Un c a s d ' a c t i n o m y c o s e p r i m i t i v e du c61on

A. DI SIMONE, P. E S P O S I T O University o f Naples, Chair o f Medical Pathology, D e p a r t m e n t o f Digestive E n d o s c o p y

Primitive actinomycosis of the colon: a case report

RI~SUMI~

Les auteurs rapportent une observation d'actinomycose, localis6e h la portion distale du c61on transverse. Ils discutent les m611hodes de diagnostic et pr6sentent une revue de la litt6rature.

SUMMARY

A case of Actinomycosis of the large bowel, involving the distal portion of the transverse colon, ts presented, along with a review of the subject.

L'act inomycose est une maladie infectieuse due Act inomyces Israelli, micro-organisme ana6robie

gram-positif, qui est l 'h6te habituel de la cavit6 buccale, en particulier au niveau des cryptes des amygdales et des dents cari6es. Ce micro-orga- nisme peut, apr6s une p6riode saprophyte prolon- g6e, devenir pathog~ne et entra~ner selon les loca- lisations, des 16sions inflammatoires cervico- faciales, ou plus ra rement h6patiques, intestinales et pulmonaires.

Un cas d 'act inomycose est rapport6, dont l 'inter- pr6tat ion fur difficile : le diagnostic de n6oplasme c61ique rut port6 en premier lieu, faute d 'avoir mis en 6vidence les 16sions typiques, constitu6es de multiples abc~s et fistules s6cr6tant les granules sulfur6s caract6ristiques.

O B S E R V A T I O N

Le malade est un homme de 69 ans, admis l 'h6pital pour des plaintes remontan t ~t 1 an : dou- leurs irr6guli6res et lancinantes de l 'hypocondre gauche, major6es avant les d6f6cations et les 6va- cuations intestinales incompl6tes ; modification du transit intestinal avec al ternance de constipation et de diarrh6e avec mucorrh6e. Le malade a pr6sent6 de faqon 6pisodique des vomissements contenant des aliments incompl6tement dig6r6s et il a perdu 6 kg en 5 mois.

A l 'examen clinique, la palpation profonde de l ' abdomen r6v61e dans l 'hypocondre gauche, une

tum6fact ion de 15 • 10 cm, dont le grand axe est parall~le au rebord costal, dont la consistance est dure et fibreuse et la surface irr6guli~re. La palpa- tion des autres quadrants de l ' abdomen ne r6v~le rien de particulier. Les tests biologiques sont nor- maux, sauf l'acc616ration de la vitesse de s6dimen- tation. Le lavement baryt6 r6v~le un remplissage incomplet et une motilit6 r6duite au niveau du c61on gauche (fig. 1).

Le patient a 6t6 soumis h une pancoloscopie, qui a mis en 6vidence au niveau de la partie distale du c61on transverse (~ environ 130 cm de l 'anus) une r6duction de 3 /4 du calibre de la lumi~re c61ique. A c e niveau, le relief muqueux pr6sente un aspect irr6gulier, non modifiable par l ' insufflation forc6e. Le diagnostic port6 est celui de st6nose organique de la port ion distale du c61on transverse avec infiltration pari6tale (fig. 2).

Le malade est adress6 au chirurgien avec le dia- gnostic pr6sum6 de cancer du c61on transverse.

La laparotomie r6v~le une volumineuse masse en amont de l 'angle spl6nique, tr~s adh6rente , 6 tendue au p6ri toine et ~t la couche musculaire p rofonde de la paroi abdominale , sur le versant post6ro-lat6ral et l 'hypocondre gauche. Une colec- tomie segmentaire a 6t6 r6alis6e, accompagn6e d 'une r6section partielle des plans musculaires adh6rant h la masse tumorale.

L ' examen histologique de la piece de r6section chirurgicale, cont ra i rement aux biopsies endoscopi- ques, a montr6 une scl6rose 6 tendue de la paroi

Tir6s h part : pr A. DI SIMONE, University of Naples, Chair of Medical Pathology, Dept. of Digestive Endoscopy, 1 ~ Policlinico, Piazza Miraglia, 80138 Napoli (Italia).

Mots-cl~s : actinomycose, c61on, coioscopie, tumeur. Key-words : actinomycosis, colon, colonoscopy, tumors.

Acta Endoscopica Volume 15 - N ~ 2 - 1985 175

Figure 2

Image endoscopique montrant le relief irreguher de la muqueuse et la r~duction du calibre de la lumiere cohque.

Endoscopic picture showing irregularity of the mucosal profile and decrease of the lumen.

Figure 1 Lavement baryt~: remplissage incomplet du cSIon transverse.

Barium-enema study, showing incomplete filling of the transverse colon.

intestinale contenant des foyers typiques d'actino- mycose. Ceux-ci se caract6risent par la prolif6ra- tion d'un enchev6trement de filaments myc61iens entour6s d'un exsudat contenant des neutrophiles en grande partie alt6r6s, avec la formation de cor- puscules de pus (fig. 3).

Le malade, revu environ 2 ans apr6s l'interven- tion chirurgicale, est exempt de sympt6mes et est en bonne sant6.

DISCUSSION

L'actinomycose du c61on est une maladie chroni- que rare, progressive, suppurative, dont les aspects cliniques sont multiples et variables.

Pour ces raisons, son diagnostic est difficile et la confusion avec d'autres maladies est commune [1, 5]. Certes, bien que l'actinomycose se pr6sente d'habitude comme une inflammation chronique localis6e associ6e gi de la fi~vre et de l'hyper- leucocytose, ce qui faisait d6faut dans notre obser- vation, la mise en 6vidence des multiples abc~s et fistules caract6ristiques s6cr6tant ce pus jaune granules sulfur6s, constitue un 616ment important du diagnostic. Quant ~t la pathog6nie, diff6rentes th6ories ont 6t6 propos6es pour expliquer la diffu- sion des micro-organismes dans les organes abdo- minaux.

Figure 3 Colonies d'actmomyces entourees de pus - - Hematoxylin Eosm x 25. Actinomycotic colony surrounded by pus. Hematoxylin and Eosin,

x 25.

L'actinomycose survient parfois apr~s une lapa- rotomie et sa localisation est typique au niveau de la fosse iliaque droite apr~s appendicectomie aigu6 ou drainage d'abc~s localis6 h cette r6gion [6, 10].

Parfois, au contraire, l'agent infectieux franchit la barri~re gastro-intestinale au niveau d'une 16sion traumatique et inflammatoire de la muqueuse et p6n6tre dans les tissus voisins{ll , 12].

Toutefois certains patients d6veloppent une acti- nomycose c61ique sans histoire clinique d'6pisode de traumatisme ou de maladie inflammatoire pr6-

176 V o l u m e 15 - N ~ 2 - 1 9 8 5 A c t a E n d o s c o p i c a

existante, et demeurent asympt6matiques pendant de nombreuses ann6es, comme ce fut le cas dans notre observation.

Les sympt6mes les plus fr6quents sont une tem- p6rature 61ev6e, une an6mie, une acc616ration de la vitesse de s6dimentation, l'hyperleucotycose, une perte pond6rale, des naus6es, des vomisse- ments et des douleurs abdominales [2, 8, 11].

En d6finitive, le diagnostic de la maladie repose

sur la mise en 6vidence des 16sions histologiques contenant la prolif6ration du myc61ium ou par mise en culture de l'Actinomyces.

L'identification correcte de la maladie rev6t une grande importance car elle est potentiellement 16tale et par contre, si elle est diagnostiqu6e, elle permet d'excellents r6sultats th6rapeutiques puis- que les Actinomyces sont sensibles aux antibioti- ques [14, 16].

RI~FI~RENCES

1. S A L M O N . A . , R U D O L F V. , M A K K I N.T. - - Act inomy- cosis of the colon : Repor t of a case. Dis. Colon Rectum, 1969, 12, 30.

2. D A V I E S M . , K E D D I E N . C . - - Abdomina l act inomycosis . Br. J. Surg., 1979, 60, 18.

3. S E C H A S M. , C H R I S T E A S N. , B A L A R O U T S O N C., D E M E R T Z I S A . , S K A L K E A S . - - Actinomycosis of the colon : Repor t o f two cases. Dis. Colon Rectum, 1972, 15, 366.

4. W A Y N E L . H . - - A b d o m i n a l Act inomycos is - - South. Med. J., 1972, 65, 762.

5. C O W G I L L R. , Q U A N S .H .Q . - - Colonic act inomycosis mimicking ca rc inoma. Dis. Colon Rectum, 1979, 22, 45.

6. M O S K O V S K A Y A M . A . - - O n pathogenesis of abdominal act inomycosis . Vestn. Chir., 1977, 119, 63.

7. PHEILS M . T . , R E I D D. J . , R OS S C.F. - - A b d o m i n a l act inomycosis . Br. J. Surg., 1964, 51, 345.

8. W E E S E W . C . , S M I T H I .M. - - A study of 57 cases of Act inomycos is ove r a 36-year period ; a diagnostic failure with good prognos is af ter t rea tment . Arch. Inter. Med., 1975, 135, 1562.

9. J A M E S A . W . , P H E L P S A . H . - - Act inomycosis of the colon. Can. J. Surg., 1977, 20, 150.

10. G I N G O L D B.S. , F A Z I O V .W. - - Abdomina l ac t inomyco- sis : a complicat ion of colonic perforat ion. Dis. Colon Rec- tum, 1978, 21, 374.

11. P U T M A N H . C . , D O C K E R T Y M.B. , W A U G H J.M. - - Abdomina l ac t inomycosis : an analysis of 122 cases. Surge- ry, 1950, 28, 781.

12. B R O W N J . R . - - H u m a n A c t i n o m y c o s i s : a s t u d y of 181 subjects . Hum. Pathol., 1973, 4, 319.

13. M I L L E R B.J . , W R I G H T J .L . , C U L Q U H O U N B.P .D. - - Some etiologic concepts of act inomycosis of the greater o m e n t u m . Surg. Gynecol. Obstet., 1978, 146, 412.

14. S A N F O R D G . E . , B A R N E S R.O. - - Massive penicillin the rapy of abdomina l act inomycosis . Surgery, 1949, 25, 711.

15. L E R N E R P.I. - - Susceptibili ty of pathogenic act inomycosis to ant imicrobial compounds . Antimicrob. Agents Chemotr., 1974, 5, 302.

16. P R I O L E A U P . G . , B R O C H U F .L . - - Penicillin and eplu- chage t r e a t m e n t of hepat ic act inomycosis . Arch. Surg., 1974, 109, 426.

Acta Endoscopica Volume 15 - N" 2 - 1985 177

Actinomycosis is an infectious disease caused in the man by Ac t inomyces Israelii, a gram-posit ive anaerobic microorganism which is found frequently like host in the oral cavity, especially in the tonsillar criptes and in the decayed teeth. After a long saprophitism, it can become pathogenic and produce, according to its localization, cervicofacial inflam- matory alterations or rarely hepatic, intestinal and pulmonary diseases.

The report o f a case of clinic difficult interpretation, at first diagnosed as neoplasia, on lack of the typical aspect o f multiple abscess formations or fistulaes that secrete the characteristic sulphurous granules, is worthy mentioned.

A 69 year old man was admitted to the hospital with a one year history o f irregular stinging pain in the left hypocondrium with greater intensity before defecation and partial resolution ; changes in bowel habit with constipation alternated to diarrhoea and mucorrhea. The patient had sporadic episodes of alimentary womit with partially digested foods and a 12 pound weight loss in five months.

The physical examination showed in the abdomen, at the deep palpation, in the left hypocondrium, a tumefaction of 15 • 10 cm dimensions, with the greatest axis parallel to the costal arcus, o f hard- fibrous consistence and irregular surface. Nothing about all the other abdominal quadrants. Blood tests were all normal except an increased erythrocyte sedimentation rate. A barium-enema study revealed an incomplete filling and limited motility o f the left colon tract (fig. 1).

The patient underwent pancolonoscopy, which demonstrated at about 130 cm from anus, at the level o f the distal portion o f the transverse colon, a sudden decrease oft the lumen in its 3/4. Here the normal mucosae architecture appeared seriously upset with irregularity o f its inner profile ; further the wall unmodifiable to the insufflation. The diagnostic trend was about an organic stenosis o f the distal transverse colon with wall's infiltration (fig. 2).

Therefore the patient was directed to the surgeon with presumptive diagnosis o f transverse colon neo- plasia.

The laparatomy showed a voluminous mass at mu f f o f the splenic flexure, adhered tenaciously and exten- ding to the peritoneal surface and deep muscolar wall at level ot the postero-lateral hypocondrium. The colic portion concerned, was resected and the part o f abdominal wall adhering to it, too.

The histological examination, o f the surgical sec- tions, on the contrary of the endoscopic biopsies,

showed an extensive sclerosis o f the intestinal wall that presented a typical focus o f Actinomycosis. In fact there were tangled heaps o f mycelial ire surrounded by a tikest exudate of neutrocytes for the most part with regressive alterations and characteristics o f pus cor- puscles (fig. 3).

The patient, after about two years from the surgical operation enjoyes looking good health.

DISCUSSION

Colon's Actinomycosis is a rare chronic, progres- sive and suppurative disease, which clinical aspects are manifold and variable.

For these reasons it causes many difficulties in the diagnosis and an easy mistake with other diseases [1, 5]. Indeed, though the Actinomycosis usually presents as a localized chronic inflammation, associated with fever and leucocytosis, not always shows, as in our clinical case, the characteristics of multiple abscesses and fistulaes secreting pus with yellow sulfur granules, important for the diagnosis.

About the pathogenesis, there are several theories of the microorganism diffusion to the abdominal organs.

Sometimes Actinomycosis follow the laparatomy and typical is the location in the right iliac region after operation for acute appendicitis or drainage of absces- ses in this region [6, 10]. Sometimes, on the contrary, the infectious agent, exceed gastrointestinal barrier by traumatic or inflammatory lesions of the mucosae and can penetrate in the contiguous tissue [11, 12].

There are patients with bowel Actinomycosis whose clinic history shows no traumatic episodes or previous inflammatory affections and proceding asymptomatic also for many years, as in our case report. The most frequent symptoms are high temperature, anemia, high erythrocyte sedimentation rate, leucocytosis, ponderal fall, nausea, vomitting and abdominal pain [2, 8, 11].

Notwithstanding this, the definitive diagnosis o f the disease, is found on the histological demonstration of the mycelial colony or on the culture of the Ac- tinomyces.

The correct acknowledgement of the disease have a great importance because the affection is potentially deadly and, i f diagnosed, allow a treatment which offers excellent results since the Actinomycosis is sensitive to antibiotics [14, 16].

178 Volume 15 - N ~ 2 - 1985 Acta Endoscopica