S

O Medical Case Reports and Short Reviews p s e s n Acce

Case Report Case Report: An Unusual Presentation of an Infected Mateo-Sanez H1*, Carmen Alexandra Moreno Moreno2, Mateo-Madrigal D3 and Adrián Dávalos Álvarez4 1Founder and General Director, Gynecologist, Obstetrician, Biologist of Human Reproduction, Santa Rosa de Lima Hospital, Ensenada, Baja California, Mexico 2Doctor in charge of the Research Department, Hospital Santa Rosa de Lima, Ensenada, Baja California, Mexico 3Social service in research at the National Institute of Pediatrics in Mexico City. Course of specialty in medical genetics at the University of Valencia, Spain 4Social service in research at the National Institute of Nutrition “Salvador Zubirán” in Mexico City

Abstract Background: There are some reports in literature about cases of endometrioma complicated by abscess, Shmidt et al. reported endometriotic cysts infected for the first time in 1981 but it was not until 1991 when Lipscomb et al. reported complicated endometrioma due to abscesses without any risk factor. Literature places this complication as the result of previous invasive procedures, use of intrauterine devices, hematogenous and lymphatic spread. Reports in which there is no recognized risk factor are isolated and exceptional; in these, the source of infection remains an enigma. Objective: Present the diagnostic possibilities of ovarian abscess in an endometrioma. Case report: A 36-year-old patient was evaluated in the emergency room at the Santa Rosa de Lima Hospital in Ensenada, Baja California, due to a 5-month history of chronic and non-quantified intermittent fever, with a previous diagnosis of urinary infection on treatment with a broad spectrum antibiotic without improvement. Transvaginal ultrasound showed a right with an image compatible with endometrioma. Laparotomy was performed by dissection of the capsule and release of multiple tube-ovarian adhesions. The histo- pathological report confirmed that it was an endometriotic cyst (endometrioma) complicated by an exacerbated chronic inflammatory process. Conclusion: It is important to study the risk factors in order to define the cause of an abscess in an endometrioma. Emphasis should be placed on a detailed clinical history and an adequate correlation with the clinical presentation. It is important not to forget that every woman with a history of advanced is susceptible to complicationsand the most serious complications are known to be lethal. Keywords: Endometrioma; Infected endometrioma; Ovarian abscess; Complicated endometriosis

Background The infected endometriotic cysts were initially described by Shmidt and his group. In 1981 Wetchiery et al. Proposed The presence of infection in is a very three primary causes for the origin of ovarian abscesses in unusual finding in clinical practice; due to this, the available endometriomas [5]: 1) inoculation of bacteria directly in the information is scarce, with only a few cases reported ovarian stroma due to surgical trauma [6], 2) haematogenous worldwide. Generally, this complication is related to the spread of bacteria [7]; and 3) lymphatic dissemination [8]. antecedent of previous invasive procedures or use of In 1991, Lipscomb and his co-authors reported a case of intrauterine devices; however, there is also the possibility endometrioma complicated by an abscess without any known that the infection occurs spontaneously, which is even more risk factor, possibly caused by hematogenous spread through unusual. In the international literature there have been reported the urinary tract [9]. To date, these types of complications as causal agents: Escherichia coli, Neisseria gonorrhoeae, are exceptional and the source of infection in isolated cases Chlamydia trachomatis, Ureaplasma urealyticum, Gardnerella represents an enigma. vaginalis, Streptococcus agalactiae, Mycoplasma hominis and genitaliumand some anaerobes that can cause , oophoritis, or abscesses [1-3]. Correspondence to: Mateo-Sanez H, Founder and General Director, Gynecologist, Obstetrician, Biologist of Human Reproduction, Santa Rosa de The formation of de novo abscesses within an endometrioma is Lima Hospital, Iturbide St #399 and 4th St, Obrera Neighborhood. Ensenada, a very rare gynecological problem [4] and results in a surgical Baja California, C.P. 22800, Mexico, Tel: 646-177-2924; E-mail: hmfertil[AT] Hotmail[DOT]com emergency that could be lethal [5]. Received: Dec 19, 2018; Accepted: Dec 21, 2018; Published: Dec 24, 2018

Med Case Rep Short Rev 1 Volume 1(1): 2018 Mateo-Sanez H (2018) Case Report: An Unusual Presentation of an Infected Endometrioma

Objective The objective of this study is to report a case of complicated endometrioma with an ovarian abscess as well as to expose and discuss the associated risk factors, in order to disseminate this rare alteration and establish an opportune diagnosis. Clinical Case A 36-year-old patient who presented chronic pelvic pain for the past five months, accompanied by decreased stools in the form of stinking, nausea, occasional dysuria of 2 weeks and intermittent fever managed with Acetaminophen 500 mg and Ibuprofen 400 mg orally every 8 hours. In a previous medical evaluation approximately 15 days ago she was diagnosed with urinary tract infection and a non-confirmed infectious Figure 2: Image of the transvaginal ultrasound in Doppler gastroenteritis managed with ciprofloxacin 500 mg every 12 mode, showing a non-vascularized lesion. hours for 6 days. Later, for the persistence of symptomatology, she was diagnosed with acute pyelonephritis, the treatment consisted of injectable gentamicin solution of 160 mg /day posterior ; painful posterior fundus occupied by bulging intramuscularly for 5 days, without satisfactory results. She of soft consistency in more than 50% of the left pelvis. The went to Santa Rosa de Lima Hospital for a new assessment. transvaginal ultrasound of the left ovary showed an image Obstetric gynecological history: menarche at 9 years old; G1 compatible with an endometrioma of 92 x 84 mm (Figure 1 C1 A0, caesarean section 9 years ago due to preeclampsia; and 2). irregular menstrual cycles, history of chronic , Laboratory tests revealed leukocytosis of 14 x 103/mm3 beginning of sexual activity at 18 years without prescription with neutrophilia (85%), hemoglobin of 10.6 g/dL, platelets of contraceptive method, sexual partners: 2, current sexual 495,000/mm3, prothrombin partial time of 14 seconds and INR activity denied, history of CIN 1 + HPV 3 years ago managed (international normalized ratio) 0.95. Anti-HIV, VDRL, anti- with cervical cryotherapy, with normal cervicovaginal cytology Mycoplasma and anti-Chlamydia trachomatis antibodies were 1 year ago. Personal pathological history: high blood pressure negative, C-reactive protein was 205 mg/L and glucose was diagnosed 8 years ago treated with Losartan 50 mg daily and 110 mg/dl. The rest of blood chemistry and the general urine Hydrochlorothiazide 25 mg daily; hemorrhoidectomy 5 years test remained within the normal parameters. ago and breast implants 3 years ago; allergies denied. Surgical intervention was performed with a presumptive On physical examination, she was afebrile with moderate diagnosis of left endometrioma. During lapatorotomy, pain on palpation in the left iliac fossa, which radiated to the of the colonic wall of the descending and lumbar region and extended to the ipsilateral posterior thigh, sigmoid colon was observed, without perforation or alteration without signs of peritoneal irritation. In the initial physical in irrigation. Dissection of the capsule of the endometriotic evaluation, was found in anteroversoflexion, central and cyst, measuring 11 x 10 cm, in the left ovary was performed, draining 500 cc of fetid liquid of dark brown color and releasing multiple tube-ovarian adhesions. Both uterine tubes were observed with signs suggestive of infection. The dissected capsule was sent to histopathology and the purulent fluid to perform aerobic bacterial cultures. She was managed during her in-hospital stay with triple antibiotic scheme based on Metronidazole 500 mg every 8 hours + Clindamycin 600 mg every 8 hours and Ceftriaxone 1 g intravenously every 12 hours; Ketorolac 30 mg IV every 12 hours for 3 days. The postoperative evolution was satisfactory and the histopathological report confirmed the diagnosis of endometrioma of the left ovary complicated with chronic inflammatory and acute processes, with formation of intramural abscesses and a wall covered with abundant fibrin Figure 1: Image of transvaginal ultrasound. In the adjacent region of the uterus, endometrioma of 10.89 x and neutrophils, which caused a chronic purulent exacerbated 10.52 cm is identified, at the expense of the left ovary. oophoritis (Figure 3 and 4). There was no growth of aerobic organisms in the purulent fluid.

Med Case Rep Short Rev 2 Volume 1(1): 2018 Mateo-Sanez H (2018) Case Report: An Unusual Presentation of an Infected Endometrioma

not given birth to more than two children are more likely to suffer from tubo-ovarian abscesses than those who do not have endometriosis [13]. The patient in this case had no history of recent surgical intervention, pelvic inflammatory disease, intrauterine device, oocyte aspiration for IVF [14] or bacterial [15]; therefore, these data demonstrate that an ovarian abscess can originate within an endometrioma without any recognized risk factor. We could even consider the possibility of a sexually transmitted infection; however, the history of sexual inactivity, absence of and no response to medical treatment led us to discard this hypothesis. Figure 3: Photograph of the external surface of This patient had never been evaluated for or endometriotic cyst of the left ovary, complicated with acute endometriosis, so we do not know the time of evolution. It and chronic inflammatory processes; corresponding to is difficult to determine the route of infection; however, the chronic exacerbated oophoritis. most accepted hypothesis indicates that the abscess could have originated in the endometrioma due to some ascending infection from the vaginal canal, due to Bacteroides (vaginal commensal), due to an alteration of balance in the vaginal flora, which increased the replicative and pathogenic potential of bacteria. In the same way, it could have been precipitated by the recent consumption of antibiotics [16]. Some reports of cases with infected ovarian endometriomas had a history of infections, such as the urinary tract [9] or gastrointestinal infection due to Salmonella [17], this case had a history of possible urinary infection, fever and stools decreased in consistency. Tests and vaginal cultures were negative, so the true cause of infection is unknown. However, the possible causes could have been the direct extension of infection from the inflamed colonic wall, spreading by blood and with an undetected bacteremia as proposed by Ghose et al. [17]. Other proposed theories suggest that endometriomas Figure 4: Internal wall of endometriotic cyst of the left have an altered immunological microenvironment, which ovary, complicated by a chronic inflammatory process, makes them more susceptible to infection [13]. The absence of where numerous intramural abscesses and lining with bacterial growth in the purulent fluid could have been due to abundant fibrin and neutrophils are observed. previous treatment with antibiotics. The high index of suspicion, the quick obtaining of images by Discussion ultrasound and the opportune abscess drainage were the key Spontaneous ovarian abscess within an endometrioma is an for the treatment of the patient. exceptional complication. The literature points out different This case report is transcendental, because an endometrioma theories related to the origin of a spontaneous abscess in an complicated by an abscess represents a true gynecological endometrioma; for example, it may be due to an immune emergency. Ovarian abscesses without rupture are difficult to disorder in the endometrial glands and stroma [10]. diagnose, because its clinical manifestation is very variable. Theoretically, the cystic wall of the endometrioma is weak, However, in case of rupture, it can be deadly [6]. compared to the normal ovarian epithelium, so it is susceptible Surgery is the treatment of choice for endometriomas. The to bacterial invasion, even the collection of menstrual blood in most common surgical technique is removal in a conservative some cystic space of the ovary represents an adequate culture manner, limited to the affected annex in order to minimize medium for the development of pathogenic agents. Kubota complications. and his group reported an incidence of tubo-ovarian abscesses of 2.3% and 0.2% in patients with and without endometrioma, Conclusion respectively (p = 0.0001), which suggests a risk factor Defining the origin of an abscess within an endometrioma for the formation of an ovarian abscess [11]. Women with is important to study the risk factors. We must be strict in endometriosis in stage III-IV [12], nulliparous or who have obtaining patient data, because their pathological history

Med Case Rep Short Rev 3 Volume 1(1): 2018 Mateo-Sanez H (2018) Case Report: An Unusual Presentation of an Infected Endometrioma

related to the clinic of the current condition can guide the 8. Wetchler SJ, Dunn Li (1985) Ovarian abscess, report of a case accurate and early diagnosis. To suspect, prevent and make and a review of literature. Obstet Gynecol. Surg 40: 476-485. the diagnosis in a timely manner is a priority to reduce the [View Article] morbidity and mortality of this complication. Any woman with 9. Lipscomb GH, Ling FW, Photopulos GJ (1991) Ovarian abscess a history of advanced endometriosis can have complications arising within an endometrioma. Obstet Gynecol 78: 951–954. (major surgery or infertility) which can be extremely severe. [View Article] Reference 10. Lebovic DI, Mueller MD, RN Taylor (2001) Immuno biology of endometriosis. Fertil Steril. 75: 1-10. [View Article] 1. Taylor BD, Ness RB, Darville T, Haggerty CL (2011) Microbial 11. Kubota T, Ishi K, Takeuchi H (1997) A study of tubo-ovarian and correlates of delayed care for pelvic inflammatory disease. Sex ovarian abscesses, with a focus on cases with endometrioma. J Transm Dis 38: 434-438. [View Article] Obstet Gynaecol Res 23: 421-426. [View Article] 2. Eschenbach DA, Buchanan TM, Pollock HM (1975) 12. Canis M, Donnez JG, Guzick DS (1997) Revised American Society Polymicrobial etiology of acute pelvic inflammatory disease. N for Reproductive Medicine classification of endometriosis: 1996. Engl J Med 293: 166-171. [View Article] Fertil Steril 67: 817–821. [View Article] 3. Hahherty CL, Hillier SL, Bass DC, Ness RB (2004) Bacterial 13. Chen MJ, Yang JH, Yangs YS, Ho HN (2004) Increased vaginosis and anaerobic bacteria are associated with endometritis. occurrence of tubo-ovarian abscesses in women with stage III Clin Infec Dis 39: 990-995. [View Article] and IV endometriosis. Fertil Steril 82: 498-499. [View Article] 4. Hameed A, Mehta V, Sinha P (2010) A rare case of de novo 14. Yaron Y, Peyser MR, Samuel D (1994) Infected endometrio tie gigantic ovarian abscess with in an endometrioma. Yale J Biol cysts secondary to oocyte aspiration for in-vitro fertilization. Med 83: 73-75. [View Article] Hum-Reprod 9: 1759-1760. [View Article] 5. Dicker D, Dekel A, Orvieto R, Bar-hava I, Feldberg D, Ben- 15. Kavoussi SK, Pearlman MD, Burke WM, Lebovic DI (2006) Rafael Z (1998) Ovarian abscess after ovum retrieval for in-vitro Endometrioma complicated by tubo- ovarian abscess in a woman fertilization. Hum Reprod 13: 1813-1814. [View Article] with . Infect Dis Obstet Gynecol 2006: 84140. 6. Shah RC, Shah JM, Mehta MN (2013) Laparoscopic management [View Article] of an endometrioma complicated by an ovarian abscess. Int J 16. Hsia L, Cheong A, Emil S (2013) Non-sexually transmitted tubo- Reprod Contracept Obstet Gynecol 2: 473-474. [View Article] ovarian abscess in an adolescent. J Ped Surg Case Reports 1: 378- 7. Schmidt CL, Demopoulos RI, Weiss G (1981) Infected 380. [View Article] endometriotic cysts: clinical characterization and pathogenesis. 17. Ghose AR, Vella EJ, Begg HB (1986) Bilateral salmonella Fertil Steril 36: 27-30. [View Article] salpingo-oophoritis. Postgrad Med J 62: 227–228. [View Article]

Citation: Mateo-Sanez H, Moreno CAM, Mateo-Madrigal D, Álvarez AD (2018) Case Report: An Unusual Presentation of an Infected Endometrioma. Med Case Rep Short Rev 1: 001-004.

Copyright: © 2018 Mateo-Sanez H, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Med Case Rep Short Rev 4 Volume 1(1): 2018