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Re: Actinomyces on pap in a woman with and IUDFrom: Efrain Ramirez (eramirezt@coqui.net)Sun Dec 4 18:31:19 2005
I know you looked this one up - for the benefit of others... I haven't seen a report of Actinomyces in a Pap smear in many, many years - I wonder why...?? and we do have an excellent Path Lab.. I'll ask them Ef
>At Sun, 4 Dec 2005, Scott Oesterling wrote: CLINICAL MANAGEMENT GUIDELINES FOR OBSTETRICIAN—GYNECOLOGISTS NUMBER 59, JANUARY 2005 What treatment options are appropriate for an asymptomatic patient with an IUD who has actinomyces identified on a Pap test? Actinomyces israelii, a gram-positive anaerobic bacterium normally found in the human gastrointestinal tract, may be a normal component of vaginal flora. This organism may be more prevalent in the genital tract of IUD users than in nonusers. The likelihood of colonization appears to increase with increasing duration of IUD use (41). Recent studies demonstrated that colonization may be lower in levonorgestrel intrauterine system users than in copper IUD users (2.9% versus 5–10%) (41–43). However, actinomyces found via a Pap test is not diagnostic of actinomycosis infection, nor is it predictive of future disease. Pelvic actinomycosis is a very rare but serious condition characterized by granulomatous pelvic abscesses. Its prevalence has been estimated to be less than 0.001%; because of its rarity, the relationship between actinomyces found on a Pap test in an asymptomatic IUD user and the eventual development of this infection is unclear. Studies of pelvic actinomycosis are limited to case reports, so management of the asymptomatic IUD user whose Pap test shows actinomyces is not clearly established. A recent review of pelvic actinomycosis underlines the ubiquity of Actinomyces israelii in both IUD users and nonusers and the lack of an association between the finding of this organism on a Pap test and adverse outcomes when no treatment is offered (44). A single randomized controlled trial has looked at management of asymptomatic IUD users with actinomyces identified on a Pap test (45). Women were randomized to undergo either removal of the IUD and receive oral antibiotics or receive oral antibiotics alone. One month after treatment, the Pap test was repeated. No Pap tests revealed actinomyces in the women whose IUDs were removed. Thirty-three percent of Pap tests still showed actinomyces in the group of women who received antibiotics alone. However, the importance of clearing the actinomyces colonization is still not established. The options for management of asymptomatic IUD users with actinomyces on Pap test are expectant management, an extended course of oral antibiotics, removal of the IUD, and both antibiotic use and IUD removal. JAMA. 1982 Feb 26;247(8):1149-52. Detection and prevalence of IUD-associated Actinomyces colonization and related morbidity. A prospective study of 69,925 cervical smears. Valicenti JF Jr, Pappas AA, Graber CD, Williamson HO, Willis NF. Cervical Papanicolaou smears from 69,925 women were screened prospectively for the presence of Actinomyces israelii. The organism was not identified in non-intrauterine (contraceptive) device (IUD)-wearers. The prevalence of A israelii among IUD wearers ranged from 1.6% (general population) to 5.3% (clinic population). Protracted IUD use seemed to predispose to a higher incidence of infection. Direct immunofluorescence proved to be a more accurate and specific method of identification when compared with conventional light microscopy and anaerobic culture. Two of 112 women with direct immunofluorescence-proved A israelii had significant clinical infections. It appears that in the vast majority of cases, IUD-associated Actinomyces colonization produces only a superficial infestation. Conservative management is suggested for asymptomatic patients with cytologically detected Actinomyces to include removal of the IUD and repeated Papanicolaou smear after the next menstrual period. PIP: Cervical Papanicolaou smears from a population of 69,700 women including 6450 IUD users were prospectively analyzed for the presence of Actinomyces israelii during a 20-month period. No clinical evidence of actinomycete-like organisms was found in any non-IUD wearers. In IUD users, 212 Papanicolaou stained smears or 1.6% were found positive with actinomycetes when examined by light microscopy. The length of time of IUD insertion averaged 6.1 years, with a range from 6 months to 14 years. A 2nd study of 225 family planning clinic patients revealed a 5.3% prevalence of Actinomyces israelii among IUD users. Average length of IUD use was 6.5 years, with a range of 1-14 years. Direct immunofluorescence appeared more accurate for diagnosis than light microscopy or Pap smears. The study suggests that protracted IUD use predisposes to a higher incidence of infection. No specific type of IUD was associated with higher risk. Only 2 patients had clinically significant infection and most were asymptomatic, suggesting that the organism causes a superficial infestation of the endometrium which is shed with the menstrual period. Full diagnostic workup with appropriate therapy is required for the management of clinically proven infection, while asymptomatic women with cytological evidence of Actinomyces may require conservative management, including IUD removal and repeated Pap smears.
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