Abstract: The patient was 36 years old female admitted due to periumbilical pain and anorexia since about 24 h prior to hospitalization. She underwent laparotomy with impression of acute appendicitis. Operative finding was Meckel`s diverticulitis, so appendectomy and resection of diverticular bearing Ileum with end to end anastomosis was performed. Post operation course was uneventful and she discharged 5 days later. Pathological study confirmed the diagnosis of Meckel`s diverticulitis due to actinomycosis as the cause of diverticular obstruction. The relatively rare incidence and preoperative diagnosis difficulties make publication of this case worthwhile.
INTRODUCTION
Actinomycosis is a localized inflammatory mass, usually of the jaw area. The most common site of involvement is oral cavity and cervicofacial area 50-60% followed by thoracic 15-25% and abdominal involvement 20% (Sarker et al., 2004; Colon-Candelaria et al., 2005).
Abdominal infection most frequently involves cecal area (usually following appendectomy), Appendix and left colon flexure (Solecki and Czupryna, 2001; Habib et al., 2002; Hohenbleicher et al., 2002; Lukacs et al., 1992).
Meckel's diverticulum involves relatively rare.
Case report: The patient was 36 years old lady who admitted due to steady periumbilical pain, anorexia, nausea and vomiting since about 24 h prior to hospital admission. On physical examination, she had tenderness of periumbilical and right lower quadrant area. On laboratory studies there was leukocytosis of 11200 with 83% PMN and 17% lymphocytes and normal urinalysis. With impression of acute appendicitis she underwent laparotomy via McBurney abdominal incision, operative finding was normally looking appendix and Meckel's diverticulitis, so appendectomy and resection of diverticulum bearing Ileum with end to end Ileo-ileostomy performed.
| Fig. 1: | Inflamed small bowel wall with presence of actinomycosis elements (H & E, X300) |
| Fig. 2: | Actinomycosis in small bowel wall with prominent PMN infiltrates (H & E, X400) |
Pathological study was consistent with Meckel's diverticulitis and Actinomycosis as the etiology of diverticular obstruction (Fig. 1 and 2). There was no data for DM or any other type of immuno-suppression and no additional further antibiotic therapy prescribed.
Post-op course was uneventful and she discharged 5 days later. She was well in one year post op follow up.
DISCUSSION
Meckel's diverticulum, the most common true and congenital GI tract diverticulum results from incomplete closure of the omphalomesentric (vitelline) duct (Ciardo et al., 2004). Complications of Meckel's diverticulum including intestinal obstruction, bleeding, acute diverticulitis, or the presence of it in hernial sac Littre's hernia (Stone et al., 2004).
On the other hand, actinomycosis is characterized by chronic inflammatory induration and sinus formation.
The causative agent is Actinomyces israelii, a gram positive anaerobic microaerophilic bacterium, a normal resident of the mouth and the cervicofacial region (Sarker et al., 2004; Cirafici et al., 2002).
The most frequently involved site is cervicofacial and oral cavity 50-60% followed by thoracic 15-25% and abdomen 20% (Sarker et al., 2004; Colon-Candelaria et al., 2005).
Abdominal infection most frequently involves the cecal area (usually following appendectomy) and left colon flexure (Solecki and Czupryna, 2001; Habib et al., 2002; Hohenbleicher et al., 2002; Lukacs et al., 1992).
The diagnosis of abdominal Actinomycosis should be suspected if an indolent mass or chronic sinus follows an appendectomy (Castillenti and Conklin, 1990; Campo et al., 2001).
Meckel's diverticulum involvement is very rare (Lukacs et al., 1992).
Actinomycosis rarely involves pelvis (Elsayed et al., 2006; Bercovich et al., 2003; Michel, 2004), liver (Chen et al., 2006; Buyukavci et al., 2004), omentum (Schulteisz and Gyorgy, 1994), urachus (Jalon Monzon et al., 2002), Thyroid (Park et al., 2005), mediastinum (Alborzi et al., 2006), spinal cord (Gaini et al., 2006), ovaries (Valko et al., 2006; Koren et al., 2002), kidneys, ureters, bladder (Hohenbleicher et al., 2002; Michel, 2004; Gidwani et al., 2005), retroperitoneum (Castillenti and Conklin, 1990; Gidwani et al., 2005), bones (Pinilla et al., 2006), orbit (Pagliani et al., 2006) and abdominal wall (Hefny et al., 2006), perineal (Bauer et al., 2006), cutaneous (Sardana et al., 2001).
Actinomyces israelii is a normal commensal inhabitable of the oral cavity and tonsillar crypts may become invasive pathogen due to unknown causes but in 75% immuno suppression or local tissue barriers break down predisposingly.
Diagnosis could be made by finding of characteristic sulfur granules on microscopic examination (Sarker et al., 2004).
Special stains should be used to exclude fungal infection.
Treatment consists of medical therapy with antibiotics including: Penicillin, Sulfonamides, or Tetracycline and surgery for abscesses and areas of chronic scarring (Sarker et al., 2004; Michel, 2004; Sardana et al., 2001).
Clinical picture, complications and surgical incision are the same in appendicitis and Meckel's diverticulitis patients, so pre-op differentiation is academic and unnecessary. During laparotomy if the diverticulum is broaden base, simple diverticulectomy would compromise the Ileal lumen, then Ileal resection and end to end ileo-ilea anastomosis is mandatory.
CONCLUSIONS
Actinomycosis most frequently involves cervicofacial, thoracic and abdominal area including appendix and left colon flexure and Meckel's diverticulum (rarely) where stasis of fecal material is present. Diabetes Mellitus or any other type of immuno suppression may be as predisposing factor and must be included in mind.
Treatment of Meckel's diverticulitis due to any etiology is the same, diverticulectomy or ileal resection and ileo-ileostomy. The important question is that in the case of Meckel's diverticulitis and Actinomycosis what antibiotic/S and how long is necessary? In our case we used cephalothin for 3 doses (1 pre-op and 2 post up), because pathologic report took about one week time, when the patient had discharged and no additional antibiotic therapy prescribed. In one year follow up she was doing well.