British Journal of Obstetrics and Gynaecology February 1985, Vol. 92, pp. 17(L172

Malakoplakia of the pelvic peritoneum in pregnancy. Case report

GILLIAN ROSE Registrar in Obstetrics and Cynaecology, ELSPETH A. MORRISON Senior Registrar in Pathology, NlGEL KJRKHAM Consultant Pathologist 6; RODNEY MACHLING Senior Chief MLSO, Department of Histopathology, Royal Sussex County Hospital, Brighton

Case report The patient was a 30-year old Mauritian woman, resident in England for 10 years. In 1978 she had an emergency caesarean section, in labour, for fetal distress. No intra-abdominal abnormality was noted. In 1981 an attack of lower abdominal pain led t o a laparotomy and appendicectomy. The fallopian tubes appeared mildly inflamed, but were not biopsied. The appendix showed mild serosal inflammation but no evidence of malakoplakia. In 1Y82 she aborted at 11 weeks gestation; thc curcttings did not show malakoplakia.

In 1983 she became pregnant for the third time. At 20 weeks gestation she was admitted complaining of a sudden attack of suprapubic and bilateral loin pain, together with frequency, dysuria, diarrhoea and vomiting. She was apyrexial and distressed, with tenderness and guarding in the lower abdomen and tenderness in the right renal angle. A mid-stream urine culture (MSU) revealed a significant (>lo5 bac- teriaiml) growth of coliform bacteria; the infec- tion responded clinically to ampicillin. During the 33rd week of pregnancy she was re-admitted with generalized abdominal pain mainly localized in the epigastrium and right iliac fossa. There were no associated urinary symptoms. A further MSU was sterile. A cystoscopy was not performed. The pain settled without further treatment.

The pregnancy then proceeded uneventfully until 39 weeks when an elective caesarean sec- tion was performed in view of her previous sec- tion and a narrow funnel-shaped pelvis shown on X-ray pelvimetry. All of the pelvic organs were

Correymv.kncc: N . Kirkham, Department of ITisto- pathology, Royal Sussex County Hospital, Eastern Road, Brighton BN2 SBE.

found to be covered in a brown film which con- tained many small brown tomato seed-like nod- ules The filmy plaques peeled easily off the visceral peritoneum. A biopsy showed typical features of malakoplakia, with sheets of large histiocytes predominating. The cytoplasm of the histiocytes was granular. Sections stained with methanamine silver and PAS methods showed a mixture of small and large granuleq. The larger granules showed the microspherular appearance of Michaelis-Gutmann bodies (Fig. 1). The patient made an uneventful recovery.

Discussion Malakoplakia is an unusual form of histiocytic inflammatory reaction found in association with coliform infections. It was originally described at the turn of the century (Michaelis & Gutmann 3902; von Hansemann 1903). The term refers to the soft yellowish-brown plaques which charac- terize the condition. They are found in numer- ous sites including the urinary bladder, the gall bladder, the colon, the endometrium and the testis (Thomas et uf. 1978). The plaques consist of large numbers of histiocytes which have PAS- positive cytoplasm, often containing Michaelis- Gutmann bodies. Electron microscopy shows that bacteria are present within the cytoplasm of these cells and also within the Michaelis-Gut- mann bodies (McClurg et al. 1973, Willen et al. 1983).

It seems to be unlikely that these patients are infected by an unusual strain of coliform or have a defect of cell-mediated immunity. An abnor- mality of intra-cellular digestion of the pha- gocytosed bacteria is the most likely explanation (Lou & Tepitz 1974; Thorning & Vracko 1975; Lewin et af. 1976). The bacteria are found within the cells, in large phagolysosomes, which even-

170

Pelvic malakoplakia in pregnancy 171

Fig. 1. Sheets of histiocytes contain granular material in their cytoplasm. Methanamine silver magnification X 128. Insets: similar Michaelis-Gutmann bodies. Methanamine silver magnification X 320.

tually become mineralized, forming concentric spherules which we recognize as Michaelis-Gut- mann bodies. These stain positively for iron and calcium.

Although very occasional fatal cases have been reported the condition seems to be self limiting, especially after appropriate antibiotic treatrncnt (Yunis et al. 1967). One case of recur- rent endometrial malakoplakia has been reported in an elderly diabetic patient (Molnar & Poliak 1983).

The present patient appears to be the first reported in which the serosal surface of the pel- vic organs has been involved. The patient suf- fered from a coliform urinary tract infection during pregnancy. The character of the patient’s symptoms was consistent with a urinary tract infection, but it is possible that the reaction pre- sent in the pelvic peritoneum was responsible for her attacks of lower abdominal pain. Ncverthe- less in the presence of proven infection, no further treatment appears to be indicated over and above appropriate antibiotic therapy.

Acknowledgment

We would like to thank Mr J . F. Bostock for permission to report this case, Martha Bush for

performing a literature search and Mrs V. Mar- shall for typing the manuscript.

References

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McClurg, F. V., D’Agostino, A. N . , Martin, J . 11. & Race, G. J . (1973) Ultrastructural demonstration of intra cellular bacteria in three cases mal- akoplakia of the bladder. AniJ Clin Pnthol60,780- 788.

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Received 29 March 1984 Accepted 13 Junp 1984