Clinical Review & Education
JAMA Surgery Clinical Challenge
Abdominal Wall Mass Kathryn Cameron, MD; Krista Bannon, MD; Vijay Mittal, MD
A
B
C
Figure 1. A, Right flank mass on initial presentation. B, Coronal view of a computed tomography (CT) scan showing a right flank mass invading the liver. C, Axial view of the CT scan showing the flank mass extending from the diaphragm to the iliac crest.
A man in his 60s presented to the emergency department with a right flank mass that had been present for 4 weeks. The mass was associated with increasing pain as it grew rapidly, starting from the size of a dime and increasing to extend 15 cm. The patient reported spontaneous drainage of pus from the mass and an unexplained weight loss. His medical history Quiz at jamasurgery.com included hypertension and diabetes mellitus; he had no recent travel. Physical examination revealed a large palpable mass with central fluctuance and surrounding erythema. The mass extended from the subcostal region to the anterior superior iliac spine on palpation and was tender to touch. No active drainage was noted; however, multiple pustules were present (Figure 1A). Computed tomography of the chest, abdomen, and pelvis showed a large (10 × 15 cm) soft-tissue mass in the right lateral abdominal wall, extending from the level of the diaphragm to the iliac crest (Figure 1B and C). The mass appeared to directly invade the liver and extend through intercostal spaces with multiple small areas of calcification. Core needle biopsy showed inconclusive results, and a recommendation was made for a fresh tissue biopsy. The patient was then taken to the operating room where an excisional biopsy was performed.
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WHAT IS THE DIAGNOSIS?
A. Malignant sarcoma B. Fungal mycetoma C. Giant infiltrating lipoma D. Bacterial abscess
JAMA Surgery July 2014 Volume 149, Number 7
Copyright 2014 American Medical Association. All rights reserved.
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Clinical Review & Education JAMA Surgery Clinical Challenge
Diagnosis B. Fungal mycetoma
Discussion Multiple yellow granules were evacuated intraoperatively, as well as a substantial amount of purulent drainage and necrotic tissue. Samples examined in the pathology laboratory showed delicate branching microorganisms within abscess material (Figure 2); these were suspicious for actinomyces. An abdominal wall actinomycotic mycetoma was diagnosed, and trimethoprim-sulfamethoxazole was started for treatment. Fungal mycetoma is a chronic cutaneous/subcutaneous infection caused by various genera of fungi. Cases are rarely reported in North America, with predilection to tropical locations. Although fun-
Figure 2. Grocott-Gomori methenamine–silver nitrate stain of tissue after excisional biopsy. Original magnification ×600.
ARTICLE INFORMATION
REFERENCES
Author Affiliations: Department of Surgery, Providence Medical Center, Southfield, Michigan.
1. Gupta SK, Shukla VK, Khanna S. Primary actinomycotic mycetoma of the anterior abdominal wall (a case report). J Postgrad Med. 1990;36(3): 175-177.
Corresponding Author: Vijay Mittal, MD, Department of Surgery, Providence Medical Center, 16001 W Nine Mile Rd, Southfield, MI 48075 (vijay [email protected]). Section Editor: Carl E. Bredenberg, MD. Accepted for Publication: June 18, 2013. Published Online: June 4, 2014. doi:10.1001/jamasurg.2013.3403. Conflict of Interest Disclosures: None reported.
744
gal mycetoma most commonly presents as an infection of cervicofacial or extremity (Madura foot) locations, cases of abdominal wall invasion have been reported.1 The disease is usually limited to the skin and subcutaneous tissue with later invasion into deeper fascial planes. Characteristically, the disease begins as a painless swelling with development of abscesses or sinus tracts draining seropurulent discharge or black, white, or yellowish granules.1,2 Patients classically experience abdominal pain, nausea, vomiting, diarrhea, chronic low-grade fever, and possible weight loss. Depending on the location of invasion a palpable mass with skin discoloration may be noted.3,4 Such a rare presentation is more common in immunocompromised patients.5 Fungal mycetoma is common in Africa, India, Mexico, and Central America. It is found primarily in rural areas among agricultural laborers with wounds inoculated with the causative organism. The disease course depends on the causative organism.2,3 The rare cases of abdominal invasion are predominantly actinomycotic, consisting of the gram-positive anaerobic bacteria Actinomyces israelii.6 These filamentous bacteria usually colonize the oral cavity, gastrointestinal tract, and vagina.5,6 A previous theory4,5 suggested that infection could be secondary to a breakdown in mucosal integrity resulting from surgery (eg, appendectomy) or trauma. However, when the site of the primary abscess is not related to disruption of the mucosal barrier, hematologic spread may be suspected. Actinomycosis is a chronic abscess-forming disease that most commonly involves the cervicofacial area or foot (ie, Madura foot). Primary abdominal wall actinomycosis involving the musculoaponeurotic layers is a diagnosis of exclusion. Imaging often reveals infiltrative lesions of irregular density. Excision and drainage and surgical intervention may be necessary for diagnostic purposes in cases suspicious for muscular tumor or sarcoma because of the extensive size of the mass, complications such as peritonitis or compression of abdominal organs, or when medical management with antibiotics has failed to achieve improvement in a patient’s condition. The first-line treatment remains penicillin. In our case trimethoprim-sulfamethoxazole was used because of the extensive size of the patient’s lesion.
2. Jung EY, Choi SN, Park DJ, You JJ, Kim HJ, Chang SH. Abdominal actinomycosis associated with a sigmoid colon perforation in a patient with a ventriculoperitoneal shunt. Yonsei Med J. 2006;47 (4):583-586.
4. Hefny AF, Joshi S, Saadeldin YA, Fadlalla H, Abu-Zidan FM. Primary anterior abdominal wall actinomycosis. Singapore Med J. 2006;47(5): 419-421. 5. Deodhar SD, Shirahatti RG, Vora IM. Primary actinomycosis of the anterior abdominal wall (a case report). J Postgrad Med. 1984;30(2):133-134. 6. Owen K, Flannery MT, Elaini AB, Rivera J. Actinomycotic tumor of the abdominal wall. South Med J. 2004;97(2):175-177.
3. Minocha VR, Sharma MM, Nair SK. Primary actinomycosis of the abdominal wall. Aust N Z J Surg. 1975;45(1):66-68.
JAMA Surgery July 2014 Volume 149, Number 7
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Tulane University User on 05/19/2015
jamasurgery.com
JAMA Surgery Clinical Challenge
Abdominal Wall Mass Kathryn Cameron, MD; Krista Bannon, MD; Vijay Mittal, MD
A
B
C
Figure 1. A, Right flank mass on initial presentation. B, Coronal view of a computed tomography (CT) scan showing a right flank mass invading the liver. C, Axial view of the CT scan showing the flank mass extending from the diaphragm to the iliac crest.
A man in his 60s presented to the emergency department with a right flank mass that had been present for 4 weeks. The mass was associated with increasing pain as it grew rapidly, starting from the size of a dime and increasing to extend 15 cm. The patient reported spontaneous drainage of pus from the mass and an unexplained weight loss. His medical history Quiz at jamasurgery.com included hypertension and diabetes mellitus; he had no recent travel. Physical examination revealed a large palpable mass with central fluctuance and surrounding erythema. The mass extended from the subcostal region to the anterior superior iliac spine on palpation and was tender to touch. No active drainage was noted; however, multiple pustules were present (Figure 1A). Computed tomography of the chest, abdomen, and pelvis showed a large (10 × 15 cm) soft-tissue mass in the right lateral abdominal wall, extending from the level of the diaphragm to the iliac crest (Figure 1B and C). The mass appeared to directly invade the liver and extend through intercostal spaces with multiple small areas of calcification. Core needle biopsy showed inconclusive results, and a recommendation was made for a fresh tissue biopsy. The patient was then taken to the operating room where an excisional biopsy was performed.
jamasurgery.com
WHAT IS THE DIAGNOSIS?
A. Malignant sarcoma B. Fungal mycetoma C. Giant infiltrating lipoma D. Bacterial abscess
JAMA Surgery July 2014 Volume 149, Number 7
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Tulane University User on 05/19/2015
743
Clinical Review & Education JAMA Surgery Clinical Challenge
Diagnosis B. Fungal mycetoma
Discussion Multiple yellow granules were evacuated intraoperatively, as well as a substantial amount of purulent drainage and necrotic tissue. Samples examined in the pathology laboratory showed delicate branching microorganisms within abscess material (Figure 2); these were suspicious for actinomyces. An abdominal wall actinomycotic mycetoma was diagnosed, and trimethoprim-sulfamethoxazole was started for treatment. Fungal mycetoma is a chronic cutaneous/subcutaneous infection caused by various genera of fungi. Cases are rarely reported in North America, with predilection to tropical locations. Although fun-
Figure 2. Grocott-Gomori methenamine–silver nitrate stain of tissue after excisional biopsy. Original magnification ×600.
ARTICLE INFORMATION
REFERENCES
Author Affiliations: Department of Surgery, Providence Medical Center, Southfield, Michigan.
1. Gupta SK, Shukla VK, Khanna S. Primary actinomycotic mycetoma of the anterior abdominal wall (a case report). J Postgrad Med. 1990;36(3): 175-177.
Corresponding Author: Vijay Mittal, MD, Department of Surgery, Providence Medical Center, 16001 W Nine Mile Rd, Southfield, MI 48075 (vijay [email protected]). Section Editor: Carl E. Bredenberg, MD. Accepted for Publication: June 18, 2013. Published Online: June 4, 2014. doi:10.1001/jamasurg.2013.3403. Conflict of Interest Disclosures: None reported.
744
gal mycetoma most commonly presents as an infection of cervicofacial or extremity (Madura foot) locations, cases of abdominal wall invasion have been reported.1 The disease is usually limited to the skin and subcutaneous tissue with later invasion into deeper fascial planes. Characteristically, the disease begins as a painless swelling with development of abscesses or sinus tracts draining seropurulent discharge or black, white, or yellowish granules.1,2 Patients classically experience abdominal pain, nausea, vomiting, diarrhea, chronic low-grade fever, and possible weight loss. Depending on the location of invasion a palpable mass with skin discoloration may be noted.3,4 Such a rare presentation is more common in immunocompromised patients.5 Fungal mycetoma is common in Africa, India, Mexico, and Central America. It is found primarily in rural areas among agricultural laborers with wounds inoculated with the causative organism. The disease course depends on the causative organism.2,3 The rare cases of abdominal invasion are predominantly actinomycotic, consisting of the gram-positive anaerobic bacteria Actinomyces israelii.6 These filamentous bacteria usually colonize the oral cavity, gastrointestinal tract, and vagina.5,6 A previous theory4,5 suggested that infection could be secondary to a breakdown in mucosal integrity resulting from surgery (eg, appendectomy) or trauma. However, when the site of the primary abscess is not related to disruption of the mucosal barrier, hematologic spread may be suspected. Actinomycosis is a chronic abscess-forming disease that most commonly involves the cervicofacial area or foot (ie, Madura foot). Primary abdominal wall actinomycosis involving the musculoaponeurotic layers is a diagnosis of exclusion. Imaging often reveals infiltrative lesions of irregular density. Excision and drainage and surgical intervention may be necessary for diagnostic purposes in cases suspicious for muscular tumor or sarcoma because of the extensive size of the mass, complications such as peritonitis or compression of abdominal organs, or when medical management with antibiotics has failed to achieve improvement in a patient’s condition. The first-line treatment remains penicillin. In our case trimethoprim-sulfamethoxazole was used because of the extensive size of the patient’s lesion.
2. Jung EY, Choi SN, Park DJ, You JJ, Kim HJ, Chang SH. Abdominal actinomycosis associated with a sigmoid colon perforation in a patient with a ventriculoperitoneal shunt. Yonsei Med J. 2006;47 (4):583-586.
4. Hefny AF, Joshi S, Saadeldin YA, Fadlalla H, Abu-Zidan FM. Primary anterior abdominal wall actinomycosis. Singapore Med J. 2006;47(5): 419-421. 5. Deodhar SD, Shirahatti RG, Vora IM. Primary actinomycosis of the anterior abdominal wall (a case report). J Postgrad Med. 1984;30(2):133-134. 6. Owen K, Flannery MT, Elaini AB, Rivera J. Actinomycotic tumor of the abdominal wall. South Med J. 2004;97(2):175-177.
3. Minocha VR, Sharma MM, Nair SK. Primary actinomycosis of the abdominal wall. Aust N Z J Surg. 1975;45(1):66-68.
JAMA Surgery July 2014 Volume 149, Number 7
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Tulane University User on 05/19/2015
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