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A T2 weighted sagittal midline and oblique axial MR images of the pelvis demonstrated features of “frozen pelvis” (fig 1A, B), with a solid and cystic tumour encasing the rectum. Differential diagnosis includes ovarian cancer and lymphoma. Transrectal ultrasound guided biopsy of the lesion showed inflammatory cells only. Due to the obstructive symptoms and uncertainty of the diagnosis, the patient underwent laparotomy and defunctioning colostomy. Actinomyces israelii was isolated from peritoneal fluid and the patient was treated with high dose penicillin. Her condition improved with antibiotics and reversal of colostomy is provisionally planned within a year.

Actinomycosis is commonly caused by Actinomyces israelii, which are Gram positive microaerophilic bacilli that present in the oropharynx and gastrointestinal tract. They can cause infection in damaged mucosa or in the presence of foreign bodies (for example, intrauterine contraceptive device in this case). Actinomycosis can mimic cancer and therefore preoperative diagnosis is difficult. Treatment is mainly conservative with antibiotics. Surgery is indicated in patients who have failed to respond to antibiotics, abscess formation, or in the presence of colonic obstruction.

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