We report the case of a 56-year-old female who presented with increased frequency of urination and haematuria. Ultrasonography showed a mass in the anterior wall of the urinary bladder. Computed tomography (CT) impression was an irregular, moderately enhancing soft tissue mass lesion involving anterosuperior wall of the urinary bladder. During investigation before surgery, she was diagnosed to to have type 2 diabetes mellitus. Urinalysis revealed 10–15 red blood cells, 2–4 epithelial cells and 4–6 pus cells/HPF. Urine culture did not reveal any growth. Biochemical examination did tested negative for albumin, phosphate, sugar, bile salts, bile pigments, urobilinogen. She was taken up for surgery. The partial cystectomy specimen on gross pathology revealed an elevated lesion in the urinary bladder wall measuring 4.5 cm × 3.5 cm × 3 cm. Histopathological examination showed urothelial lining with ulceration and presence of granulation tissue. In the lamina propria, there was a dense collection of lymphocytes, plasma cells and eosinophils. Many actinomycotic colonies were seen in the urinary bladder wall, within the granulation tissue with Splendore–Hoeppli phenomenon (Figure 1). In this case, histopathology helped in definitive diagnosis of actinomycosis. On further enquiry, no history of intra-uterine contraceptive device (IUCD) use could be elicited. She was treated with oral amoxycillin and is currently doing well.
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Figure 1: Computed tomography of abdomen (coronal view) showing irregular, moderately enhancing soft tissue mass lesion involving antero-superior wall of urinary bladder (arrow) (a). Photomicrographs showing Actinomycotic colonies in the wall of urinary bladder (Haematoxylin and eosin, ×40) (b), actinomycotic colony surrounded by inflammatory cells (Haematoxylin and eosin, ×400) (c), Splendore–Hoeppli phenomenon around actinomycotic colony (arrow) (Haematoxylin and eosin, ×400) (d), Actinomycotic colonies (Gram stain, ×400) (e)
Actinomycosis is caused by the anaerobic, Gram-positive, branching, filamentous bacteria, Actinomyces.[1] Very few cases of genitourinary cases have been reported. Actinomycosis at times mimics urothelial malignancy, for which the patient gets surgically treated as in the present case. The clinical symptoms of Actinomyces are also not specific. Because of this, often, it is difficult to diagnose clinically.[2,3]
Actinomyces israelii is the most prevalent species causing infection in humans. Actinomycesisraelii and Actinomycesgerencseriae cause about 70% of oro-cervico-facial infections. Female genital tract is usually colonised by several species of Actinomyces such as Actinomyces meyeri, Actinomyces neuii, Actinomycesradingae, Actinomycesturicensis, and Actinomycesurogenitalis. Recent literature includes many novel species termed Actinomyces-like organisms.[2–4]
After invasion of tissue, Actinomyces species develop a chronic granulomatous infection characterised by the formation of sulphur granules. These are seen as basophilic masses in haematoxylin and eosin stain. Gram stain shows Gram-positive filamentous branching bacteria at the periphery of the granule helps in confirming the diagnosis of actinomycosis.
Splendore–Hoeppli phenomenon is characterised by radiating intensely eosinophilic material surrounding microorganisms such as fungi, bacteria and parasites or biologically inert substances.[5] The eosinophilic material seen in Splendore–Hoeppli phenomenon is said to be antigen–antibody complexes and host inflammatory cells debris deposits. Microscopically, it appears as strongly eosinophilic amorphous materials surrounding or adjacent to the causative agent with radiating star-like or club-shaped-like configurations.[5]
Pelvic actinomycosis is often associated with use of IUCD. In IUCD-associated actinomycosis, there is often formation of abscess in the genital tract. The organisms can spread from pelvic sites to the abdominal region or also in reverse way causing abdominopelvic actinomycosis. The complications of abdominopelvic actinomycosis are dense adhesions with adjacent structures, such as, small bowel. It may result in fibrosis, fistula formation and peritonitis.[2] A similar case of urinary bladder Actinomyces has been described by Bottai etal.[3] Few cases of primary vesical Actinomyces also have been described.[5,6] The present patient did not give any history of IUCD use.
Antimicrobial therapy helps in resolution of genitourinary tract actinomycosis if detected pre-operatively. Patients with genitourinary tract actinomycosis are treated with several weeks of intravenous high doses of a beta-lactam which is followed by oral therapy for 2–6 months.[4]
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The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
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