2019 Research Forum

Carlos D’Assumpcao MD R1, Matthew Gilbert MS IV, Arash Heidari MD Tubo-Ovarian Abscess on Fire Kern Medical, Bakersfield, CA

Discussion Corynebacterium species • Aerobic G-positive bacilli • Often a contaminant Coryneform bacteria • Gram-positive rods • Diphtheroids • Corynebacterium species Growth characteristics • Aerobic • Asporogenous • Non-partially-acid-fast

Case Presentation Continued

Introduction

She returned one week later with dyspnea. Due to respiratory failure and sepsis she was intubated.

Tubo-ovarian abscess: • a complex polymicrobial adnexal infection • a sequela of an ascending pelvic inflammatory disease

Imaging showed left sided subdiaphragmatic and loculated pleuritic abscess. CT guided chest tubes and abdominal drain were placed. Cultures grew Prevotella disiens , Candida albicans and Corynebacterium species. Vancomycin, piperacillin/tazobactam, and micafungin were started. Corynebacterium species and Candida glabrata and albicans were sent for sensitivities. Due to continued septic shock she underwent exploratory laparotomy, total abdominal hysterectomy with bilateral-oopherectomy, adhesiolysis. Pathology confirmed tubo- ovarian abscess. After 18 hospital days, patient was discharged with a 14 day course of amoxicillin/clavulanate. Speciation and sensitivities of Corynebacterium species returned one week after discharge with Actinomyces europaeus sensitive to penicillin. Amoxicillin 1000mg was started with plan for 6 months course. One week later, patient returned with recurrent culture negative left pleural effusion that was successfully drained. Patient was discharged with close outpatient follow up.

Most commonly recovered bacteria: • Escherichia coli • Bacteroides fragilis and others spp . • Peptostreptococcus • Peptococcus • Aerobic stretococci

Treatment options: • total abdominal hysterectomy and bilateral salpingo-oophorectomy • conservative intravenous antibiotics and drainage. This is a case of a tubo-ovarian abscess causing recurrent intraabdominal and intrathoracic abscesses due to coryneform Actinomyces europaeus .

• Irregularly shaped G-positive rods • Some may have branching filaments

CT imaging showing progression of

Actinomyces europaeus • First described in 1997 • Facultative anaerobes • Short Gram-positive rods with irregular morphology • No filament formation • ID in 48 hours in aerobic and anaerobic conditions

intraabdominal into intrathoracic abscess despite maximal medical management.

Top: coronal. Bottom: sagittal.

Learning Objectives

Actinomyces spp. • Facultative anaerobic • G-positive bacilli • Filamentous • Slow growth (10 days incubation)

Petri dish at 48 hours incubation. Coryneform A. europaeus at 10x magnification

Physicians should be aware of fast growing facultative anaerobe coryneform bacteria like Actinomyces europaeus and others, as it can change long term clinical outcomes.

Typical Actinomycosis examples: • Dental abscess • Pelvic IUD abscess • Pulmonary abscess in smokers with poor dental hygiene • Malignancy mimic at other anatomical sites • Necrosis with sulfur granules • Require prolonged high doses of penicillin G or amoxicillin References Funke G et al. Actinomyces europaeus sp. nov., isolated from human clinical specimens. Int J Syst Bacteriol. 1997 Jul;47(3):687-92. Funke G et al. Clinical microbiology of coryneform bacteria. Clin Microbiol Rev. 1997 Jan;10(1):125-59. Kairys N, Roepke C. Abscess, Tubo-Ovarian. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. 2017 Oct 13. Valour F et al. Actinomycosis: etiology, clinical features, diagnosis, treatment, and management. Infect Drug Resist. 2014 Jul 5;7:183-97. Acknowledgements Authors wish to acknowledge the contributions of Joan Buddecke for assistance with the literature search and Danna Mejia for microbiological guidance.

Case Presentation 49 year old female with history of endometriosis and methamphetamine abuse and multiple abdominal surgeries presented with left lower quadrant abdominal pain, fever, nausea, abdominal distension and vaginal bleeding. Imaging revealed multiple pelvic and intraabdominal abscesses. Empiric ciprofloxacin, ceftriaxone and then metronidazole were started. Source control was attempted with CT guided drainage. Cultures grew Peptostreptococcus prevotii , Prevotella melaninogenica , Corynebacterium species. Vancomycin, piperacillin/tazobactam and gentamicin were added to metronidazole. Unfortunately, she left against medical advice.

Hospital visit 1

Hospital visit 2

Hospital visit 3

Coryneform genera

Corynebacteria, Turicella, Arthrobacter, Brevibacterium, Dermabacter, Propionibacterium, Rothia, Exiguobacterium, , Oserskovia, Cellulomonas, Sanguibacter, Microbacterium, Aureobacterium, Aracnobacterium, Actinomyces (A. pyogenes, A. neuii, A. bernardiae, A. radingae-A.turicensis complex) (Funke et al 1997)

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