Actinomyces-Related Tubo-Ovarian Abscess in a Poorly Controlled Type II Diabetic With a Copper Intrauterine Device

Background: The historic association of Actinomyces israelii infection with intrauterine devices (IUDs) has long been recognized. In recent years, the risk of developing pelvic inflammatory disease with a copper or levonorgestrel IUD has been less than 1% in women who are low risk for sexually transmitted infections. IUD-related pelvic infections secondary to actinomyces have largely vanished from contemporary practice. Case: A 49-year-old using a copper IUD for contraception with poorly controlled type II diabetes mellitus was admitted for suspected tubo-ovarian abscess on the basis of abdominopelvic pain, leukocytosis, and computed tomography findings. After she was treated with intravenous and outpatient antibiotics with clinical improvement, repeat imaging 1 month later revealed a persistent complex left adnexal mass. Tumor markers were negative but given the persistence and complex nature of the mass, surgical management was recommended. A robotic-assisted hysterectomy with bilateral salpingo-oophorectomy was performed. Adhesiolysis, profuse irrigation, and ureteral stenting were required. Pathology revealed bilateral tubo-ovarian abscesses with actinomyces species identified on intraoperative culture. The patient had a total of 10 days of postoperative antibiotics and improved glucose control with no further signs of infection. Conclusion: Although actinomyces-related IUD PID is considered an outdated diagnosis, there are intermittent case reports of bizarre presentations in older women, often mimicking malignancy. Actinomyces should be a consideration in tubo-ovarian abscesses or pelvic inflammatory disease in patients with an IUD in place, particularly those who have poor glucose control or are other-wise immunosuppressed. Early identification and treatment of actinomyces tubo-ovarian abscesses may reduce surgical morbidity and overall improve patient outcomes and safety.