy et al.640F9.7 × 4.5 cmTransverse colon + descending colonAcute large bowel obstructionPostoperative anatomopathological examinationSurgery + antibiotic therapy
2020Morais-Kansaon et al.1546F3.2 × 3.6 × 2.8 cmTransverse colonAcute abdominal painPostoperative anatomopathological examinationSurgery + antibiotic therapy
2020Jabi et al.1648M_Sigmoid colonAcute abdominal pain, fever, general health state deteriorationPostoperative anatomopathological examinationSurgery + antibiotic therapy
2019Hui et al.1735F8 cmCaecumAbdominal discomfort, fever, right iliac fossa massPostoperative anatomopathological examinationSurgery + antibiotic therapy
2018Yang et al.1055F_Sigmoid colonColon perforationPostoperative anatomopathological examinationSurgery + antibiotic therapy
2016García-Zúñiga et al.1841M_Distal ileum + ascending colonAcute abdominal pain, fever, diarrhea, weight lossPostoperative anatomopathological examinationSurgery + antibiotic therapy
2008Valko et al.1938F10 cmSigmoid colonAcute large bowel obstructionPostoperative anatomopathological examinationSurgery + antibiotic therapy
2007Saha et al.20___Transverse colonAcute abdominal painPostoperative anatomopathological examinationSurgery + antibiotic therapy
2006Jung2127F6 × 7 cmSigmoid colon + small bowel + mesenteryColon perforationPostoperative anatomopathological examinationSurgery + antibiotic therapy
2005Filippou et al.2272F5 × 5 cmCaecumPericolic abscessPostoperative anatomopathological examinationSurgery + antibiotic therapy
2005Işık et al.2328M8 × 6 cmAscending colonAcute abdominal pain + vomitingPostoperative anatomopathological examinationSurgery + antibiotic therapy
2004Bittencourt et al.2458M_Caecum + distal ileumAcute large bowel obstructionPostoperative anatomopathological examinationSurgery + antibiotic therapy
2003Lin et al.1345F_Caecum (mass)
Entire colon (colitis)
Acute abdominal pain, weight loss, diffuse colitisEndoscopic biopsyAntibiotic therapy
2000T.C.A Ferrari et al.2556F3 cm
15 cm
Transverse colon
Descending colon
Colon fistulizationPostoperative anatomopathological examinationSurgery + antibiotic therapy

In our particular case, emergency surgery was inevitable given the obstructive character of the sigmoid colon lesion. We underwent a total colectomy due to the pre-perforative lesions appearing on the cecum. Due to anatomopathological findings, he was prescribed long-term antibiotherapy based on doxycycline and Bactrim regarding his penicillin allergy.

Despite appropriate treatment, abdominal actinomycosis may recur and patients should be followed up. Currently, there is no standardized protocol for this monitoring. However, patients should at least undergo ultrasonography or computed tomography after treatment.12

Conclusion

Abdominal actinomycosis, though rare, presents diagnostic challenges. It can be mistaken for malignancy, leading to unnecessary surgery in non-complicated cases. The diagnosis should be considered when there is an abdominal mass with local invasion signs, whether or not an infectious syndrome is present. As a result, all efforts should be made to confirm the diagnosis. Once the diagnosis is certain through microbiological or pathological examinations, antibiotic treatment with penicillin should be started, lasting for six to 12 months, depending on the extent of the infection. This extended treatment duration helps reduce the risk of recurrence and often completely resolves the lesions. In complicated cases, a combined approach involving surgery and antibiotic therapy is necessary until the infection is completely eradicated.

Ethical approval statement

Written informed consent was obtained from the patient for the publication of this case report and the accompanying images.

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Hajri M, Zouari R, Mallek I et al. Case Report: Acute large bowel obstruction with actinomycosis of the sigmoid colon mimicking neoplasm [version 2; peer review: 2 approved]. F1000Research 2024, 13:669 (https://doi.org/10.12688/f1000research.151907.2)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 2
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PUBLISHED 29 Aug 2024
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Reviewer Report 12 Sep 2024
Mhasisielie Zumu, Medical Gastroenterology, The Madras Medical Mission, Chennai, Tamil Nadu, India 
Dr Arun RS, Medical Gastroenterology, The Madras Medical Mission Hospital, Chennai, Tamil Nadu, India 
Approved
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Thank you for addressing the concerns in version 1. ... Continue reading
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Zumu M and RS DA. Reviewer Report For: Case Report: Acute large bowel obstruction with actinomycosis of the sigmoid colon mimicking neoplasm [version 2; peer review: 2 approved]. F1000Research 2024, 13:669 (https://doi.org/10.5256/f1000research.170479.r318558)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Reviewer Report 21 Aug 2024
Prajwal Dahal, Grande International Hospital, Tokha, Kathmandu, India 
Approved
VIEWS 6
I would like to congratulate the author for writing a comprehensive case report in a entity that is less encountered in clinical practice. The manuscript adds on our current knowledge of actinomycosis infection of bowel and  stimulates clinicians and radiologists ... Continue reading
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Dahal P. Reviewer Report For: Case Report: Acute large bowel obstruction with actinomycosis of the sigmoid colon mimicking neoplasm [version 2; peer review: 2 approved]. F1000Research 2024, 13:669 (https://doi.org/10.5256/f1000research.166599.r311560)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 30 Aug 2024
    Mohamed Hajri, Visceral surgery, University Hospital Center Mongi Slim, La Marsa, Tunisia
    30 Aug 2024
    Author Response
    Thank you very much for your positive feedback and constructive suggestions. I appreciate your time and effort in reviewing my manuscript.
    1. I will include the values of vitals,
    ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 30 Aug 2024
    Mohamed Hajri, Visceral surgery, University Hospital Center Mongi Slim, La Marsa, Tunisia
    30 Aug 2024
    Author Response
    Thank you very much for your positive feedback and constructive suggestions. I appreciate your time and effort in reviewing my manuscript.
    1. I will include the values of vitals,
    ... Continue reading
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15
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Reviewer Report 22 Jul 2024
Mhasisielie Zumu, Medical Gastroenterology, The Madras Medical Mission, Chennai, Tamil Nadu, India 
Dr Arun RS, Medical Gastroenterology, The Madras Medical Mission Hospital, Chennai, Tamil Nadu, India 
Approved with Reservations
VIEWS 15
1) Details on blood sugar controlled, alcohol used, smoking, oral hygiene and history of prolonged used of PPI may be mentioned, if present.  
2) Serum HbA1c level at admission may be mentioned 
3) No risk factor of immunosuppression?  ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Zumu M and RS DA. Reviewer Report For: Case Report: Acute large bowel obstruction with actinomycosis of the sigmoid colon mimicking neoplasm [version 2; peer review: 2 approved]. F1000Research 2024, 13:669 (https://doi.org/10.5256/f1000research.166599.r299051)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 29 Aug 2024
    Mohamed Hajri, Visceral surgery, University Hospital Center Mongi Slim, La Marsa, Tunisia
    29 Aug 2024
    Author Response
    I am grateful for the time and effort you and the reviewers have invested in offering valuable feedback on my manuscript. I sincerely appreciate the reviewers' insightful comments on our ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 29 Aug 2024
    Mohamed Hajri, Visceral surgery, University Hospital Center Mongi Slim, La Marsa, Tunisia
    29 Aug 2024
    Author Response
    I am grateful for the time and effort you and the reviewers have invested in offering valuable feedback on my manuscript. I sincerely appreciate the reviewers' insightful comments on our ... Continue reading

Comments on this article Comments (0)

Version 2
VERSION 2 PUBLISHED 21 Jun 2024
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Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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