Actinomyces israelii in the genital tract of women with and without intra-uterine contraceptive devices

Actinomycosis involving the female genital tract is more common among IUD users than others. The diagnosis is difficult and often delayed. It has been suggested that the finding of Actinomyces-like organisms or A. israelii in cervical smears indicates a risk of developing actinomycosis. A. israelii has not been regarded as a part of the indigenous genital flora. A group of IUD users without symptoms of genital tract infections were compared with a control group without IUDs. No Actinomyces-like organisms were found on cytological examination of cervical smears. Immunofluorescent staining and cultures identified A. israelii in 4% of the IUD users and in 3% of the non-users. Serologic precipitin tests for actinomycosis were negative in all women. None developed actinomycosis on follow-up of positive cases. The study indicates that A. israelii is a commensal of the female genital tract. The identification of A. israelii alone does not indicate that the patient risks developing actinomycosis. Other methods such as a serology test should be useful in defining the clinical significance of the findings.     

SEM observations of an IUD from a patient with Actinomyces-like organisms on papanicolaou smear

Scanning electron microscopy (SEM) was used to study an IUD from an asymptomatic patient with Actinomyces-like organisms on Papanicolaou smear and in whom Actinomyces israelii was determined to be present in cervical smears. The objective was to determine if there were any variations in surface morphology that might be correlated with the Actinomyces-like organisms. SEM revealed numerous areas of thick surface encrustation. The surface morphology of the IUD fragments showed basic similarities to the morphologies observed in other cases. Encrustations were attached to the arms and stem of the device. A unique finding was apparently biological material adherent to a fragment of encrusted material. Filamentous structures radiated perpendicularly from a central core. These filaments resembled Actinomyces-like organisms in the patient's Pap smear. Also of interest was a delicate network of hair-like structures at the bottom of a naturally occurring space in the surface encrustation.     

Eubacterium nodatum mimics Actinomyces in intrauterine device-associated infections and other settings within the female genital tract.

Eubacterium nodatum is an obligately anaerobic, gram-positive, branching rod that markedly resembles Actinomyces, particularly Actinomyces israelii, in its cellular and colonial characteristics. Its isolation from the female genital tract was examined for a study period in which use of intrauterine contraceptive devices (IUDs) was common, and additional characteristics of the organism were investigated. Fifteen genital isolates of E nodatum were all associated with the presence of a foreign body, usually an IUD (12 patients). Six of these 12 patients had presented with clinically severe pelvic inflammatory disease. The remaining six had signs and symptoms related to IUD use and/or had a report of probable Actinomyces (five patients) by a Papanicolaou smear, demonstrating that E nodatum can be mistaken for Actinomyces in a Papanicolaou-stained smear. The three other patients had different types of foreign bodies. The frequency of isolation from cultures associated with IUD use during the study period was five (6.4%) of 78 for Actinomyces versus the 12 (15.4%) of 78 for E nodatum. In vitro-prepared E nodatum was not demonstrated to cross-react with A israelii or A naeslundii antisera. Both E nodatum and A israelii were shown to adhere in vitro to an inanimate object, indicating their propensities to colonize a foreign body. The present data, with the previous reports of isolation of E nodatum from cases of lumpy jaw and severe periodontitis, suggest that it is an opportunistic pathogen very much like A israelii.     

Bilateral female pelvic actinomycosis

A case of bilateral actinomycotic salpingitis is described. The woman used an IUD and the course of the disease was protracted. Later, Actinomyces israelii was coincidentally identified from vaginal cultures. Attention is drawn to the need for distinction between the presence of Actinomyces israelii and actinomycosis.     

The IUCD-assodated Incidence of Actinomyces israelii in the Female Genital Tract

Cervical swabs and in many cases also intrauterine contraceptive devices were examined from 973 women for the presence of Actinomyces israelii. It was detected in 11.6% of these women, the majority of whom were asymptomatic. The detection, however, of A. israelii in the female genital tract was associated with an almost 4-fold increase in the incidence of pelvic inflammatory disease (PID), indicating that colonization may progress to an infection in a small number of women. The incidence of A. israelii in the female genital tract of IUCD wearers was more than doubled when the IUCD was worn for longer than 4 years. The type of IUCD worn did not appear to be an important risk factor. Immunofluorescent staining of cervical smears identified 64% of cases. Specific culturing for A. israelii or cytological screening of Papanicolaou smears in addition were required to increase the isolation rate to nearly 90%.     

Epidemiological data, cytology and colposcopy in IUD (intrauterine device), E-P (estro-progestogens) and diaphragm users. Study of cytological changes of endometrium IUD related

The author compares the epidemiological, cytological and colposcopical data found in IUD users, with a control population of estro-progestogens and condom users. The age, parity and clinical symptomatology, mainly leukorrhea, was higher in IUD users. At the colposcopic examination a normal pattern was found in condom users more frequently, but the suspect colposcopic signs were frequently associated with the use of the IUD. The oncologic evaluation of smears showed a slight dysplasia in 17.65% and 10.53% in IUD users and estro-progestogen users respectively. The only case of carcinoma in situ was found in the IUD users group. The bacteriological diagnosis on the smears did not reveal a quantitative difference in the three groups, while a qualitative difference was found, particularly with a high frequency of Trichomonas vaginalis and Corynebacterium vaginalis, and one case of Actinomyces in IUD users. The cytological study of the endometrium obtained by mono-use devices, revealed an aspect of aspecific non plasmacellular endometritis in 75% of the cases; a dysfunctional hormonal cytological aspect in 32.50%, and the oncological evaluation in 60% of the cases revealed atypical endometrial cells IUD related. No neoplastic lesion was found. The author concludes that the use of IUD must be prudent and accurate follow up must be carried out.     

Actinomyces-like organisms in users of intrauterine contraception

Actinomyces-like organisms (ALO) were found in 6.9% of cervical smears in 2133 IUD users. The chance of having co-infection with Trichomonas vaginalis was 2.7 times higher in women with ALO than in ALO negative women. The proportion of IUD users with ALO in cervical smears increased with the duration of the IUD use. A total of 108 IUD users with ALO were compared with the same number of IUD users without ALO in cervical smears. The women in the two groups were matched for the duration of the IUD use. During the IUD use the women with ALO had PID and vaginitis significantly more frequently than ALO negative women. No difference was found regarding the type of the IUD used in women with ALO in cervical smears compared to controls.     

Pelvic actinomycosis with retained intrauterine fetal bone: a case report

BACKGROUND: Pelvic actinomycosis is a rare infection that can manifest as pelvic inflammatory disease and in severe cases can cause extensive fibrosis. Most cases are associated with long-standing use of an intrauterine device (IUD). CASE: A 30-year-old woman presented with abdominal pain, fever and a pelvic mass. She underwent removal of an intrauterine foreign body, surgical drainage of a tuboovarian abscess and intravenous antibiotic therapy. Pathology studies revealed that the foreign body consisted of bone tissue, and the agent of infection was identified as Actinomyces israelii. CONCLUSION: Pelvic actinomycosis, although usually occurring in women using an IUD, may result from retained intrauterine fetal bone through a similar pathogenesis.     

A case of ovarian actinomycosis

BACKGROUND: Pelvic actinomycosis is uncommon and often presents as a complication of an intrauterine device (IUD). A diagnosis of actinomycosis can be made from the finding of sulfur granules within inflammatory exudate on histologic examination after surgery. However, it may be possible to diagnose actinomycosis before surgery by finding Actinomyces-like organisms on Papanicolaou smears. CASE: A 41-year-old woman had been diagnosed as having a pelvic abscess, and bilateral salpingo-oophorectomy was performed. She had been an IUD user for 6 years. Actinomyces-like organisms were detected in her previous Papanicolaou cervical smears. If the patient had been treated when the Actinomyces-like organisms were detected by Papanicolaou smears, the serious ovarian actinomycosis might have been avoided. CONCLUSION: We suggest that routine cervical examinations are important for women who are IUD users.     

Abdominal wall actinomycosis associated with an IUD. A case report

Abdominal wall actinomycosis without pelvic organ involvement in users of intrauterine contraceptive devices (IUDs) has not been reported on previously. We encountered one such patient, whose uterine cervix was colonized superficially with Actinomyces. We suggest that systemic actinomycosis be included in the differential diagnosis of pain in IUD users when Actinomyces is found on Papanicolaou smears or in endocervical curettings. Such patients should be treated with appropriate antibiotic therapy, especially prior to any surgical intervention.     

Tubo-ovarian abscess formation in users of intrauterine devices remote from insertion: a report of three cases

Background: The association between tubo-ovarian abscess formation and the presence of an intrauterine device (IUD) is well recognized. It has been suggested that the risk of upper-genital-tract infection is highest during the immediate period following the insertion of an IUD, returning to baseline by 5 months postinsertion. We present 3 cases of women who, 10-21 years after insertion of their IUDs, developed tubo-ovarian abscesses that were not causally related to sexually transmitted diseases (STDs) or actinomycetes.Cases: Three women, ages 39-47 years, presented to our gynecology service for evaluation of abdominal pain. One woman had bilateral tubo-ovarian abscesses and the other 2 had unilateral tubo-ovarian abscesses. All 3 were IUD users, with an interval from IUD insertion to presentation of 10-21 years. In each case, the cervical cultures for gonorrhea and chlamydia were negative at presentation and the sexual history was not consistent with an STD mode of spread. All 3 women initially received broad-spectrum antibiotics, but 2 eventually required definitive surgical therapy.Conclusion: Long-term users of IUDs remain at risk for serious, indolent pelvic infections. These women should be counseled by their gynecologists on an ongoing basis as to this persistent risk. Tubo-ovarian abscess should be strongly considered in the differential diagnosis of an IUD user who presents with an adnexal mass, fever, or abdominal pain.     

Actinomyces in the vaginas of women with and without intrauterine contraceptive devices

Either Actinomyces israelii, A. naeslundii, or Arachnia propionica was found, by immunofluorescence studies, in cervicovaginal mucus from 36% of 50 women. One or more of these organisms were found in a surprising 27% of those with neither intrauterine contraceptive devices (IUDs) nor intravaginal foreign bodies. The only common finding was abundant vaginal mucus, and no clinical features were more serious than vaginal itching, odor, or vague discomfort. Among those women who harbored actinomycetes, the average duration of continuous IUD use was 5.3 years; the comparable figure for those with no infection was 2.1 years.     

Actinomyces adnexitis in a woman

The course of actinomycetic infections in two females with IUD is presented. Both patients needed surgery. Literature review taking into a special consideration laboratory diagnosis has been performed. Infection caused by other than Actinomyces israelii species was observed.     

Pelvic colonization with Actinomyces in women using intrauterine contraceptive devices

Recent reports suggest a relationship between intrauterine contraceptive device (IUD) use and colonization or infection of the genital tract with Actinomyces species. This prospective, case-controlled study was designed to determine the incidence of colonization or infection with Actinomyces in IUD users. None of 50 control patients and four of 50 study patients (8%) had Actinomyces identified. None of the patients with positive results had symptomatic pelvic infection. Cervical cytology was effective in detecting each of the four study patients with positive results. It appears that the presence of any type of IUD is a major predisposing factor to colonization with Actinomyces.     

Cytologic detection and clinical significance of Actinomyces israelii in women using intrauterine contraceptive devices.

Pancervicovaginal (Papanicolaou) smears exhibiting pseudomycilial-like clumps of organisms obtained from 35 women employing IUD's were studied by direct immunofluorescent technique for identification of A. israelii and A. naeslundi. In every case the specific fluorescence was achieved with species-specific antiserum against A. israelii. The clinical profile of these 35 women was retrospectively analyzed.     

Actinomyces and the intrauterine contraceptive device: aspects of the fluorescent antibody stain

Using fluorescein-conjugated globulins specific for Actinomyces israelii and Arachnia propionica, we observed large dispersed actinomycete populations in vaginal smears of several asymptomatic women. Mycelial granules, commonly revealed by the Papanicolaou stain, were not seen. These observations are discussed in regard to the threat of infection and sensitivity of the fluorescent stain.     

Cytologic picture of smears from the cervix uteri of women using intrauterine contraceptive devices (IUD)

During 1986-87, cervical smears were taken at various phases of menstrual cycles from 63 women aged 25-53 (average age of 34.8 years) wearing IUDs for 3 months to 17 years for the sake of cytological evaluation. 43 patients had Copper T-devices of Finnish make, 8 women had Spider Ws of Polish make, 1 had a Lippes Loop, and 10 had IUDs whose manufacturer could not be verified. The samples were preserved in an alcohol-ether solution, dyed with hematoxylin and eosin, and evaluated according to the 5-degree Papanicolaou scale. The presence of granulocytes indicative of inflammation was ranked: few granulocytes (+), the normal count in healthy women during anovulation wearing no IUDs; an adequate number of granulocytes (++); numerous granulocytes (+++); and a high number of granulocytes (++++). Cytogram II of the Papanicolaou scale was found in 49 women, and cytogram I in 14 women. 5 of 25 women wearing IUDs for 3 years had cytogram I, while 20 had cytogram II. Among 21 patients wearing IUDs for 2 years, there were 4 cases of cytogram I and 17 instances of cytogram II. Women with IUD use of 4-17 years were put into the second group, while all 4 of those with 3 months to 1.5 years of IUD use were listed in the first group. The remaining 6 were sorted into the second group. In 45 (71%) women, varying degrees of inflammation were detected in the presence of neutrophilic granulocytes. In 14 cases (22%) the presence of erythrocytes was demonstrated: few in 7 cases, an adequate number of 4, and an excess number in 3 cases caused either by the IUD or by hormone-induced cervical bleeding. Numerous neutrophilic granulocytes were found in 4 cases and a high number of them in 1 case. The granulocyte count was 10 (+), 17 or 16 (++), 12 (+++), and 6 (++++) indicating moderate or severe inflammation in most preparations. The presence of cytologically suspect or atypical cells was absent in the cervical smears of longterm IUD users. In most women, IUD use was associated with inflammation indicated by the increased number of granulocytes. The persistence of such inflammation may justify the removal of the IUD.     

Placental invasion by actinomyces resulting in preterm delivery: a case report

BACKGROUND: Actinomyces is a gram-positive rod, some of which organisms are anaerobic and others which are facultative anaerobes. Most species of Actinomvces cluster together, forming a structure resembling a fungal colony. The organism is an opportunistic pathogen most commonly seen in the oral cavity but may also infect the gastrointestinal tract, lungs and uterus. Actinomyces is also a part of the normal vaginal flora and can result in infection independent of intrauterine device (IUD) use. Abscesses and swelling are common at the site of the infection. The organisms are grossly apparent by the formation of sulfur granules. Chorioamnionitis due to Actinomyces is exceptionally rare. CASE: A 23-year-old woman delivered a male infant at 28 weeks' gestational age after premature labor. The mother had an unremarkable hospital course. There was no prior IUD history. The infant had an extended stay in the fetal intensive care unit secondary to prematurity. Evaluation of the placenta revealed necrotizing acute chorioamnionitis and organisms with a filamentous growth pattern. The morphology was consistent with Actinomyces spp. CONCLUSION: This case is important because of the rarity of the infection. Clinicians and pathologists alike must be aware of this possibility even in the absence of IUD use.     

Pelvic abscess in intrauterine device users.

OBJECTIVE: To assess the causality between pelvic abscess formation and intrauterine device (IUD) use through a clinical study in a hospital. METHOD: Sixty-two pelvic abscesses were retrospectively evaluated over a 7-year period. Patient records retrieved for the women enrolled in this study consisted of demographic characteristics, duration of IUD use and clinical management details. RESULTS: All the women were monogamous Muslim women without any suspicious sexual contacts, immunosupressive states, or drug use at the time of IUD insertion. In 10 cases (16.1%), a history of pelvic surgery was present. The mean age of the women was 36.1 +/- 2.3 years (range 19-50 years). Of the 62 women, 14 (22.6%) were current IUD users. The mean time interval for women using IUD prior to the diagnosis of pelvic abscess was 5.7 +/- 1.2 years (range 1-14 years). In all cases, a pelvic mass and abdominal pain constituted the referral signs and symptoms. All women received an initial antibiotic regimen comprising penicillin (24 mU/day), clindamycin (900 mg/day) and gentamycin (240 mg/day) in divided doses. In 38 cases (61.3%), medical treatment yielded a satisfactory clinical outcome, defined as a decreas in mass volume together with pain relief and a decrease in leukocytosis. Twenty-four cases (38.7%) underwent a subsequent surgical procedure, either laparotomy (n = 19) or laparoscopy (n = 5). The type of surgery ranged from abscess drainage to more radical approaches such as total abdominal hysterectomy and/or unilateral or bilateral salpingo-oophorectomy. There were no differences between those women responding to medical therapy and those who did not respond in terms of mean age, percentage of past pelvic surgery, gravidity, parity and the size of pelvic abscess. CONCLUSIONS: A substantial number of women with an IUD were diagnosed as having a pelvic abscess within a 7-year period at the university clinic. Despite current knowledge that pelvic inflammatory disease and pelvic abscess are rarely encountered in long-term IUD users, the presence of an IUD should be investigated in cases with an initial diagnosis of pelvic abscess based on clinical and ultrasonographic evaluation, demonstrating mostly acquisition via sexually transmitted disease.     

The effect of long-term use of intrauterine devices

Of 10,223 Japanese women examined for uterine cancer between 1952 and 1967, 1333 were or had been wearing an IUD during that period; 1075 of the IUD users were studied to assess the results of long-term IUD use and its effect on fertility after removal. Results indicated that fertility after removal was normal depending on the age of the patient. The patients' ages ranged from 21 to 35 years. Closure for medical reasons, e.g., hemorrhage, pain, and unintended pregnancy, were most frequent during the 1st year of use; however, the IUD was removed in almost 1/2 of the patients after 5 years of use because of desire for pregnancy, physician's advice, or other personal reasons. Pregnancy rates before IUD insertion were 64.6/100 woman-years of use (total woman-months, 83,065); after IUD insertion, the rate was 1.05/100 woman-years of use (total woman-months, 37,642); and following removal, the rate was 23.43 (based on 449 cases). Vaginal cytology did not differ in Class 1, 2, and 3 smears between 1058 IUD users and 7226 non-IUD users.