or Cancer Dr Syed Umair Mahmood Dr Aanand Vibhakar Dr James Stephenson Dr Ratan Verma University hospitals leicester Start from the top 45 year old male ex smoker ID: 1044302
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1. ‘Is it always Crohn's or Cancer’Dr. Syed Umair MahmoodDr. Aanand VibhakarDr. James StephensonDr. Ratan VermaUniversity hospitals leicester
2. Start from the top….45 year old male ex smokerOccupation – gardener. Previous appendectomy aged 14. No other significant past medical historyIndependent.Admitted with a 5 day history of abdominal pain, nausea & vomiting and altered bowel habit. On admission was pyrexial and septic.WCC 13.1 CRP 253CT abdomen/pelvis with contrast was performed on admission.
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4. 1st Surgical Biopsy – the ‘gold standard’Reactive fibrosis.No granulomas, foreign material or evidence of malignancy was identified.
5. The patient stabilised post operatively and was discharged with antibiotics.He presented again in 2 months with similar abdominal pain.Another CT abdomen/pelvis with contrast was performed.Everyone thought it was over…..
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7. ColonoscopyInpatient colonoscopy was performed.It demonstrated an inflammatory sigmoid polyp, patchy caecal and terminal ileal inflammation. Colonic Biopsy results showed low grade tubular adenoma. No evidence of inflammatory bowel disease or malignancy.
8. Repeat laparotomy, adhesiolysis and resection of mesenteric and small bowel abscess. Defunctioning ileostomy and closure of enterotomy was performed.
9. Blood CultureNo growth after 5 days. Repeated multiple times during various admissions.
10. 2nd Surgical Biopsy Spindle cell proliferation composed of myofibroblastic type cells. No evidence of necrosis.Cytology does not demonstrate no features of atypia or malignancy.Differentials include myofibroblastic type proliferation or fibromatosis.
11. Case was discussed at Inflammatory Bowel Disease (IBD), Sarcoma and Lmyphoma MDT. Also, the patient was reviewed by infectious diseases. In the context of the biopsy results, radiological appearances suggest possible actinomycosis. He was started on IV benzylpenicillin for 6 weeks, followed by long term oral co-amoxiclav for 1 year. No other biopsies or histological samples were obtained as the mass was not amenable to percutaneous biopsy and the surgeons didn’t fancy performing another laparotomy.
12. Marked improvement on long term antibiotics.Patient was treated for Actinomycosis.Finally……
13. Latest CT
14. Discussion – Actinomycosis the mimic (1,2,3)Actinomycosis is prominently surrounded by inflammatory infiltrates.It crosses tissue planes.Hallmark of actinomycosis is extensive and dense fibrosis. The surrounding soft tissue strands around the mass tend to show strong enhancement after contrast material administration. The invasive nature of the mass is misleading and often suggests tumour. Regional adenopathy is rare in invasive actinomycosis.Ascites is minimal.It rarely spreads into the entire peritoneal cavity.
15. Learning points (1,2,3)Actinomycosis has non specific features. It is easily misinterpreted as inflammatory bowel disease or invasive malignancy. It has a highly infiltrative nature, strong enhancement after contrast material administration, and suppurative necrosis within the mass.Given that actinomycosis can be cured with antibiotic therapy alone, it is axiomatic that the timely detection of actinomycotic infection offers the greatest chance for cure without unnecessary surgery. Actinomycosis is generally diagnosed based on histological identification of actinomycotic granule or culture of the Actinomycoces.Multiple sections need to be studied and often granules are scarce. Prior administration of antibiotics significantly reduces the likelihood of a successful culture.
16. References1. Lee IJ, Ha HK, Park CM, et al. Abdominopelvic actinomycosis involving the gastrointestinal tract: CT features. Radiology 2001;220(1):76–802. Yegüez JF, Martinez SA, Sands LR, Hellinger MD. Pelvic actinomycosis presenting as malignant large bowel obstruction: a case report and a review of the literature. Am Surg 2000;66(1):85–90.3. Ha HK, Lee HJ, Kim H, et al. Abdominal actinomycosis: CT findings in 10 patients. AJR Am J Roentgenol 1993; 161:791-794.