Actinomycotic endocarditis is a rare disease with only 18 documented cases to date. Most of these cases are sub-acute or chronic infections and usually lack the stigmata of classic endocarditis. This article reviews the details of previously published reports of endocarditis due to various species of actinomyces, along with consensus opinion on diagnosis and treatment. We also present our unique case of Actinomyces naeslundii infective endocarditis, the first case ever attributed to this organism in medical literature.

A 58-year-old woman with an unconfirmed diagnosis of uterine fibroids, and a past medical history of uterine polyps, two cesarean sections and a right inguinal herniorraphy presented to the emergency department with 1 month of sharp right lower quadrant pain that had become debilitating 24 h prior to presentation. She also complained of vaginal discharge and bleeding while denying nausea, vomiting and fever. Physical examination revealed a mass in the right inguinal area that was exquisitely tender to palpation and irreducible at the bedside. Her symptoms were exacerbated with a valsalva maneuver. Bowel sounds were present in all four quadrants. Laboratory findings were all within normal limits. She remained afebrile. The patient had an abdominal/ pelvic MRI earlier that day at an outlying facility ordered by her gynecologist. Unfortunately, the results were not available at the time the patient presented. On further consultation, recommendations were made for outpatient follow up. Given the patient's presentation, undifferentiated gynecologic pathology and history of multiple abdominal surgeries, further evaluation was warranted to solidify the diagnosis, and to confirm the need for surgical intervention for the most likely diagnosis of an incarcerated inguinal hernia. Computed tomography (CT) of the abdomen revealed a fibroid uterus, focal lesions in the urinary bladder and right indirect inguinal hernia containing the appendix with mild stranding and thickening of the hernia sac wall concerning for acute appendicitis (Figs. 1, 2 and 3). The appendix measured 7.0 cm in length and 0.7 cm in diameter on pathologic evaluation. DiscussionAn inguinal hernia containing a vermiform appendix is known as an appendicocele. Claudius Amyand is noted as the first surgeon to perform a successful appendectomy and herniorraphy in an appendicocele. In 1735, Amyand operated on an 11-year-old boy whose inguinal hernia encompassed an inflamed appendix [1]. Of all incarcerated hernias, it has been estimated that only 1 % contain a normal appendix, and most present as did our case with a strangulated right-sided inguinal hernia [1,2]. Even more rare is the presence of appendicitis within the hernia sac at 0.13 % [1]. Pain is often described as crampy, achy or burning with tenderness to palpation over the inguinal region [4]. Plain radiographs are of little help unlike ultrasound or CT scans that assist in the diagnosis [3]. In one report studying appendicoceles in adults, this rare condition was more common in men than women with a median age of 42 years [3]. The treatment of choice for appendicocele is appendectomy through a herniotomy incision followed by herniorraphy [4]. The use of prosthetic material is not advised with evidence of inflammation [3].Our patient, within 4 h of diagnosis, was treated preoperatively with intravenous antibiotics followed by open appendectomy and inguinal hernia repair, without the use of prosthetic material.