Malakoplakie of the ovary: Case report and litterature review

Malakoplakie, also known as malakoplasia [1], is an infl ammatory granulomatous disease induced by defective phagocytic macrophagic activity. It usually affects the whole body, but the genitourinary tract in about 75% of reported cases. Other organs such as the gastrointestinal tract, thyroid, pancreas, liver, brain, lymph nodes, adrenals, skin, bones, backpertis and ovary are less common. It represents a defi cit in the macrophagic digestion of bacteria, but its precise pathogenesis is not yet clear [1]. Its treatment is essentially based on antibiotic therapy [2]. We report a malakoplakie observation in order to expose the diffi culties associated with its management in a resource-limited environment.

Remote evolution was towards a recurrence of symptomatology with chronic parietal suppuration and armour of the pelvis. The patient was remissioned on fl uoroquinolonesbased antibiotic therapy (ciprofl oxacin 5OOmg every 12 hours) and metronidazole 500mg every 8 hours scheduled for three weeks. In front of the abdominal-pelvic armour, a surgical abstention was indicated with continued medical treatment. Under this treatment the evolution gradually turned to hematuria, a unilateral edema of the left pelvic limb. The requested abdominal-pelvic scanner could not be carried out due to a lack of fi nancial means. The patient was discharged 3 days later against medical advice.

Discussion
Malakoplakie is originally a Greek word meaning "soft plate." It is an unusual infl ammatory disease that was initially described as affecting the bladder. It can be observed at any age with a peak frequency at the age of fi fty. Both sexes can be achieved, but with a preference for the female sex [3]. The case described in our observation had interested a 41-year-old woman.
In 1902, Michaelis and Gutmann discovered during the autopsy of two women with a long history of cystitis, curious lesions in the bladder [4] before reporting cases of damage to the entire urogenital system, the digestive system, the skin, lungs, bones and mesenteric ganglia [5].
Extra-urinary lesions are less common and occur in 40% of cases. They are of interest to the digestive tract in 20% of cases and backperittisy in 10% of cases [3]. Isolated cases have been reported in the skin, vulva, vagina, endometrial, adrenal and brain [6].
Favourable factors such as intercurrent disease or immunosuppression were reported in 40% of cases by Long and Stanton [7]. The use of long-term anti-infl ammatory in our patient could be considered in our case as a factor promoting a decrease in immunity and therefore of the disease.
Recent cases have been reported in heart, kidney and AIDS transplant patients [8].
Malakoplakie does not clinically offer any specifi city [7].   cotrimoxazole trimethophyprime [11]. The addition of ascorbic acid to these drugs appears to improve the performance of treatment [9]. Immunosuppressive treatments should be discontinued whenever possible. In case of abscess, drainage may be indicated. Surgical treatment is indicated in case of destruction of the affected organ [8]. In our case, we had used fl uoroquinolones with the cessation of anti-infl ammatory drugs. Exeresis of the affected organ may be necessary as the left oophorectomy performed in our case followed by drainage of the peritoneal cavity. Unfortunately, appropriate antibiotic therapy was instituted with a little delay and was not always well followed, therefore not allowing good infection control.
The evolution can be made towards aggravation by impacting on the neighboring and compression organs of the pelvis [12]. This has been observed in our patient. Unilateral edema in our patient may be related to neurovascular extrinsic compression. Departure against medical advice is a common fact on the periphery. As in our current case, it does not allow for good patient follow-up or effective assessment of management.

Conclusion
Malakoplakie is a rare condition. Its management is medical and sometimes surgical. The follow-up of our patient was not satisfactory due to a departure against medical advice. This is a behaviour to be discouraged under our skies because it does not allow a good evaluation of the treatments instituted.