Case 33-2016: A 30-Year-Old Woman with Severe Lower

n engl j med 375;17 nejm.org October 27, 20161672

T h e n e w e ngl a nd j o u r na l o f m e dic i n e

Pr esen tation of C a se

Dr. Katelyn M. Dorney (Obstetrics and Gynecology): A 30-year-old woman presented to the emergency department of this hospital with chills and sudden worsening of abdominal pain in both lower quadrants.

The patient was in her usual good health until 10 days before admission, when, after eating at a restaurant, she had nonbloody, nonbilious emesis that she attrib-uted to food poisoning. The vomiting persisted for 2 days and then resolved. One day later, bilateral abdominal pain developed; the pain waxed and waned for a few days. She then completed a 2-day driving trip as part of her relocation to New England for a new job. During the trip, she had watery, nonbloody diarrhea every time she tried to eat (about four times per day). Her travel companion ate foods that were similar to the foods she ate but was well. After the patient arrived at her final destination, chills, fevers, and “sharp” abdominal pain in both lower quad-rants, with bloating, developed. She took naproxen every 8 hours for the pain and noted some improvement. She had minimal appetite, and she noted that the fre-quency of the diarrheal episodes decreased when her eating decreased. However, abdominal pain persisted and intensified until she rated it as 9 to 10 on a scale of 0 to 10, with 10 indicating the most severe pain. Two nights later, she was seen in the emergency department of this hospital because of abdominal pain and dis-tention, diarrhea, and chills.

On arrival, the patient reported nausea and increased abdominal pain without further episodes of emesis. There was no hematochezia, melena, vaginal dis-charge, dysuria, or foul-smelling urine. Menarche had occurred at 12 years of age. Her menstrual periods occurred in normal 30-day cycles; her most recent men-strual period had been 2 weeks before this presentation. She had had no known contact with persons who were ill. She had no chest, flank, back, or neck pain, no dyspnea, and no swelling or pain in the calves. She had not lost weight.

The patient had a history of a 1-cm ovarian cyst, which had been identified during her early teenage years. She was of East Asian descent, had lived in the Midwest for the previous 10 years, and worked in a medical field. At presentation, she was taking no medications except naproxen, as well as ibuprofen for pain dur-ing menstruation. She had no known drug allergies. She did not smoke or use

From the Departments of Medicine (L.H.S.), Radiology (A.J.G.), Obstetrics, Gynecology, and Reproductive Biology (D.M.B.), and Pathology (J.N.S.), Massa‑chusetts General Hospital and Harvard Medical School — both in Boston.

N Engl J Med 2016;375:1672-81.DOI: 10.1056/NEJMcpc1609308Copyright © 2016 Massachusetts Medical Society.

Founded by Richard C. Cabot Eric S. Rosenberg, M.D., Editor Nancy Lee Harris, M.D., Editor Jo‑Anne O. Shepard, M.D., Associate Editor Alice M. Cort, M.D., Associate Editor Sally H. Ebeling, Assistant Editor Emily K. McDonald, Assistant Editor

Case 33-2016: A 30-Year-Old Woman with Severe Lower Abdominal Pain and Chills

Leigh H. Simmons, M.D., Alan J. Goldstein, M.D., David M. Boruta II, M.D., and Jennifer N. Stall, M.D.

Case Records of the Massachusetts General Hospital

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Case Records of the Massachusetts Gener al Hospital

alcohol or illicit drugs. She had never been sexu-ally active. Her father had diabetes mellitus, hyperlipidemia, and hypertension. There was no family history of cancer.

On examination, the temperature was 36.5°C, the heart rate 129 beats per minute, the blood pressure 123/66 mm Hg, the respiratory rate 20 breaths per minute, and the oxygen satura-tion 97% while the patient was breathing ambient air. Her body was well developed. She appeared to be uncomfortable except when she was lying flat. She appeared to be flushed, but there was no scleral icterus or rash. She had tachycardia, but the cardiac examination was otherwise nor-mal. The abdomen was mildly distended, with tenderness in both lower quadrants that was worst in the midline; there was voluntary guard-ing on palpation but no rebound, and bowel sounds were diminished. The remainder of the examination was normal.

Results of coagulation tests were normal, as were red-cell indexes and blood levels of magne-sium and globulin; other test results are shown in Table 1. Two sets of blood culture specimens and a urine culture specimen were obtained. A chest radiograph showed low lung volumes and patchy bibasilar opacities. A urine test for human chorionic gonadotropin was negative.

Intravenous normal saline, ciprofloxacin, metro-nidazole, and morphine were administered. Im-aging studies were obtained and additional diag-nostic procedures were performed.

Differ en ti a l Di agnosis

Dr. Leigh H. Simmons: This previously healthy 30-year-old woman presented with progressively worsening abdominal pain in both lower quad-rants, chills, leukocytosis, and a markedly ele-vated level of CA-125. I will begin by discussing how I might have approached this patient’s initial evaluation. At first glance, the key features of her presentation are the subacute nature of her illness, which included an initial period of vomit-ing, followed by a brief period of improvement, and then worsening abdominal pain, chills, and diarrhea. Notable elements of her history include her good health before this 10-day period of ill-ness began, a history of no abdominal operations, her place of birth in East Asia, and her report of never having had sexual intercourse.

The first days of the patient’s illness, which were characterized by vomiting, are consistent

with infectious gastroenteritis, although the per-sistence of gastrointestinal symptoms for more than 48 to 72 hours is unusual. If features of the illness deviate from those that are expected to occur over the self-limited, short course of gastroenteritis, we have to look for other causes. The sharp abdominal pain, chills, and fever that occurred later in the course of the patient’s ill-ness raise concern for a serious intraabdominal infection.

Initial Diagnostic Evaluation

The findings of tachycardia and discomfort un-less she was lying flat, with voluntary guarding, are suggestive of a process that is causing peri-tonitis, and at this point I would be concerned about conditions that can cause an intraabdom-inal abscess, such as diverticulitis, inflammato-ry bowel disease, ruptured appendix, and pelvic inflammatory disease. We know the patient is not pregnant and that she has marked leukocy-tosis. We do not have the results of the initial pelvic examination, but unless an adnexal mass or cervical discharge is present, I would proceed with cross-sectional imaging with computed tomography (CT), rather than ultrasonography, as an initial imaging method, since it is impor-tant to obtain images of the gastrointestinal and pelvic organs to determine whether abscess or visceral-organ inflammation is present. I would also contact a surgical colleague to evaluate the patient with me. May we see the imaging studies?

Dr. Alan J. Goldstein: A CT scan of the abdom-inal and pelvic regions was obtained after oral and intravenous administration of contrast material. The scan revealed a cystic structure (maximum diameter, 8.8 cm) with an asym-metrically thickened and enhancing wall in the pelvis, associated with the right adnexa. A simi-lar peripherally enhancing cystic structure (max-imum diameter, 4.3 cm) was associated with the left adnexa. Other findings included extensive retroperitoneal lymphadenopathy, ascites (with a moderate volume of f luid), and mild, diffuse thickening of multiple bowel loops (Fig. 1).

Dr. Simmons: After reviewing the imaging stud-ies, we learn that the patient has bilateral ovarian masses, ascites, and retroperitoneal lymphade-nopathy. Using this new information, we can reframe the differential diagnosis. Although these findings, when considered in combination with the patient’s clinical history, are suggestive of an infectious process, we must consider the possi-





VariableReference Range,

Adults†On Arrival, Emergency

Department of This HospitalThis Hospital,

Day 2

Blood

White‑cell count (per mm3) 4500–11,000 27,400 18,800

Polymorphonuclear cells (%) 40–70 93.1 93.4

Lymphocytes (%) 22–44 2.4 2.4

Hemoglobin (g/dl) 12.0–16.0 13.7 11.8

Hematocrit (%) 36.0–46.0 39.1 34.9

Platelet count (per mm3) 150,000–400,000 335,000 307,000

Sodium (mmol/liter) 135–145 132 134

Potassium (mmol/liter) 3.4–5.0 3.5 3.3

Chloride (mmol/liter) 100–108 92 98

Carbon dioxide (mmol/liter) 23–32 27.7 22.6

Urea nitrogen (mg/dl) 8–25 10 8

Creatinine (mg/dl) 0.60–1.50 0.56 0.35

Glucose (mg/dl) 70–110 85 70

Lactic acid (mmol/liter) 0.5–2.2 1.1

Calcium (mg/dl) 8.5–10.5 9.0 8.0

Protein (g/dl)

Total 6.0–8.3 7.0 5.6

Albumin 3.3–5.0 3.4 2.8

Aspartate aminotransferase (U/liter) 9–32 19 15

Alanine aminotransferase (U/liter) 7–33 15 11

Alkaline phosphatase (U/liter) 30–100 106 85

Lipase (U/liter) 13–60 14

Bilirubin (mg/dl)

Total 0.0–1.0 0.5 0.3

Direct 0.0–0.4 0.22 0.11

Human chorionic gonadotropin (IU/liter) <6 <6

CA‑125 (U/ml) 0.0–35.0 196.1

Urine

Specific gravity Not defined 1.020

Leukocyte esterase Negative 1+

Nitrite Negative Negative

Urobilinogen Negative 2+

Ketones Negative 2+

Sediment (per high‑power field)

Red cells 0–2 0–2

White cells 0–2 20–50

* To convert the values for urea nitrogen to millimoles per liter, multiply by 0.357. To convert the values for creatinine to micromoles per liter, multiply by 88.4. To convert the values for glucose to millimoles per liter, multiply by 0.05551. To convert the values for calcium to millimoles per liter, multiply by 0.250. To convert the values for bilirubin to micro‑moles per liter, multiply by 17.1.

† Reference values are affected by many variables, including the patient population and the laboratory methods used. The ranges used at Massachusetts General Hospital are for adults who are not pregnant and do not have medical condi‑tions that could affect the results. They may therefore not be appropriate for all patients.

Table 1. Laboratory Data.*





bility that she may have a benign or cancerous condition involving the ovaries.

Ovarian Cancer

Had I seen the radiology report in isolation, I would be very concerned about ovarian cancer. However, it would be unusual for a patient of this age to have ovarian cancer, and she has no family history of ovarian or breast cancer, which lends little support to the possibility that she has a genetic predisposition to early ovarian cancer. Her CA-125 level was markedly elevated, but I will discuss later that this tumor marker is rather nonspecific for ovarian cancer and that CA-125 levels can be elevated in patients who have various peritoneal diseases. At this point, I cannot rule out a diagnosis of ovarian cancer, but I think that the imaging studies showing ovarian masses with rim enhancement are far more likely to suggest an infectious process than cancer. Therefore, I will focus the differential diagnosis on tubo-ovarian infectious conditions.

Tubo-Ovarian Abscesses

Tubo-ovarian abscesses are manifestations of pelvic inflammatory disease that are usually caused by ascending genital tract infections. The infections that cause the abscesses are often polymicrobial, though Chlamydia trachomatis and Neisseria gonorrhoeae may occur in isolation. Risk factors for tubo-ovarian abscesses include sexu-ally transmitted infections, current or prior use of an intrauterine device (IUD), a history of instrumentation inside the genital tract, and a predisposition to gastrointestinal-tract inflam-mation caused by diseases such as diverticulitis and Crohn’s disease.

Our patient reported never having had sexu-al intercourse. This renders the most common cause of tubo-ovarian abscesses (ascending genital-tract infection in association with C. tra-chomatis or N. gonorrhoeae infection) less likely. However, other causes of tubo-ovarian abscesses, including actinomyces and Mycobacterium tubercu-losis infection, should be considered.

Actinomycosis has been reported to be a cause of pelvic infection and may mimic ovarian can-cer, since it causes bilateral ovarian masses, peri-toneal lymphadenopathy, and elevated CA-125 levels.1 However, nearly all reports of pelvic acti-nomycosis involve women who currently have (or have recently had) an IUD in place. This patient

has no history of ever having used an IUD. Thus, actinomycosis is an unlikely diagnosis.

Pelvic tuberculosis can also mimic ovarian cancer, since it causes adnexal masses, peritoneal lymphadenopathy, and elevated CA-125 levels. This patient’s age is within the range commonly

Figure 1. Imaging Studies of the Abdomen and Pelvis.

A contrast‑enhanced CT scan of the abdomen and pelvis shows bilateral cystic adnexal masses (Panel A, asterisks) with thick enhancing walls. Free fluid is present within the cul‑de‑sac, with thickening and enhancement of the peritoneum (Panel A, arrow). Coronal reformatted images show subtle peritoneal thickening and enhance‑ment (Panel B, arrowheads), as well as omental nodu‑larity (arrow) and retroperitoneal lymphadenopathy (asterisk).

*

*

A

B

*





associated with genital-tract tuberculosis, since this infection typically occurs in women who are 25 to 40 years of age.2 She was born in East Asia and could be at higher risk than the average patient for previous exposure to tuberculosis. However, several features of her presentation are less consistent with a diagnosis of pelvic tuber-culosis. Other than a remote history of an ovar-ian cyst, we have no information suggesting that before this acute illness, the patient was not feel-ing well; in addition, pelvic tuberculosis typically has an insidious onset. The radiograph of her chest also shows no evidence of a previous granulomatous disease, and although this does not exclude the possibility of extrapulmonary tuberculosis, it makes this diagnosis less likely.

Extension of a Bowel Infection

I am concerned that this patient’s pelvic infec-tion could be the result of an extension of a bowel infection. Complications of inflammatory bowel diseases such as Crohn’s disease or ulcer-ative colitis can lead to formation of a fistula and infection throughout the pelvis. A more acute condition such as diverticulitis or appendi-citis can cause extension of infection to involve the adnexa. There was no evidence on the CT scan of underlying bowel-wall thickening sugges-tive of inflammatory bowel disease, or diverticu-litis. The appendix could not be located on the CT scan — a “nonfinding” that occurs in up to 15% of CT scans.3 Visualization of a normal ap-pendix on this scan would have been highly re-assuring. The absence of a visualized appendix could suggest that the patient has a ruptured ap-pendix, with the appendix now subsumed with-in the inflammatory mass involving the right adnexa.

On my initial review of this case, I believed that a reasonable explanation for this patient’s symptoms was delayed manifestation of intra-abdominal infection associated with a ruptured appendix, which resulted in tubo-ovarian ab-scesses. She did not have the traditional risk factors for tubo-ovarian abscesses (i.e., she had no history of sexual intercourse or use of an IUD). The difficulty of differentiating tubo-ovarian abscesses (particularly tubo-ovarian ab-scesses that are on the right side only) from acute appendicitis is a well-described clinical challenge.4

A ruptured bowel with subsequent infection

could conceivably cause the development of tubo-ovarian abscesses, but the large cystic structures associated with both ovaries in this patient would be unusual features. I suspect that these cysts are underlying and were preexisting. Al-though ultrasonography would provide a clearer image of the cysts themselves and would be likely to aid us in reaching a more specific diag-nosis, the CT imaging study does show that the patient has cysts (maximum diameters, 8.8 cm and 4.3 cm) associated with her ovaries. These large cysts could represent benign ovarian neo-plasms such as cystadenomas, endometriomas, or cystic teratomas.

Complications of Benign Ovarian Neoplasms

There are two possible associations between pre-existing ovarian cysts and development of acute abdominal pain, fever, and leukocytosis: the rup-ture of a cyst or an infection of a cyst. A ruptured cyst can cause pain, fever, and leukocytosis. Blood from a cystadenoma or endometrioma might be intensely irritating to the peritoneum, and rupture of a teratoma, the contents of which include sebaceous fluid, hair, and cartilage, might also lead to intense irritation. However, this pa-tient had marked leukocytosis and pelvic lymph-adenopathy, and her white-cell count decreased after she received treatment with intravenous antibiotic agents. Thus, I suspect she had an in-fection of an ovarian cyst.

Elevated CA-125 Level

How should we interpret the elevated CA-125 level? As a large transmembrane glycoprotein derived from coelomic mesothelial cells (i.e., cells originating in the pericardium, pleura, or perito-neum) and müllerian epithelium (i.e., epithelium that lines the endometrium, endocervix, and fal-lopian tubes), CA-125 is a nonspecific marker for peritoneal inflammation. Many factors make an elevated CA-125 level unreliable for the screening and diagnosis of ovarian cancer, because many conditions can elevate the CA-125 level (Table 2), and specific patient characteristics can raise and lower the level. For example, CA-125 levels are higher in premenopausal women and in women of African or Asian descent and lower in post-menopausal women, in women who smoke, and in women who have had a hysterectomy.5 Thus, I do not think that the markedly elevated CA-125 level in this patient is diagnostic of ovarian can-





cer; rather, it indicates a high degree of pelvic and peritoneal inflammation. If she does have an infected endometrioma, both her underlying endometriosis and the acute infection could ac-count for the elevated CA-125 level.

Given the absence in this patient of tradi-tional risk factors for the common causes of tubo-ovarian abscesses, her low risk of ovarian cancer, the presence of large, bilateral ovarian cystic structures, and the markedly elevated CA-125 level, I think that the most likely diagnosis is a ruptured endometrioma. Although a rup-tured endometrioma alone can cause peritoneal irritation, I suspect that she has a superimposed infection, given her presenting symptoms and the finding of rim-enhancing masses on the imaging studies. Once an ovarian cyst has been opened to the peritoneum, an infection resulting from the translocation of bowel flora or ascend-ing genital-tract bacteria can develop.

I assume that this patient will be evaluated by a gynecologic surgeon. If her infection does not respond to antibiotics, drainage of the abscesses will be at the discretion of the managing surgeon.

Dr. David M. Dudzinski (Medicine): Dr. Dorney, what was your impression when you evaluated this patient?

Dr. Dorney: Initially, we were most concerned about the presence of a tubo-ovarian abscess or another infectious process. The patient’s CA-125 level was 196 U per milliliter, but because it was less than 200 U per milliliter in a premenopausal woman, we were less concerned about cancer than we would normally be for a patient with her CA-125 level, although we could not rule out peritoneal carcinomatosis.

Clinic a l Di agnosis

Tubo-ovarian abscess.

Dr . Leigh H. Simmons’s Di agnosis

Ruptured endometrioma with infection.

Discussion of M a nagemen t a nd Surgic a l Decision-M a k ing

Dr. David M. Boruta II: When I evaluated this pa-tient, I was confronted with several key questions: Was surgery necessary? If so, how urgently was it needed, what procedures should be performed, and what approach should be used? Her presenta-tion and imaging findings suggested an infec-tious process, despite her low risk of pelvic inflam-matory disease. Although surgical intervention may be necessary for the treatment of tubo-ovarian abscesses, antibiotic therapy alone may be effective in up to 70% of cases.6 In other cases, drainage of the abscesses, with the use of interventional radiologic techniques, has been reported to be a successful adjunct to antibiotic therapy.7

With the patient’s input and consent, a clear plan was developed before surgery, with contin-gencies for possible findings such as cancer, appendicitis, or bowel perforation. Her desire to preserve fertility and the ability to bear children was established. The risks and benefits of pri-oritizing these goals, with an emphasis on the use of procedures that would preserve her pelvic organs, if possible, were discussed, along with an explanation of the rationale and potential need for more extensive procedures, such as hysterec-tomy and bilateral salpingo-oophorectomy. Final-ly, the safety and feasibility of attempting a minimally invasive, laparoscopic procedure was considered, but we all agreed that a low thresh-old for conversion to laparotomy, if deemed nec-essary for safety or for surgical efficacy, would be maintained.

Despite the initiation of antibiotic therapy, signs and symptoms developed, including in-creased abdominal pain and tachycardia, that triggered our concern for a possible rupture of the adnexal mass and sepsis. This prompted our decision to proceed expediently with an opera-tive intervention. Although laparoscopy was ini-tiated, conversion to laparotomy was instituted when extensive peritoneal inflammation with bowel adherence blocking access to the pelvis was encountered. Most reports that describe the successful incorporation of laparoscopy into the

Endometriosis

Uterine fibroids

Menstruation

Pelvic inflammatory disease

Pleural effusion

Systemic lupus erythematosus

Diverticulitis

Table 2. Some Noncancerous Conditions That Can Increase Serum CA-125 Levels.





management of tubo-ovarian abscesses involve patients who do not have a rupture.8 In the case of this patient, extensive peritoneal inflamma-tion and agglutination of small bowel and peri-toneal surfaces were visualized with the laparo-scope. Our priority for ensuring the safety of the patient and efficacious treatment of the condi-tions we were encountering assumed precedence over our goal of maintaining a minimally inva-sive approach.

At laparotomy, the extent of peritoneal inflam-mation and the degree to which the right fallo-pian tube and the right ovary appeared to be abnormal prompted their complete removal. Specimens for bacterial cultures were obtained.

Although simple drainage with resection of the abscess cavity has been reported to be an effective strategy for managing tubo-ovarian abscesses, we believe that complete right salpingo-oophorectomy, with preservation of the patient’s uterus and her left adnexa, achieved an appropri-ate balance between preservation of the patient’s fertility and a more aggressive management strategy (i.e., hysterectomy and bilateral salpingo-oophorectomy) in this patient with evolving sepsis.8 A rupture of the right cyst, with spillage of purulent material, occurred during dissection of the patient’s right adnexa from the surround-ing tissues. A specimen of the fallopian tube and ovary obtained during the right salpingo-oopho-rectomy was sent for intraoperative pathological examination for assessment of a possible cancer. The left ovarian cyst, which measured 4.3 cm in the maximal diameter, was drained of fluid that was similar in appearance to chocolate syrup — a feature that was clinically consistent with an endometrioma. The surface of the patient’s appendix was generally inflamed but otherwise appeared normal; however, it was removed to ensure that an underlying appendicitis would not be missed.

Pathol o gic a l Discussion

Dr. Jennifer N. Stall (Pathology): Specimens obtained during the right salpingo-oophorectomy and the appendectomy were submitted for examination. The patient’s right ovary had been replaced by a unilocular cyst (measuring 9.3 cm by 6.0 cm by 4.0 cm) that was filled with a brown purulent fluid. The lining of the cyst was covered by a

yellow exudate. In areas where the exudate was less conspicuous, the underlying tissue was hem-orrhagic (Fig. 2A). The attached, fimbriated fallo-pian tube and the appendix (which had been submitted separately) had adhesions and a hem-orrhagic serosal surface but were otherwise un-remarkable.

Examination of a frozen section revealed a cyst with extensive fibrin deposition and acute inflammation; the cyst was benign, and possibly endometriotic. On histologic examination of the permanent sections, the wall of the ovarian cyst was fibrotic and lined by an adherent exudate that was composed of fibrin and inflammatory cells (Fig. 2B and 2C). Residual normal ovarian parenchyma was difficult to identify, but the pres-ence of scattered cystic follicles (Fig. 2C) con-firmed that the abscess was occurring in the ovary. Extensive sectioning revealed background residual foci of endometrioid-type epithelium (i.e., epithelium resembling that seen in the endometrium) and stroma with associated hem-orrhage and very few hemosiderin-laden macro-phages, features that are diagnostic of an under-lying endometriotic cyst (Fig. 2D). The fallopian tube was adherent to the ovary owing to the presence of serosal peritonitis but was otherwise unaffected (Fig. 2E). The appendix was also his-tologically unremarkable, except for secondary involvement by the peritonitis on the outer sur-face. A final diagnosis of an acutely inflamed endometriotic cyst with overlying acute peritoni-tis involving the ovarian surface, fallopian tube, and appendix was rendered. Three cultures of specimens obtained intraoperatively grew vary-ing amounts of methicillin-sensitive Staphylococ-cus aureus, although a course of antibiotics had been initiated before surgery. Anaerobic, myco-bacterial, and fungal cultures were all negative, as were three blood cultures.

Most ovarian abscesses that occur in patients in the Western world are associated with pelvic inflammatory disease and are preceded by in-volvement of the fallopian tube as part of an ascending bacterial infection. Direct extension from nongynecologic infections or hematogenous or lymphatic spread may occur less commonly. The absence of marked tubal involvement, as in this case, is uncommon. As compared with tubo-ovarian abscesses, ovarian abscesses without tubal involvement are frequently unilateral, with





Figure 2. Adnexal Mass.

A photograph shows the internal aspect of the resected right adnexal mass (Panel A). The internal surface of the cystic ovarian mass, which measured 9.3 cm by 6.0 cm by 4.0 cm in the maximal dimensions, was replaced by a yellow fibrinopurulent material that separated easily from the underlying tissue, which was hemorrhagic in appear‑ance. Cross sections of the cystic mass showed a thickened fibrous wall, with associated serosal peritonitis (Panel B, hematoxylin and eosin) and residual cystic follicles (asterisk). The internal surface (arrow) was lined predominantly by dense exudate composed of fibrin and inflammatory cells (Panel C, arrowhead). The residual cystic follicles con‑firmed that the abscess was occurring in the ovary. Extensive sampling revealed foci of endometrioid‑type epithelium (Panels C and D, arrows), with underlying endometrial stroma (Panel D, arrowhead), hemorrhage, and hemosiderin‑laden macrophages, which together are diagnostic of a background endometriotic cyst. The fallopian tube (Panel E, arrow) was adherent to the isolated ovarian cyst (asterisk) owing to the presence of serosal peritonitis but was other‑wise unaffected.

BA

C D

E

*

*





bilateral involvement present in only 20% of cases.9 In contrast to tubo-ovarian abscesses, which frequently involve the surface of the ovary, isolated ovarian abscesses are often unremark-able on the surface, and the abscess becomes apparent only on sectioning. A rupture of the abscess may lead to secondary peritonitis or even fistula formation. Chronic infections may result in the formation of solid, tumorlike masses, which on imaging can potentially raise the possibility of cancer.

An extensive body of literature exists regard-ing the types of infectious organisms associated with tubo-ovarian abscesses, with such abscesses attributed to N. gonorrhoeae, C. trachomatis, mixed aerobic and anaerobic organisms that are reflec-tive of normal vaginal or cervical flora, and, in-frequently, mycobacteria. A less extensive body of literature exists regarding the causative agents in cases of isolated ovarian abscesses. Such cases have revealed a variety of causative organisms, including those found in the urinary, respiratory, or oropharyngeal and gastrointestinal tracts.10-12

A number of theories have been postulated with respect to the route of infection, including direct extension of a nongynecologic infection such as diverticulitis, appendicitis, or inflamma-tory bowel disease; hematogenous or lymphatic spread from a distant infection; and direct in-oculation caused by procedural or operative manipulation of the ovary.9,10,13,14 Historically, the literature has focused on direct inoculation, with procedural and surgical manipulation be-ing an obvious risk factor. Occasionally, such as in this case, infection of a preexisting cyst may occur. In a study of 510 endometriotic cysts, 11 (2%) had pathological evidence of infection.15 Endometriosis and endometriotic cysts are com-monly associated with a low-grade inflammatory response that is generally chronic. Acute inflam-mation with abscess formation is rare. Adhe-

sions are a frequent complication; peritonitis occurs less commonly. Rarely, an acute abdomi-nal event, with the potential for exsanguination, may occur.16 Finally, the potential for endome-triosis and endometriotic cysts to progress to cancer (typically, endometrioid or clear-cell) is well known.

Foll ow-up

Dr. Boruta: A course of intravenous antibiotic therapy was continued for 2 weeks postopera-tively. The patient’s recovery was complicated by postoperative ileus and mild incisional cellulitis, each of which was not surprising, given the ex-tent to which her peritoneal cavity was contami-nated and inflamed.

For any nulliparous woman of reproductive age who presents with acute abdominal symp-toms and fever and who has no known history of pelvic inflammatory disease or surgical inter-vention, a high level of suspicion for an isolated ovarian abscess should be maintained. Prompt imaging, administration of antibiotics, and con-servative surgical intervention are essential. If possible, a concurrent culture of a potential pri-mary source of infection should be performed. In the case of an isolated ovarian abscess, the possibility that an infection has spread from a distant site should be considered.

A nat omic a l Di agnosis

Acutely inflamed endometriotic cyst with overly-ing acute peritonitis involving the ovarian sur-face as well as the fallopian tube and appendix.

This case was presented at the Medical Case Conference.No potential conflict of interest relevant to this article was

reported.Disclosure forms provided by the authors are available with

the full text of this article at NEJM.org.

References1. Lee YK, Bae JM, Park YJ, Park SY, Jung SY. Pelvic actinomycosis with hydro-nephrosis and colon stricture simulating an advanced ovarian cancer. J Gynecol Oncol 2008; 19: 154-6.2. Chhabra S, Saharan K, Pohane D. Pel-vic tuberculosis continues to be a disease of dilemma — case series. Indian J Tuberc 2010; 57: 90-4.3. Ganguli S, Raptopoulos V, Komlos F, Siewert B, Kruskal JB. Right lower quad-

rant pain: value of the nonvisualized ap-pendix in patients at multidetector CT. Radiology 2006; 241: 175-80.4. Boyd CA, Riall TS. Unexpected gyne-cologic findings during abdominal sur-gery. Curr Probl Surg 2012; 49: 195-251.5. Dorigo O, Berek JS. Personalizing CA125 levels for ovarian cancer screening. Cancer Prev Res (Phila) 2011; 4: 1356-9.6. Reed SD, Landers DV, Sweet RL. Anti-biotic treatment of tuboovarian abscess:

comparison of broad-spectrum beta-lactam agents versus clindamycin-containing reg-imens. Am J Obstet Gynecol 1991; 164: 1556-61.7. Gjelland K, Ekerhovd E, Granberg S. Transvaginal ultrasound-guided aspiration for treatment of tubo-ovarian abscess: a study of 302 cases. Am J Obstet Gynecol 2005; 193: 1323-30.8. Rosen M, Breitkopf D, Waud K. Tubo-ovarian abscess management options for





women who desire fertility. Obstet Gyne-col Surv 2009; 64: 681-9.9. Willson JR, Black JR III. Ovarian ab-scess. Am J Obstet Gynecol 1964; 90: 34-43.10. Black WT. Presacral sympathectomy for dysmenorrhea and pelvic pain. Ann Surg 1936; 103: 903-13.11. Tohya T, Yoshimura T, Onoda C. Uni-lateral ovarian abscess caused by Salmo-

nella. Infect Dis Obstet Gynecol 2003; 11: 217-9.12. Cohen JI, Bartlett JA, Corey GR. Extra-intestinal manifestations of salmonella infections. Medicine (Baltimore) 1987; 66: 349-88.13. Wetchler SJ, Dunn LJ. Ovarian abscess: report of a case and a review of the litera-ture. Obstet Gynecol Surv 1985; 40: 476-85.14. Lipscomb GH, Ling FW, Photopulos GJ.

Ovarian abscess arising within an endo-metrioma. Obstet Gynecol 1991; 78: 951-4.15. Schmidt CL, Demopoulos RI, Weiss G. Infected endometriotic cysts: clinical char-acterization and pathogenesis. Fertil Steril 1981; 36: 27-30.16. Golditch IM. Endometriosis present-ing as an acute abdominal emergency. Ob-stet Gynecol 1965; 26: 780-5.Copyright © 2016 Massachusetts Medical Society.

Lantern SLideS Updated: CompLete powerpoint SLide SetS from the CLiniCopathoLogiCaL ConferenCeS

Any reader of the Journal who uses the Case Records of the Massachusetts General Hospital as a teaching exercise or reference material is now eligible to receive a complete set of PowerPoint slides, including digital images, with identifying legends, shown at the live Clinicopathological Conference (CPC) that is the basis of the Case Record. This slide set contains all of the images from the CPC, not only those published in the Journal. Radiographic, neurologic, and cardiac studies, gross specimens, and photomicrographs, as well as unpublished text slides, tables, and diagrams, are included. Every year 40 sets are produced, averaging 50-60 slides per set. Each set is supplied on a compact disc and is mailed to coincide with the publication of the Case Record.

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Documents

Case 33-2016: A 30-Year-Old Woman with Severe Lower