Pelvic inflammatory disease (PID) is one of the most commonly encountered serious infectious disease entities in gynecology. The past decade has witnessed many advances in our understanding of the pathogenesis of PID. It is now evident that such pelvic infections are largely polymicrobial in origin, with major involvement by anaerobic organisms. Salpingo-oophoritis is a part of the spectrum of PID. Included among this group of infections are tubo-ovarian abscesses, traditionally referred to as either gonococcal or non-gonococcal in origin. Within the latter group of infections the importance of anaerobic organisms has also been elucidated. Of particular interest is the reported observation of an increased frequency of salpingo-oophoritis among users of intrauterine devices (IUDs). These reports have noted the specific occurrence of serious pelvic infections due to Actinomyces species, and this will be the topic of the infectious disease conference. Our patient presented with a chronic illness characterized by lethargy, back pain, fever, and anemia; subsequently evaluation disclosed the presence of a large pelvic mass which was confirmed as a tubo-ovarian abscess at surgery. Histological evaluation demonstrated involvement by Actinomyces species. This patient's illness is discussed as a complication of chronic IUD usage with reference to specific management for this emerging problem.
PIP: A case history is reported of a 29-year old patient who presented with a chronic illness characterized by lethargy, back pain, fever, and anemia. Evaluation disclosed the presence of a large pelvic mass which was confirmed as a tubo-ovarian abscess at surgery. Histological evaluation demonstrated involvement by Actinomyces species. The patient's illness is discussed as a complication of chronic IUD usage with reference to specific management for this emerging problem. Data from the National Fertility Study conducted in 1973 revealed that nearly 2 million married women in the US, ages 15-44, were using IUDs. Scott noted the serious potentially fatal complications associated with IUD use, including pelvic inflammatory disease (PID), uterine perforation, ectopic pregnancy, and spontaneous or septic abortion. The relative risk of PID among IUD users has been reported to be increased 2-12 fold over controls. The risk of infection appears to increase as the period of IUD use lengthens, but the risk associated with the use of copper IUDs may be slightly less than with plastic IUDs. Actinomycosis has traditionally been described in 3 anatomical regions, the cervicofacial, thoracic, and abdominal areas, but pelvic and genital disease has been recognized with increasing frequency over the past decade. The common denominator associated with the latter syndrome appears to be the concurrent presence of an IUD. The Actinomyces are gram positive, nonacid fast, anaerobic, obligate parasites which are classified somewhere between the true bacteria and the complete fungi. Actinomyces species are not generally considered part of the normal vaginal flora but rather are associated with the presence of a foreign body, most often an IUD. It is thought that the IUD causes the initial tissue injury which permits subsequent colonization by these organisms. It is not known whether orogenital contact is a means of transmission of Actinomyces to the lower genital tract of sexual partners. One might estimate that the overall rate of cytological detection of A. israelii in cervical smears of IUD users at about 10%. This incidence increases sharply in patients being evaluated for symptomatic pelvic infection. Conversely, in women with IUDs in place and Actinomyces demonstrable in cervical smears, PID is up to 4 times as common as in those who have negative smears. Antibiotic treatment should probably be dictated by the clinical setting. As a general guide, the threshold for treatment should be low, since the therapy is relatively benign and the extent to which colonization and tissue invasion may have occurred is unknown.