Case notes

A copious watery vaginal discharge was the symptom in 2 similar, although unusual cases. The first patient, a 51-year-old woman, also reported that the discharge was bloody. Twelve years earlier, she had undergone surgery and chemoradiation therapy for cervical cancer. Three years later, she had laser ablation for vaginal intraepithelial neoplasia grade 2. She was then lost to follow-up evaluation until 6 months before her current admission, when she sought treatment for the vaginal exudate. A biopsy identified colonies of Actinomyces species, and she was treated with penicillin. When her symptoms persisted, a second biopsy was performed that revealed squamous cell carcinoma. After a metastatic work-up, she underwent total pelvic exenteration.

The second patient, an 81-year-old woman with a history of breast cancer, had a profuse malodorous watery vaginal discharge. Her physical examination disclosed an elevated erythematous mass under the urethral orifice. A biopsy showed colonies of Actinomyces species, but these were in close proximity to an amelanotic malignant melanoma tumor ( Figure ). She was treated with penicillin; after a metastatic work-up, she underwent radical anterior vulvectomy and distal vaginectomy with groin dissection. Surgery confirmed that the tumor had metastasized to the groin; the disease later progressed to pulmonary metastasis.

The vaginal biopsy showed that colonies of Actinomyces species ( black arrow ) coexisted with an amelanotic malignant melanoma tumor ( white arrow ). (Hematoxylin and eosin; original magnification, ×200.)

Grisaru. A peculiar presentation. Am J Obstet Gynecol 2012.

Conclusion

Actinomycosis, a rare subacute or chronic infectious disease, results in a characteristic granulomatous inflammatory response followed by necrosis and extensive fibrosis. It is caused by Actinomyces species, Gram-positive anaerobic bacteria, or facultative anaerobic bacteria that normally colonize the vagina, colon, and mouth. The oral-cervicofacial and thoracic forms are more common, with the latter often misdiagnosed as a neoplasm. Pelvic actinomycosis, the rarest form of the disease, can manifest as pelvic inflammatory disease, tuboovarian abscess, or a pseudoneoplastic formation. Prolonged use of intrauterine contraceptive devices has been shown to account for actinomycotic infections that ascend from the uterus.

Because of its unusual presentation and rare occurrence, most cases are diagnosed only postoperatively during histopathologic examination. Preoperative radiologic findings might resemble disseminated malignancy. Biopsies can assist in obtaining a preoperative diagnosis; a high index of suspicion should arise when a tumor is found and malignancy cannot be confirmed. In these cases, multiple microbiologic examinations of the biopsies should be obligatory. Another obstacle that further complicates the diagnosis is the low yield and slow growth of Actinomyces species in culture. To establish the diagnosis, the pathogen itself or sulfur granules, which are a reliable marker, must be demonstrated microscopically in the biopsy or in smear materials.

We describe 2 cases of symptomatic vaginal actinomycosis as the symptom of vaginal neoplasms. Symptoms of vaginal actinomycosis (an abundant, watery discharge that was bloody in 1 patient and malodorous in the other) preceded the diagnosis of a vaginal malignancy. Both women were postmenopausal, and neither woman was using an intrauterine device. As mentioned, Actinomyces species are part of the normal vaginal flora and, as such, ordinarily do not cause symptoms. Healthy vaginal mucosa ordinarily may act as a barrier to the spread of the organism, but tissues that have been damaged by neoplasm might be vulnerable to invasion and, subsequently, to symptomatic infection and inflammation. These 2 cases encourage clinicians to consider and rule out the presence of a vaginal tumor in postmenopausal women with symptomatic vaginal actinomycosis.