30 October 2024: Articles
Ruptured Appendiceal Diverticulum Leading to Tubo-Ovarian Abscess in a Non-Sexually Active Woman: A Case Study
Challenging differential diagnosis, Management of emergency care, Rare coexistence of disease or pathology
Hiba Alenazi1E*DOI: 10.12659/AJCR.945366
Am J Case Rep 2024; 25:e945366
Abstract
BACKGROUND: Pelvic inflammatory diseases and tubo-ovarian abscesses (TOAs) are rarely seen in non-sexually active (NSA) women. While the pathogenesis of TOA remains unclear, its risk factors include ascending infection of the genital tract, gastrointestinal tract translocation, congenital genitourinary anomalies, as well as virulence of the causative agents, with preceding bacteremia and septicemia.
CASE REPORT: Herein, we present the case of a 25-year-old female patient who was initially diagnosed with ovarian torsion and underwent diagnostic laparoscopy. Her intraoperative findings included bilateral TOAs and adhesions. Owing to this uncommon presentation, further investigation was conducted, including postoperative computed tomography. The results showed a likelihood of a perforated appendix, with a repeat laparoscopy confirming this diagnosis. Appendectomy and drainage were done. The microbial culture from the ovarian abscess revealed Streptococcus constellatus, a commensal organism found in the oral, gastrointestinal, and urogenital flora. This microorganism is rarely isolated as a pathogenic organism in immune-competent populations. Furthermore, the histopathology report of the appendix showed a rare occurrence of chronic active diverticulitis, with perforation and peri-appendicitis.
CONCLUSIONS: TOA in NSA women should be considered when evaluating differential diagnoses, with the possibility of infection with an atypical organism. Broad-spectrum antibiotics or multidrug therapy should be administered. When suspicion is raised, an imaging study with a broader view to detect the pathology of other organ systems is recommended. Lower abdominal pain in young female patients still poses a diagnostic dilemma and should be investigated; however, when the clinical presentation suggests a gynecological emergency, the time frame can pose challenges.
Keywords: diverticulitis, Abscess, Diverticulum, Ovary, Fallopian Tube Diseases, Appendix
Introduction
Tubo-ovarian abscess (TOA) is a serious complication of pelvic inflammatory disease (PID) that develops in 18–34% of PID cases [1]. TOAs typically occur when PID evolves into an inflammatory mass. Although
TOA can be misdiagnosed and mismanaged in NSA women because the clinical presentation varies, and the pathogenesis is unclear. Probable causative factors include ascending lower genital tract infections, urinary tract infections, translocation of gastrointestinal tract infections, and infection with a virulent organism, with bacteremia/septicemia, leading to peritonitis and seeding of the infection in the ovary [12]. However, TOAs caused by bacterial spread from appendicitis or other bowel diseases can result in polymicrobial infections [7]. The incidence of PID complicated by TOA in NSA females remains unclear [1]. The clinical presentation of TOA and its relationship with complicated and ruptured diverticulitis of the colon have been reported in the literature [13]; however, ruptured appendiceal diverticulitis is considered rare and has not been reported yet in association with TOA [10,12,14].
Case Report
We present the case of a 25-year-old nulliparous woman who had been referred from the adult emergency department with a history of lower abdominal pain, sudden-onset on-and-off cramping, nausea, vomiting, and lightheadedness. Her gyneco-logical history was unremarkable, and she denied having menstrual disorders or recurrent vaginal discharge. The patient was single and had no history of sexual contact. Her medical history included a gastric sleeve 5 years before the present visit, for weight reduction, and treatment for depression. Initial vital signs were normal, and abdominal examination revealed tenderness in both lower quadrants. Sonography revealed a mildly enlarged right ovary that had deviated to the midline with preserved vascularity (Figures 1, 2). The probability of torsion/detorsion was suggested; hence, the treatment plan included admission and a diagnostic laparoscopy; however, the patient was discharged against medical advice. Two days later, the patient presented with fever, abdominal guarding, and persistent severe lower abdominal pain. She also reported a single diarrheal episode. Complete blood count showed white blood cell count: 1425 cells/µL, hemoglobin: 7.0 g/dL, mean corpuscular volume: 58.3 fL, mean corpuscular hemoglobin concentration: 28.3 g/dL, neutrophils: 1025 cells/µL, and platelet count: 353 000 cells/µL. Urinalysis was negative for nitrate, leucocytes, blood, and bacteria. Results of repeat pelvic ultrasonography revealed findings similar to the previous ultrasound, suggestive of ovarian torsion. Further imaging studies, including transrectal ultrasound and computed tomography (CT), were omitted preoperatively because the patient was already misdiagnosed with ovarian torsion, with the possibility of ongoing ovarian necrosis. The patient was admitted and underwent an emergency diagnostic laparoscopy.
The intraoperative findings included an enlarged right ovarian abscess that was frail and adhered to the bowel, as well as adherent bowel loops on the posterior uterine wall. Further, visualization of the left ovary was incomplete due to adhesions. Microbiological swabs were collected from the right ovarian abscess. The right ovarian abscess was drained and washed. The clinical picture was suggestive of PID; hence, a postoperative antibiotic regimen (ampicillin, clindamycin, and gentamycin) was initiated according to the guidelines. Owing to this uncommon finding in an NSA woman, the literature was reviewed, and the possibility of bacterial translocation from the bowel to the genitourinary system was considered. Postoperative CT (Figures 3–5) revealed the likelihood of complicated appendicitis with perforation and abscess formation. Clinically, abdominal pain was mildly relieved postoperatively. The radiologist, gynecologist, and general surgeon all recommended a repeat laparoscopy. The radiological diagnosis was confirmed intraoperatively, and an appendectomy was performed. The appendiceal abscess was drained and evacuated. The patient showed significant health improvement and was discharged on the 5th day following the operation.
The causative organism was
Discussion
PID refers to an acute and subclinical infection of the upper genital tract involving any or all of the following: uterus, fallopian tubes, and ovaries. It is often accompanied by involvement of the neighboring pelvic organs. This results in endometritis, salpingitis, oophoritis, peritonitis, perihepatitis, and/or TOA. TOAs complicate approximately 30% of PID cases; they occur mostly in sexually active women, are usually polymicrobial, and are a form of sexually transmitted disease
Although TOAs are uncommon in NSA women, several case reports and case series have nevertheless been published in the literature. The mechanism remains unclear; however, multiple factors can contribute to the development of TOA in this population, including ascending infection of the genital tract due to vaginal voiding secondary to obesity, recessed urethra or concomitant urinary tract infection, gastrointestinal tract translocation, congenital genitourinary anomalies [1,6], and bacteremia and septicemia leading to peritonitis, serositis, and subsequent infection and abscess formation [12].
Gastrointestinal tract or bowel translocation occurs when viable bacteria pass through the gastrointestinal tract wall to extraintestinal organs, such as the ovaries and fallopian tubes, even without bowel perforation or a ruptured appendix. Intestinal bacterial overgrowth is associated with decreased host immunity. In addition, increased permeability of intestinal mucosal barriers secondary to surgery, bowel obstruction, and chronic constipation can all contribute to this translocation [6].
Acute or chronic appendicitis and appendectomy (7–9) have been associated with the development of TOAs in NSA female patients. Additionally, during menstruation in adolescents, the fallopian tubes secrete more nutrients and hormones in the presence of adhesions or active appendicitis, which may lead to the development of TOAs [7]. Furthermore, in a developing vaginal microbiome, an imbalance in the vaginal flora can lead to disruption, and a change in the bacterial replicative and pathogenic capabilities may trigger the infection. Vaginal flora may also be altered by recent intake of antibiotics [3]. Organisms such as
In our patient, there was a possibility of a preceding appendiceal pathology that led to TOA. A single organism,
The histopathological findings of acute diverticulitis mimic the clinical presentation of acute appendicitis, and it is usually diagnosed postoperatively. The incidence of appendicular diverticulitis is considered rare, ranging between 0.014% and 1.9%, and reaches approximately 2.1% [14]. Risk factors are male sex, age >30 years, chronic appendicitis, cystic fibrosis, and Hirschsprung’s disease [18,19]. AlAli et al reported 5 cases; in 2 of these cases, the patients were young and female [20]. Preoperative CT imaging might aid in the diagnosis [20]; however, in our case, the appendiceal diverticulitis led to perforation and subsequent infection of the adjacent organs, including the inner female genital tract, leading to PID and abscess formation.
Misdiagnosed TOAs or those complicated by diverticulitis have been reported previously [13]. If diagnosed early, TOA and acute diverticulitis can be managed with a broad-spectrum antibiotic; however, severe cases require surgery [13].
Management of PID commences with prompt broad-spectrum antibiotic administration (eg, ceftriaxone 1 g i.v. every 24 hours, doxycycline 100 mg orally or i.v. every 12 hours, metronidazole 500 mg orally or i.v. every 12 hours), followed by interventional radiology for assisted percutaneous drainage, and subsequently, surgery.
Data on the treatment options for TOAs in the absence of sexually transmitted organisms are limited [6]. Due to the rarity of TOAs in NSA women, diagnosis can be challenging and time-consuming, as it might require extra imaging modalities and laboratory tests, resulting in delayed treatment and intervention.
Conclusions
TOA in NSA women should be considered as a differential diagnosis, with the possibility of infection with an atypical organism. Broad-spectrum antibiotics or multidrug therapy should be administered promptly to avoid long-term complications such as infertility. When suspicion is raised, an imaging study with a broader view to detect pathology of other organ systems preoperatively is recommended. Lower abdominal pain in young female patients still poses a diagnostic dilemma and should be investigated; however, when the presentation suggests a gynecological emergency, the timeframe can pose challenges.
Figures
Figure 1.. Transabdominal ultrasound of the left ovary. Figure 2.. Transabdominal ultrasound of the right ovary. Figure 3.. Coronal view abdominopelvic CT showed (arrow) a right ovarian abscess surrounded by fluid collection, obscuring visualization of the appendix. CT – computed tomography. Figure 4.. Axial plain of abdominopelvic CT. CT, computed tomography. Figure 5.. Sagittal plane of abdominopelvic CT showing the site (arrow) of ruptured retrocecal appendix. CT – computed tomography.References:
1.. Hakim J, Childress KJ, Hernandez AM, Bercaw-Pratt JL, Tubo-ovarian abscesses in nonsexually active adolescent females: A large case series: J Adolesc Health, 2019; 65; 303-5
2.. Chernick LS, Tubo-ovarian abscesses in nonsexually active adolescents: A rare but consequential miss: J Adolesc Health, 2019; 65; 175-76
3.. Cheong LHA, Emil S, Non-sexually transmitted tubo-ovarian abscess in an adolescent: J Pediatr Surg Case Rep, 2013; 1; 378-80
4.. Cho HW, Koo YJ, Min KJ, Pelvic inflammatory disease in virgin women with tubo-ovarian abscess: A single-center experience and literature review: J Pediatr Adolesc Gynecol, 2017; 30; 203-8
5.. Fei YF, Lawrence AE, McCracken KA, Tubo-ovarian abscess in non-sexually active adolescent girls: A case series and literature review: J Pediatr Adolesc Gynecol, 2021; 34; 328-33
6.. Goodwin K, Fleming N, Dumont T, Tubo-ovarian abscess in virginal adolescent females: A case report and review of the literature: J Pediatr Adolesc Gynecol, 2013; 26; e99-102
7.. Hsu A, Sarowa BK, Abdessalam SF, Ruptured appendicitis leading to development of a tubo-ovarian abscess in a non-sexually active adolescent patient.: Cureus., 2023; 15; e41226
8.. Mora-Palma JC, Guillot-Suay V, Sánchez Gila MM, Gutiérrez-Fernández J: Rev Esp Quimioter, 2020; 33; 285-88 [in Spanish]
9.. Nishida N, Shono T, Shono K, Late occurrence of the tubo-ovarian abscess after appendectomy for perforated appendicitis in a virginal adolescent girl: J Pediatr Adolesc Gynecol, 2022; 35; 509-11
10.. Pradhan S, Kyrillos A, Hayes K, Pelvic inflammatory disease in non-sexually active pediatric and adolescent patients: J Pediatr Adolesc Gynecol, 2020; 33(2); 242
11.. Alsahabi JA, Aldakhil LO, Alobaid AS, Tubo-ovarian abscess in non-sexually active adolescents: Int J Adolesc Med Health, 2017; 29; 0051
12.. Pilarczyk-Zurek M, Sitkiewicz I, Koziel J: Front Microbiol, 2022; 13; 956677
13.. Kazemi SN, Raoufi M, Samsami M, A case report on diverticulitis mis-diagnosed as tubo-ovarian abscess: Ann Med Surg (Lond), 2021; 72; 103049
14.. Altieri ML, Piozzi GN, Salvatori P, Appendiceal diverticulitis, a rare relevant pathology: Presentation of a case report and review of the literature: Int J Surg Case Rep, 2017; 33; 31-34
15.. Mills D, Sharon B, Schneider K: Pediatr Emerg Care, 2018; 34; e100-e1
16.. Pardo MI, Fernández-Rial M, Campos S, [Pelvic and tubo-ovarian abscess in a woman with an IUD for 16 years.]: Clin Invest Ginecol Obstet, 2012; 39; 174-76 [in Spanish]
17.. Tymon-Rosario J, Atrio JM, Yoon HA: Case Rep Obstet Gynecol, 2019; 2019; 6491617
18.. Albeeshi MZ, Alwanyan AA, Salim AA, Albabtain IT, Appendiceal diverticuli-tis presenting as acute appendicitis diagnosed postoperatively.: J Surg Case Rep., 2019; 2019 rjz332
19.. Williams JM, Adamo DA, Olson MC, Acute appendiceal diverticulitis: A case report: Radiol Case Rep, 2021; 16; 1072-74
20.. AlAli MN, Alsweed NI, Alshehri A, Is appendiceal diverticulitis mimicking acute appendicitis?: Cureus, 2023; 15; e51214
Figures
In Press
Case report
Hybrid Repair of Ascending Aortic Intramural Hematoma and Arch Ulcer in a 74-Year-Old Woman – A Case ReportAm J Case Rep In Press; DOI: 10.12659/AJCR.946212
Case report
Capnocytophaga canimorsus in Iliac Artery Mycotic Aneurysm: The Role of Molecular DiagnosticsAm J Case Rep In Press; DOI: 10.12659/AJCR.946054
Case report
Invasive Hydatidiform Mole Mimicking Ectopic Pregnancy: A Case Report and Literature AnalysisAm J Case Rep In Press; DOI: 10.12659/AJCR.946388
Case report
Managing Chyle Leakage Following Right Retroperitoneoscopic Adrenalectomy: A Case StudyAm J Case Rep In Press; DOI: 10.12659/AJCR.945469
Most Viewed Current Articles
21 Jun 2024 : Case report 81,501
Intracranial Parasitic Fetus in a Living Infant: A Case Study with Surgical Intervention and Prognosis Anal...DOI :10.12659/AJCR.944371
Am J Case Rep 2024; 25:e944371
07 Mar 2024 : Case report 48,315
Neurocysticercosis Presenting as Migraine in the United StatesDOI :10.12659/AJCR.943133
Am J Case Rep 2024; 25:e943133
20 Nov 2023 : Case report 22,130
Azithromycin Treatment for Acne Vulgaris: A Case Report on the Risk of Clostridioides difficile InfectionDOI :10.12659/AJCR.941424
Am J Case Rep 2023; 24:e941424
07 Jul 2023 : Case report 19,303
A Classical Case of Cesarean Scar Endometriosis in a 35-Year-Old Woman Presenting with Cyclical Abdominal P...DOI :10.12659/AJCR.940200
Am J Case Rep 2023; 24:e940200