Abstract
Introduction
Actinomycosis is a chronic bacterial infection caused primarily by Actinomyces israelii, an organism typically part of the human oral and gastrointestinal flora. 1 Pelvic actinomycosis, although rare, is most frequently linked to the use of intrauterine devices in women, serving as a potential nidus for infection. The bacteria can cause a significant inflammatory reaction, leading to scar formation and tissue destruction, which may mimic more sinister conditions such as malignancy or pelvic inflammatory disease. 2 The diagnosis is often made retrospectively after biopsy.
The standard treatment for actinomycosis involves prolonged antibiotic therapy. In cases involving significant tissue destruction, surgical debridement may also be required. 3 The presence of Escherichia coli with actinomycosis in the vagina is unusual and poses additional challenges considering the potential for antibiotic resistance. 4 The management of vaginal bleeding in children must be approached with caution. A meticulous history and physical examination, in addition to appropriate imaging and laboratory studies, are crucial. 5
Case report
An 8-year old girl presented with a six-month history of intermittent vaginal bleeding and foul-smelling vaginal discharge associated with occasional itching. Notably, there were no signs of fever, weight loss, trauma, or any indication of foul play.
A gynaecological examination revealed excoriated skin over the labia majora and a small amount of necrotic tissue visible at the vaginal orifice.
Laboratory tests, including a full blood count, erythrocyte sedimentation rate, and C-reactive protein and ultrasound of the pelvis were within normal limits.
A course of Amikacin, a broad-spectrum antibiotic effective against both organisms, was commenced, and a full examination under anaesthesia was performed. The Killian nasal speculum was used to inspect the vagina thoroughly. A 1 × 2 cm blackish, foul-smelling necrotic mass was identified in the lower vagina (Fig. 1). The cervix appeared healthy, and there was no evidence of disease invasion into deeper tissues.
Follow-up visits showed no further episodes of bleeding or discharge, and the symptoms of itching and discomfort resolved completely. The necrotic tissue was removed using artery forceps. Culture results indicated the presence of E. coli, and surprisingly, histopathological examination revealed colonies of actinomycotic bacteria (Fig. 2).
Discussion
Our case highlights the challenges of diagnosing and managing vaginal actinomycosis in children, rarely found in the absence of intrauterine device usage.
Targeted treatment with surgical debridement and antibiotic therapy resulted in complete symptom resolution.
Other similar cases have been reported6,7 and poor hygiene was deemed a contributory factor in the second case. Prompt diagnosis is recommended 8 and surgical debridement combined with long-term antibiotic treatment is important for complete resolution of symptoms.9,10
P/S examination showing necrotic mass.
Showing the tissue removed.
Footnotes
Author contributions
Shifa Qureshi: Drafting the work for important intellectual content. Arifa Anwar Elahi: Agreement to be accountable for all aspects of the work. Dina Aisha Khan: Substantial contributions to the conception and final approval of the version to be published.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
