26.     Actinomyces.

Abbreviations:

ALO:      actinomyces-like organisms.

FSRH:   The Faculty of Sexual and Reproductive Health

There are loads of Actinomyces and Actinomyces-like organisms.

They are commensals in mouth and vagina.

The one we are interested in is Actinomyces Israeli.

This is not another illustration of anti-Semitism.

James Israel first described actinomyces.

Israel, J. Neve beobactungen anf dem bebiete der mykosen des menshen. Virchows Arch Pathologische Anatomie 1878; 74:15. 

He and Wolfe subsequently reported a case of human clinical infection.

Wolfe, M, Israel, J. Ueber reincultur des actinomyces and seine uebertragbarkeit auf thiere. Virchows Arch Pathologische Anatomie 1891; 126:11. 

Actinomyces is a rare cause of pelvic and jaw abscess formation, but fatalities have been described.

"Sulphur granules" are present in the pus.

The sort of useless data beloved of MCQ compilers for the MRCOG.

It is usually a surprise finding on a routine cervical smear obtained from an asymptomatic woman.

Something like half of the patients in whom it is found will have an IUCD, particularly the old fashioned plastic devices.

The usual management has been removal of the IUCD and treatment with penicillin.

Some have advocated IM administration.

Current thinking is that in an asymptomatic woman the IUCD can be left.

Some say repeat the smear in three months.

In almost all cases, the organism will have vanished.

Given this, some say don't bother repeating the smear.

In practice, the smear will usually be reported "inflammatory" with advice to repeat the smear.

Some remove the IUCD and insert another, though I can’t see the logic in this.

The truth of the matter is that there is no science and I doubt that there ever will be.

Actinomyces as a clinical problem is exceptionally rare.

I have not seen a case since being a senior house officer and that is decades ago.

It is not even all that common on smears.

I can’t see anyone doing the research to quantify the risks and ascertain the best treatment.

As a result, management can only be a matter of opinion!

The FSRH gives advice in table 6 on page 11 of its document "Intrauterine Contraception" of November 2007.

It says that if "Actinomyces-like organisms" are identified but the woman has no symptoms:

    she should be told that there is no need to remove the IUCD, unless symptoms occur,

    and that there in no need for a further appointment.

Should symptoms such as pain occur,

    she should seek medical advice,

    other causes of infection should be considered,

    and "it may be appropriate to remove the intrauterine method".

They ought to have added to consider other pathologies, e.g. ectopic pregnancy, but let's not nit-pick.

As the Faculty is part of the RCOG, I'd be inclined to use its advice.

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This is the typical appearance of Actinomyces on a smear.

It could just turn up in the MRCOG OSCE with a variety of other smears asking you to decide which shows what.

It reminds me of the old Western movies with tumbleweed blowing across the screen.

The Actinomyces in the above are the two huge lumps in the centre of the picture and at 9 o’clock.

Although the bug is a bacterium, it tends to form into filaments.

Note the masses of white cells, which are the tiny black dots.

This is a fairly pronounced inflammatory reaction.

There are lots of squames, which look OK, but a smear of this kind would be difficult to report because of the overlying actinomyces and white cells.

The smear which shows actinomyces will often report “inflammatory changes”, which is hardly surprising, given the above appearances.