What's Wrong With This Picture?

A 24-year-old woman presents to the emergency department with increasing left lower quadrant pain, nausea, and persistent retching and vomiting of 48 hours’ duration. The pain ranges from dull and aching to cramping; it has become generalized, and there is no specific relieving factor. During the last 12 hours, she has also had fever and chills. She has no urinary symptoms, hematemesis, melena, diarrhea, constipation, or abdominal distention.

Her last menstrual period was about 3 weeks earlier; her cycles are usually normal. She is sexually active, has 1 partner, and had an intrauterine device (IUD) placed about 1 year ago. She has not noticed any vaginal discharge recently, and she has no history of pelvic inflammatory disease (PID) or sexually transmitted diseases. She takes no medications and does not drink alcohol or use illicit drugs.

This young woman appears to be in agony. Pulse rate is 110 beats per minute and regular; temperature, 38.4^oC (101^oF); respiration rate, 22 breaths per minute; blood pressure, 102/72 mm Hg. She is well hydrated. Head, eyes, ears, nose, and throat are normal: no icterus, candidal infection, or erythema. Skin is flushed but without rashes. No evidence of adenopathy or ankle swelling; thyroid is not palpable. Abdomen has normal contours; generalized diffuse tenderness and guarding is noted in the left lower quadrant. No palpable organomegaly. Stool is guaiac-negative, and bowel sounds are normal. Vaginal examination is difficult to perform because of the patient’s severe pain. The remainder of the examination is normal.

White blood cell count is 24,000/μL, with 90% neutrophils and 10% lymphocytes; hemoglobin level, 14 g/dL; platelet count, 212,000/μL; erythrocyte sedimentation rate (ESR), 88 mm/h. Urinalysis results are normal.

You order an ultrasound scan of the abdomen and pelvis.

What abnormality does the scan reveal-and to what diagnosis does the clinical picture point?A. Ectopic pregnancy
B. Acute appendicitis
C. Tubo-ovarian abscess.
D. Torsion of ovarian cyst
E. Rupture of an ovarian follicle

 A CASE IN POINT
Tubo-ovarian abscess formation is most commonly associated with acute or recurrent episodes of PID. From 20% to 54% of patients with a tubo-ovarian abscess have an IUD or have undergone recent uterine instrumentation.

Causative organisms. Those implicated in the development of tubo-ovarian abscesses are predominantly mixed flora: anaerobes, such as Bacteroides fragilis; and facultative or aerobic gram-negative enteric bacteria, such as Escherichia coli (Table). Anaerobic bacteria are isolated from 63% to 100% of abscesses.

In various studies, the most common organisms isolated from tubo-ovarian abscess aspirates have been E coli, B fragilis, Prevotella species, aerobic streptococci, Peptococcus species, and Peptostreptococcus species. Actinomycetes (most commonly Actinomyces israelii, a grampositive anaerobe) are also associated with tubo-ovarian abscesses, particularly in patients with IUDs. Eighty-eight percent of patients with PID caused by Actinomyces infection had a tubo-ovarian abscess. In developing countries, Mycobacterium tuberculosis is responsible for tubo-ovarian abscesses of insidious onset that have a chronic course. Neisseria gonorrhoeae and Chlamydia trachomatis-the primary pathogens in PID-play little role in the development of tubo-ovarian abscesses.

Clinical manifestations. Tubo-ovarian abscesses typically occur in young, nulliparous women. The presentation can vary widely. An asymptomatic adnexal mass may be found on routine examination, or the patient may have signs and symptoms of septic shock. Abdominal and/or pelvic pain is the presenting complaint in up to 90% of patients. Associated symptoms often include fever, chills, nausea, vomiting, and vaginal discharge or bleeding.

Physical examination typically reveals an elevated temperature and diffuse abdominal tenderness. An adnexal mass may be palpable; however, an adequate bimanual examination may be difficult because of patient discomfort.

Patients with a ruptured tubo-ovarian abscess can present with an acute abdomen. Signs and symptoms of sepsis-including hyperthermia or hypothermia, tachycardia, mental status changes, hypotension, and tachypnea- may be evident.

Differential diagnosis. For an asymptomatic unruptured tubo-ovarian abscess, the differential includes unruptured ectopic pregnancy, ovarian cysts or tumors, and uterine fibroids. A symptomatic unruptured abscess must be differentiated from ruptured ectopic pregnancy, urinary tract infection, acute appendicitis, or diverticular disease. Systemic illnesses that can cause abdominal pain, such as diabetic ketoacidosis and porphyria, also must be considered.

Laboratory and imaging studies. Leukocytosis and an elevated ESR are characteristic laboratory findings; however, almost 20% of patients have a normal leukocyte count.

A variety of noninvasive imaging techniques can help detect and confirm tubo-ovarian abscess. Ultrasonography is frequently used; this test is relatively sensitive and inexpensive. The ultrasound scan typically reveals a discrete mass that has internal echogenicity because of its complex structure. Ultrasonography is also useful for assessing the response to medical therapy.

CT is more sensitive and specific than ultrasonography, but it is also more costly. A common approach is to order an ultrasound scan initially and reserve CT scanning for patients in whom ultrasonography fails to confirm the diagnosis.

Treatment. The management of a tubo-ovarian abscess may be medical and/or surgical. Patients who have an unruptured symptomatic abscess should be hospitalized for supportive and antimicrobial therapy. Parenteral agents with good anaerobic coverage are essential. A combination of penicillin G, clindamycin, and an aminoglycoside is preferred. A fluoroquinolone in combination with metronidazole or clindamycin is another option.

Surgery is required for patients whose condition does not improve in 48 to 72 hours. Larger abscesses (greater than 10 cm) typically respond less frequently to antibiotics alone. Surgical intervention can involve CT- or ultrasound-guided drainage of the abscess; laparoscopy with drainage; or more aggressive management, including laparotomy with hysterectomy and adnexectomy.

Although the management of tubo-ovarian abscesses has become more conservative, surgical drainage is still performed in most patients after antibiotic therapy. If initial surgical therapy is successful, give an oral antibiotic, such as doxycycline, for 10 to 14 days.

A ruptured tubo-ovarian abscess is an emergency; immediate surgical intervention is warranted. Hysterectomy with bilateral salpingo-oophorectomy is usually performed.

Prognosis. When treated with antibiotics and surgical intervention if needed, patients with an unruptured tubo-ovarian abscess have an excellent prognosis. Before the advent of aggressive medical regimens to treat overwhelming sepsis, the mortality rate in patients with a ruptured tubo-ovarian abscess approached 80% to 90%. As a result of modern medical and surgical advances, the mortality rate is now less than 5%.

References:

FOR MORE INFORMATION:

• Cromer BA, Brandstaetter LA, Rischer RA, et al. Tubo-ovarian abscess in adolescents.Adolesc Pediatr Gynecol. 1990;3:21.
• Landers DV, Sweet RL. Tubo-ovarian abscess: contemporary approach tomanagement. Rev Infect Dis. 1983;5:876-884.
• McNeeley SG, Hendrix SL, Mazzoni MM, et al. Medically sound, cost-effectivetreatment for pelvic inflammatory disease and tuboovarian abscess. Am JObstet Gynecol. 1998;178:1272-1278.
• Nebel WA, Lucas WE. Management of tubo-ovarian abscess. Obstet Gynecol.1968;32:382-386.