Non-Sexually Transmitted Tubo-Ovarian Abscess in an Adolescent

J Ped Surg Case Reports 1 (2013) 378e380

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Journal of Pediatric Surgery CASE REPORTS

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Non-sexually transmitted tubo-ovarian abscess in an adolescent

Li Hsia Alicia Cheong, Sherif Emil*

Division of Pediatric General and Thoracic Surgery, The Montreal Children’s Hospital, McGill University Health Centre, Montreal, Quebec, Canada article info abstract

Article history: Pelvic inﬂammatory disease and tubo-ovarian abscesses are infections that are typically transmitted Received 12 August 2013 sexually. Very few reports of non-sexually transmitted tubo-ovarian abscesses in children and adults Received in revised form have been published. We present a case of diffuse peritonitis secondary to a tubo-ovarian abscess in a 13 October 2013 13-year-old non-sexually active, virginal female. The causative organisms were Streptococcus viridans and Accepted 15 October 2013 Peptostreptococcus. The disease was treated with salpingectomy and adnexal debridement. Despite the Available online xxx absence of recognizable ovarian tissue, a left ovary was found on subsequent imaging after recovery. The case, along with a review of previous literature, is presented to raise awareness of this rare entity in girls Key words: Tubo-ovarian and discuss risk factors for its occurrence. Ó Abscess 2013 The Authors. Published by Elsevier Inc. Open access under CC BY license. Non-sexually transmitted

1. Case report At laparoscopy, the appendix was found to be un-involved. There was a large abscess in the pelvis accompanied by a severe A 13-year-old postmenarchal girl of South Asian origin pre- inflammatory process with omental caking, inflammatory debris, sented to the emergency department with fever, anorexia, vom- and gelatinous exudate (Fig. 1). After debridement and drainage iting, and fluctuating abdominal pain. The pain had lasted four of the pelvic abscess, the right adnexae were found to be days, resolved, then recurred seven days later with increasing secondarily inflamed due to a left tubo-ovarian abscess. The left intensity. She also complained of difficulty urinating and foul- pyosalpinx was aspirated for turbid, dark-colored fluid (Fig. 2), smelling, yellow vaginal discharge. She had never been sexually but the left ovary could not be visualized (Fig. 3). The procedure active and insisted that there was no history of sexual trauma or was converted to a laparotomy through a short Pfannenstiel exploration. On exam, the patient was febrile (39.4 C) and incision. Again, no discrete left ovarian tissue could be visualized, tachycardic (114 beats/min). She was toxic-appearing with diffuse with necrotic tissue found in the region of the left ovary. This was peritoneal signs. No abdominal mass was appreciated. Pelvic exam again debrided and a left salpingectomy was completed. The was deferred due to her virginal status. Laboratory testing inflamed right fallopian tube and ovary were left intact. revealed increased white blood cell (26.75 109/L) and neutrophil Final cultures of abscess contents and fluid aspirated from the counts (23.27 109/L). Urinalysis was normal and a pregnancy test left fallopian tube grew Streptococcus viridans and Peptos- was negative. Ultrasound could not identify the ovaries but treptococcus. Cultures for Neisseria gonorrhea and Chlamydia tra- revealed a large retrouterine heterogenous collection measuring chomatis were negative. The patient was treated post-operatively 10 8 11.4 cm that was compatible with an abscess secondary to with intravenous piperacillin/tazobactam for 5 days. She was perforated appendicitis. discharged on oral amoxicillin/clavulanic acid for two weeks. There were no complications. Pathologic exam of the specimen confirmed a pyosalpinx and necrotic ovarian tissue, consistent with tubo-ovarian abscess. An ultrasound performed by a gynecologist two months post- operatively identified normal right adnexae, without visualiza- tion of the left ovary. The patient continued to have regular * Corresponding author. Division of Pediatric General Surgery, Montreal Chil- menstrual periods without further symptoms. An ultrasound dren’s Hospital, Room C-818, 2300 Tupper Street, Montreal, Quebec, Canada H3H 1P3. Tel.: þ1 514 412 4497; fax: þ1 514 412 4289. performed 18 months after the episode showed a normal right E-mail address: [email protected] (S. Emil). ovary, and a small, but present, left ovary.

2213-5766 Ó 2013 The Authors. Published by Elsevier Inc. Open access under CC BY license. http://dx.doi.org/10.1016/j.epsc.2013.10.005

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Fig. 1. Laproscopic view after removing the omentum from the pelvis showing a severe Fig. 3. The left ovary is replaced by necrotic tissue with no identifiable normal ovary. pelvic inflammatory process in the cul-de-sac pushing the uterus anteriorly. The inflammation consisted of debris, pus, and gelatinous exudate. found to be higher in pre-pubertal girls than in normal adult women [16]. Disruption in the balance of the vaginal flora may 2. Discussion alter bacterial replicative and pathogenic potential in a syner- gistic fashion [13,17]. This may have precipitated the condition in Most tubo-ovarian abscesses (TOA) occur in the setting of our pubertal patient with a maturing vaginal flora. Vaginal flora sexually-transmitted pelvic inflammatory diseases (PID) due to may also change with recent antibiotic use. Our patient had not N. gonorrhea or C. trachomatis. Several case reports of TOA in non- used any antibiotics recently. We did not perform vaginal cul- sexually active female adolescent and virginal women have been tures, but it is likely the same organisms would have been e reported [1 12]. Approximately two-thirds of the patients retrieved. reported have been in the pediatric age group [1e4,6,7].The This case report adds TOA to the differential diagnoses of condition may mimic perforated appendicitis, the most common pediatric appendicitis in children, both clinically and on imaging. etiology for peritonitis in the pediatric age group. We present this Only one case of tuberculous TOA mimicking acute appendicitis report to alert pediatric surgeons to this pathology. has been previously reported [18]. Our service rarely performs CT fl Table 1 summarizes the prior reports of pelvic in ammatory scans in the work-up of abdominal pain in children to minimize disease and TOA in non-sexually active females. Most infections radiation risks. Furthermore, differentiating appendicitis and TOA fi were due to single organisms. The organisms identi ed in our using CT scans is not straightforward, posing a challenge even to fl patient, S. viridans and Peptostreptococus could be a re ection of experienced radiologists [19,20]. The only symptom in our pa- fl her maturing vaginal ora. These bacteria are commonly found in tient that was not consistent with perforated appendicitis was fl healthy, commensal ora as non-pathogenic organisms [13].In vaginal discharge. In retrospect, this should have raised the fl the human vaginal ora, their presence has been shown to possibility of an infection of the reproductive organs. However, ’ change with the female s pubertal stage, menstrual cycle, and PID and TOA were not entertained due to her age and report of e fl pregnancy [13 15]. Peptostreptococcus in vaginal ora was also sexual inactivity. A literature review of previously reported TOA in non-sexually active females suggests that eliciting last menstrual periods or the presence of vaginal discharge did not offer diagnostic clues. Based on the etiology of TOA in these females, important factors that can be considered include body habitus, pet or animal exposure, gastrointestinal pathology, and genito- urinary pathology [1,5e7,9e12]. Management of TOA remains controversial, but preserving reproductive potential is a priority. When possible, conservative management should be encouraged. Image-guided drainage, especially using ultrasound, is associated with fewer complications [21].Significant fertility was preserved in women who were treated with a combination of antibiotics and ultrasound-guided TOA drainage [22]. This may have been a viable treatment alter- native in our patient if the diagnosis was made pre-operatively. Surgical intervention should be considered if there is little improvement with antibiotics alone, unsuccessful drainage, increasing TOA size, or an uncertain diagnosis [23,24]. Laparos- copy is an ideal modality that allows for drainage and resection, if required. In our patient’s case, surgical intervention was driven by the septic picture associated with diffuse peritonitis. Excision Fig. 2. A view of the pelvis showing inflamed but intact right adnexa and a left of the pyosalpinx and debridement of the abscess contents were pyosalpinx. performed. The procedure was converted to a laparotomy in an

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Table 1 Previous case reports of pelvic inﬂammatory disease in non-sexually active females.

Author (year) Age Organism(s) Possible etiology Treatment Kielly and Jamieson (2013) [2] 11 None isolated Unknown Abdominal irrigation 15 Hartmann et al. (2009) [6] 12 E. coli Ascending genital tract infection Diagnostic laparoscopy due to poor hygiene, obesity 16 B. uniformis, coagulase Primary manifestation of Crohn’s disease Diagnostic laparoscopy negative staphylococcus, S. milleri Goodwin et al. (2013) [3] 13 E. coli Bacterial translocation Open drainage of TOA and left pyosalpinx Simpson-Camp et al. (2013) [4] 14 S. viridans Direct ascension Exploratory laparotomy, drainage of TOA Moore et al. (1999) [7] 15 E. coli Ascending genital tract infection Left salpingo-oophorectomy due to chronic pooling of urine in posterior vagina Arda et al. (2004) [1] 15 E. coli Possible concomitant pathology in genital tract Laparoscopic drainage Dogan et al. (2004) [5] 19 E. coli alpha-hemolytic Ascending genital tract infection Drainage and partial oophorectomy streptococci due to changes in cervical ﬂora Gensheimer et al. (2010) [9] 20 Abiotrophia Granulicatella Unknown Right salpingo-oophorectomy Leong et al. (2001) [10] 23 None isolated Unknown Laparoscopic right salpingo-oophorectomy Ashrafganjooei et al. (2011) [8] 24 None isolated Unknown Hysterectomy and right salpingo-oophorectomy Teng et al. (1999) [12] 47 P. multocida Possible cat-related trauma Supracervical hysterectomy & bilateral salpingo-oophorectomy Myckan et al. (2005) [11] 50 P. multocida Cat scratch disease Vaginal drainage

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