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Actinomysis Is a Potential Cause of Perforated and Gangrenous Appendicitis
Saju Joseph1, Ravi Patel*1, Charles E. Burns2
1Dept of Surgery, Texas Tech University Health Sciences, Odessa, TX; 2Pathology, Medical Center Hospital, Odessa, TX
Background:
Acute appendicitis can present with a wide range of symptoms from an indolent course to severe peritonitis and overwhelming sepsis. The patients clinical status often indicates the severity of the disease and if perforation and diffuse peritonitis is present. While there have been many attempts to identify patients who may develop sepsis and peritonitis, little has been found as to the cause of the most severe cases.
Actinomysis, a gram positive facultative anaerobe, is part of the normal flora of the mouth, GI tract, and female vagina, however when pathologic it causes severe inflammation, perforation, and gangrene. Actinomysis can easily be identified on pathologic examination by the formation of sulfur granules. We hypothesized that Actinomysis could be a causative agent in patients who present with perforated or gangrenous appendicitis.
Methods:
We did a retrospective review of the last 50 appendix specimens removed for acute appendicitis at our institution. Pathologic specimens were reviewed by a single pathologist to identify sulfur granules or actual actinomysis species within the specimen. Demographic data, lab value, and radiology were reviewed for all patients in the review. Appendiceal specimens were categorized as either gangrenous/perforated or acute inflammation.
Results:
There were a total of 16 cases of perforated/gangrenous appendicitis amongst our 50 cases for a total of 32%. For patients with gangrene/perforation (n=16) there were 6 cases of Actinomysis identified in the pathologic specimen (37.5%). For the 34 patients with acute inflammation Actinomysis was not identified on any of the pathologic specimens.
The average white blood cell (WBC) level for all patients in our sample was 13.72. We did not find a difference in WBC levels between gangrenous/perforated and acutely inflamed (13.71/13.73). Patients with Actinomysis found on pathology however had an average WBC of 14.58.
Conclusions:
In patients with gangrenous or perforated appendicitis there is a 37.5% chance that Actinomysis is present in the appendix. While in patients without perforation or gangrene no Actinomysis was identified on pathologic review. Actinomysis could be the cause of severe inflammation and early gangrene in patients with appendicitis. Since Actinomysis is best treated with a long course of Penicillin based antibiotics, patients with gangrene may benefit from penicillin based treatment for longer than the standard 2 week course.
Demographic Data
| Gender | M=35 F=15 | | Age | 32.6 | | Gangrene/Perforation | 16/50 | | Nonperforated | 34/50 | | Actinomysis | 6/50 | | Actinomysis Associated with Gangrene/Perforation | 6/16 | | Actinomysis Associated with Nonperforated | 0/34 | | WBC all cases | 13.72 | | WBC Gangrene/Perforation | 13.71 | | WBC Nonperforated | 13.73 | | WBC Actinomysis | 14.58 |
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