| Author | Affiliation |
|---|---|
| Kristi Stanley, MD | Keck School of Medicine, University of Southern California, Los Angeles, California |
| Daniela Morato, MD | Keck School of Medicine, University of Southern California, Los Angeles, California |
| Mikaela Chilstrom, MD | Keck School of Medicine, University of Southern California, Los Angeles, California |
CASE REPORT
A previously healthy 30-year-old woman (gravida 1 para 1) presented to the emergency department (ED) with 5 days of lower abdominal pain, fever, and nausea. On examination, she had a temperature of 37.6° Celsius, pulse 116 beats/ minute, blood pressure 123/65 mmHg, respiratory rate 18 breaths/minute, and oxygen saturation 98% on room air. On bimanual examination, the patient exhibited bilateral adnexal tenderness, but no cervical motion tenderness. Relevant laboratory studies included negative urine beta-hCG, white blood cell count 17.4×103/μL and lactate 2.4 mmol/L.
A bedside transabdominal pelvic ultrasound demonstrated bilateral complex adnexal masses suspicious for tubo-ovarian abscesses (Video). The patient received intravenous piperacillin/tazobactam, doxycycline, and clindamycin and was admitted to the gynecology service. Surgery was initially deferred and she was managed conservatively with intravenous antibiotics. By the third day of hospitalization, her symptoms had not resolved and an exploratory laparotomy demonstrated purulent ascites and necrotic uterus, ovaries, and fallopian tubes, necessitating a total abdominal hysterectomy and bilateral salpingo-oophorectomy. The patient was discharged home 3 days following the surgery without further complications.
DISCUSSION
Tubo-ovarian abscess (TOA) is the most common form of intra-abdominal abscess in premenopausal women,1,2 occurring in up to 30% of women hospitalized with pelvic inflammatory disease.3,4 Ultrasound is the preferred diagnostic study for TOA, with moderate sensitivity (56–93%) and high specificity (86–98%) among radiology-performed studies.5,6 The increasing availability of ultrasound in the ED can aid in the early diagnosis of this common and potentially life-threatening condition.7 Ultrasound findings suggestive of TOA include loss of tissue boundaries between pelvic organs; thick, dilated fallopian tubes; and complex adnexal masses with irregular margins.7,8 TOAs should be treated with intravenous broad-spectrum antibiotics.9 Surgery should be considered in patients with signs of rupture, abscess >9 cm, and who do not improve with antibiotics.10
Transverse transabdominal ultrasound of the pelvis performed with a 5-2MHz curvilinear probe demonstrates bilateral complex septated adnexal masses.
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Footnotes
Address for Correspondence: Daniela Morato, MD. 1975 Zonal Ave., Los Angeles, CA 90089. Email: daniela.morato@gmail.com. 11 / 2013; 14:641 – 642
Submission history: Revision received June 5, 2013; Submitted July 8, 2013; Accepted July 15, 2013
Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none. The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the United States Army, Department of Defense, or the United States government
REFERENCES
1. Zeger W, Holt K Gynecologic infections. Emerg Med Clin North Am. 2003; 21:631-648
2. Slap GB, Forke CM, Cnaan A Recognition of tubo-ovaran abscess in adolescents with pelvic inflammatory disease. J Adolesc Health. 1996; 18:397-403
3. Sørbye IK, Jerve F, Staff AC Reduction in hospitalized women with pelvic inflammatory disease in Oslo over the past decade. Acta Obstet Gynecol Scand. 2005; 84:290-296
4. Landers DV, Sweet RL Tubo-ovarian abscess: contemporary approach to management. Rev Infect Dis. 1983; 5:876-884
5. Lee DC, Swaminathan AK Sensitivity of ultrasound for the diagnosis of tubo-ovarian abscess: a case report and literature review. J Emerg Med. 2011; 40:170-175
6. Lambert MJ, Villa M Gynecologic ultrasound in emergency medicine. Emerg Med Clin North Am. 2004; 22:683-696
7. Adhikari S, Blaivas M, Lyon M Role of bedside transvaginal ultrasonography in the diagnosis of tubo-ovarian abscess in the emergency department. J Emerg Med. 2008; 34:429-433
8. Timor-Tritsch IE, Lerner JP, Monteagudo A Transvaginal sonographic markers of tubal inflammatory disease. Ultrasound Obstet Gynecol. 1998; 12:56-66
9. Pelvic inflammatory disease – 2010 STD treatment guidelines. . ;
10. Wiesenfeld HC, Sweet RL Progress in the management of tuboovarian abscesses. Clin Obstet Gynecol. 1993; 36:433-444