Abdominal actinomycosis is a rare condition caused by anaerobic gram-positive bacteria habituating in human oral flora, usually diagnosed as abdominal mass. Three major locations for actinomycosis are described: cervicofacial, thoracic and abdominal. Abdominal involvement occurs in only 20% of cases. This pathology is mostly seen in women using intrauterine devices and is rarely reported in childhood. It can also mimic appendicitis, malignant diseases, tuberculosis and inflammatory bowel disease [1
Although medical treatment is suggested by some authors, most of the patients require surgery at the primary presentation. The diagnosis is mainly confirmed with histopathological examination.
Medical treatment with high dose injectable penicillin followed by oral penicillin is recommended for several weeks after discharge. Ultrasound and CT examinations can detect the mass, but this mass can be easily misinterpreted as in our case. Although experienced radiologist can suspect the pathology, still the preoperative diagnosis is difficult [4
Rarity of the abdominal actinomycetes infection during childhood period overrules making an adequate algorithm for the treatment in this period. Therefore, the management is usually similar to adult cases. The main aim at operation should be to avoid unnecessary extensive resections, and restriction to the removal of the mass alone. This could be achieved with the help of frozen section during surgery and preoperative suspicion of the entity though very rare [6
]. In our case, we did not have frozen section; but the atypical location without any obstruction, and absence of any gross infiltration to the corresponding tissues especially to the sigmoid colon, made us to decide to the removal of the mass alone.
A relation to trauma is rarely reported and the mechanism is not clearly understood. Our patient had a history of fall before hospitalization and the symptoms were on the left lower quadrant. Therefore, it seems that the mass formation was most likely related to this fall event.
Optimal therapy includes wide excision of necrotic, infected tissue and debris followed by an intense protracted antibiotic therapy. Intravenous 10-20 million units’ daily aqueous penicillin followed by 2-15 million units/day orally for a minimum of 2 months and long follow-up is recommended [4
]. Triple antibiotics were administered in our case before confirmation of diagnosis. The therapy continued with oral penicillin.
In conclusion, abdominal actinomycosis is difficult to diagnose preoperatively and surgery is required in most of the cases. CT scan and US can detect the mass but differential diagnosis requires a high index of suspicion.