Ruptured Appendiceal Diverticulum Leading to Tubo-Ovarian Abscess in a Non-Sexually Active Woman: A Case Study.

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.

MICROSPORIDIA-ASSOCIATED GRANULOMATOUS DISEASE IN TWO AUSTRALIAN COLLECTIONS OF CAPTIVE INLAND BEARDED DRAGONS (POGONA VITTICEPS).

Microsporidia are obligate, intracellular fungi. In reptiles, they are most commonly reported in squamates. We report the first detection of microsporidiosis in inland bearded dragons (Pogona vitticeps) from Australia, and for the first time, mixed infections of microsporidium and adenovirus in asymptomatic inland bearded dragons. In one collection there were five individuals, one of which was lethargic, inappetent, and had lost weight. Two large ovarian granulomas were palpated (42 × 23 mm and 26 × 19 mm) and were surgically removed. This animal died shortly after surgery. Histological evaluation of these granulomas revealed granulomatous inflammation within or adjacent to ovarian tissue, containing numerous aggregates of microorganisms consistent with microsporidia. The organisms were confirmed as Encephalitozoon pogonae by polymerase chain reaction (PCR) and sequencing. Agamid adenovirus-1 was also detected. These two infectious agents were also detected by PCR in all the other bearded dragons in this collection (n = 5), all of which were asymptomatic. A single dragon from a second collection presented for a routine wellness examination after the sudden death of another dragon in the collection. This dragon had similar intracelomic masses to the dragon from the first collection. These were removed surgically, but the dragon died 5 wk later following 3 wk of treatment with 25 mg/kg fenbendazole PO q7 days. Necropsy samples were collected and the microsporidian Encephalitozoon pogonae was detected in oral-cloacal swabs, blood, and multiple tissues by PCR and sequencing. Agamid adenovirus-1 was not detected in this dragon.

A novel case of bilateral tubo-ovarian abscesses attributed to Ruminococcus gnavus without gastrointestinal involvement.

Ruminococcus gnavus is a Gram-positive anaerobe and normal gut commensal in the human host. There have been a small number of reported cases of infections attributed to R. gnavus, and no cases of urogenital infections have previously been published. We describe here a case of bilateral tubo-ovarian abscesses (TOAs) which cultured a pure growth of R. gnavus in a young female with concurrent deep infiltrating endometriosis and evidence of pelvic inflammatory disease. This case provides an insight into the behaviour of R. gnavus as a coloniser of the human host and provides further incentive to investigate its potentially pathogenic role in inflammatory conditions such as pelvic inflammatory disease.

Core curriculum case illustration: tubo-ovarian abscess.

This is the 47th installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at: http://www.erad.org/page/CCIP_TOC.

Respiratory and Reproductive Impairment of Commercial Layer Chickens After Experimental Infection with Gallibacterium anatis Biovar haemolytica.

The prevalence of Gallibacterium anatis in poultry production has increased over the last two decades. However, only a few studies have explored the pathogenicity of this bacterium in commercial layer chickens. This trial studied the aspects of the pathogenicity of a Gallibacterium anatis biovar haemolytica local Egyptian isolate (previously registered as strain B14 with GenBank accession no. KJ026147). We used 500 base pairs of a 16S ribosomal RNA gene and the 16S-23S ribosomal RNA intergenic spacer, partial sequence in an experimental infection trial in commercial White Shaver layer chickens aged 19 wk. The hens were divided into three groups of 40 birds each. The hens in Groups 1 and 2 were experimentally infected through the intranasal (IN) and intravenous (IV) routes, respectively, with a dose of 0.2 ml/bird containing 1.2 × 109 colony-forming units/ml. In contrast, Group 3 was kept as a noninfected control group. Both IN and IV infections resulted in a delayed egg laying for 1 wk and a significant (P ≤ 0.05) drop in egg production by 7.81% and 10.28% compared with the control group over 7 wk. Severe lesions in the form of hemorrhagic pneumonia, catarrhal tracheitis, ovarian follicle and oviductal regression, and septicemia were evident on necropsy, demonstrating the pathogenicity of G. anatis as a primary pathogen.

Ovarian abscess caused by Salmonella enterica serovar Typhi: a case report.

BACKGROUND: Typhoid fever is a human-specific disease caused by a bacterium, Salmonella enterica subspecies enterica serovar Typhi. It is transmitted through ingestion of contaminated food or water. It is mostly diagnosed by blood culture. Salmonella Typhi usually manifests as a febrile illness with bacteremia after initial entry through the gastrointestinal route, but it can occasionally cause significant disease in extraintestinal sites. We report a case of a girl in Fiji with a right ovarian abscess infected by Salmonella Typhi. CASE PRESENTATION: A 14-year-old iTaukei (indigenous Fijian) girl presented to our hospital with abdominal pain of 1 month's duration. Two days prior to her admission, she developed high-grade fever and nausea and had one episode of vomiting. On presentation, she appeared unwell; she was tachycardic (116 beats per minute) and febrile (38.8 °C). Her abdominal examination revealed generalized tenderness. Other examination findings were normal. The provisional diagnosis of abdominal sepsis led to an emergency laparotomy during which an enlarged right ovary was found to be spontaneously discharging pus. The ovary was incised and drained, and the patient was commenced on intravenous ceftriaxone 1 g twice daily, cloxacillin 1 g four times daily, and metronidazole 500 mg three times daily. She recovered promptly and was discharged to home on the sixth postoperative day. The purulent material from the ovary grew Salmonella Typhi. CONCLUSION: Extraintestinal infections caused by Salmonella Typhi are rare but can cause severe and life-threatening disease. Our patient had a prolonged history of abdominal pain and was found to have a ruptured right ovarian abscess due to Salmonella Typhi. Ovarian abscesses in girls who are not sexually active are not associated with pelvic inflammatory disease and suggest local or hematogenous spread. This case report may increase health workers awareness to include common and endemic infections in the differential diagnosis of unusual clinical presentations to help the initiation of appropriate investigation and management as quickly as possible.

Tube-ovarian abscess caused by Rothia aeria.

Rothia aeria is a gram-positive amorphous bacillus and was discovered in the Russian space station 'Mir' in 1997. It shows phylogenetic similarity to Actinomyces israelii, and as determined using 16 s ribosomal RNA gene analysis R. aeria is classified as a bacteria of the genus Actinomyces It was found to colonise in the human oral cavity, and there are some infectious reports but none specifies gynaecological infection. A 57-year-old woman, who had been continuously using intrauterine contraceptive device, presented with fever and lower abdominal pain. She was suspected tube-ovarian abscess caused by A. israelii, but the uterine cavity culture revealed R. aeria infection. Considering surgical treatment, conservative treatment by intravenous benzylpenicillin and subsequently oral ampicillin for 6 months improved the abscess, and she has no recurrence for over 1 year.

Fertility outcomes in patients with tubo-ovarian abscesses after an oocyte retrieval: a longitudinal cohort analysis.

PURPOSE: To determine the impact of pelvic inflammation caused by tubo-ovarian abscess (TOA) on ovarian response to stimulation. METHODS: This retrospective longitudinal cohort analysis that was carried out in a tertiary university-affiliated medical center included 15 women with TOA during in vitro fertilization (IVF) cycles. The ovarian response to stimulation and the pregnancy rate were compared in two subsequent cycles, the initial IVF cycle that was complicated by TOA after oocyte retrieval (first treatment cycle) and the following IVF treatment (second treatment cycle) that occurred within a period of a year from the first cycle. RESULTS: The mean number of retrieved oocytes was significantly higher in the first IVF cycle compared to the second cycle (8.1 ± 3.2 vs. 5.4 ± 2.5, P = .003], corresponding to a 30% reduction in ovarian response to gonadotropin stimulation. Fertilization rates were significantly lower in the second cycle (4.1 ± 2.9 vs. 2.9 ± 1.7, P = .015). Twelve women (80%) reached embryo transfer in the first cycle compared to 14 women (93.3%) in the second cycle. The mean number of transferred embryos was similar between the two cycles. There were no clinical pregnancies following the first cycle, and only one patient (6.6%) had a clinical pregnancy in the second treatment cycle. CONCLUSIONS: TOA following fertility treatment has a detrimental effect on ovarian function. The pregnancy rate in the immediate period following TOA is poor. Current data for recommending the deferral of fertility treatment following a TOA episode are insufficient, calling for more studies to address these issues.

[Management of tubo-ovarian abscesses and complicated pelvic inflammatory disease: CNGOF and SPILF Pelvic Inflammatory Diseases Guidelines]. / Prise en charge des abcès tubo-ovariens (ATO) et des formes compliquées d'infections génitales hautes. RPC infections génitales hautes CNGOF et SPILF.

A tubo-ovarian abscess (ATO) should be suspected in a context of pelvic inflammatory disease (PID) in case of severe pain associated with the presence of general signs and palpation of an adnexal mass at pelvic examination. Imaging allows most often a rapid diagnosis, by ultrasound or CT, the latter being irradiant but also allowing to consider the differential diagnoses (digestive or urinary diseases) in case of pelvic pain. MRI, non-irradiating examination, whenever it is feasible, provides relevant information, more efficient, guiding quickly the diagnosis. The diagnosis of tubo-ovarian abscess should lead to the hospitalization of the patient, the collection of bacteriological samples, the initiation of a probabilistic antibiotherapy associated with drainage of the purulent collection. In severe septic forms (generalized peritonitis, septic shock), surgery (laparoscopy or laparotomy) keeps its place. In other situations, ultrasound-guided trans-vaginal puncture in the absence of major hemostasis disorders or severe sepsis is a less morbid alternative to surgery and provides high rates of cure. Today, ultrasound-guided trans-vaginal puncture has been satisfactory evaluated in the literature and is part of a logic of therapeutic de-escalation. Randomized trials evaluating laparoscopic drainage versus radiological drainage should be able to answer, in the coming years, questions that are still outstanding (impact on chronic pelvic pain, fertility). The recommendations for the management of ATO published in 2012 by the CNGOF remain valid, legitimizing the place of radiological drainage associated with antibiotic therapy.

Case Report of a Tubo-ovarian Abscess Caused by Candida kefyr.

BACKGROUND: Candida species are harmless commensals of hosts, including humans, but they can cause infection when the immune system is compromised. Infections with non-albicans species can occur, ranging from urinary tract infections to sepsis, especially among patients in intensive care units. CASE: The patient, a 37-year-old woman, presented with severe abdominal pain, fever, and vomiting. The patient's symptoms and fever continued in spite of treatment with antibiotics, and she underwent exploratory laparotomy. Cyst content culture results showed that Candida kefyr was present in the cyst. CONCLUSION: To the best of our knowledge, this is the first case report of a tubo-ovarian abscess caused by C. kefyr. Rare pathogens can be found in patients with a tubo-ovarian abscess, so culture of the abscess material is important for determining subsequent treatment, particularly in women who require an operation for tubo-ovarian abscess.

Sepsis Secondary to Bacteroides Fragilis Tubo-Ovarian Abscess Requiring Hysterectomy and Bilateral Salpingo-Oophorectomy.

A 45-year-old, G0P0 premenopausal woman was admitted for investigation of right lower quadrant pain, fever, leucocytosis and right adnexal abscess on CT. She was started on intravenous antibiotics and underwent CT-guided percutaneous drainage from which Bacteroides fragilis was cultured. A few days later, she had an exploratory laparotomy with incision and drainage. Once stabilised, she was discharged on intravenous antibiotics. She was followed outpatient and subsequent imaging demonstrated significant improvement of the abscess. After being asymptomatic for 3 months, she again presented to the emergency department with right lower quadrant abdominal pain, fever and leucocytosis. Two days later, she underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy. She made a full recovery and began treatment with a herbal oestrogen derivative to prevent early menopause.

Tubo-ovarian abscess infected by Salmonella typhi.

We report a case of a tubo-ovarian abscess infected with Salmonella enterica serotype typhi A 19-year-old Nepalese woman presented to a hospital in Kathmandu with lower abdominal pain, constipation, fever and a non-healing, suppurative surgical wound from an emergency caesarian section performed 2 months previously at 37 weeks of pregnancy. She also had an exploratory laparotomy for an appendix perforation with peritonitis at 25 weeks of gestation. Her wound infection did not respond to cloxacillin and she had an exploratory laparotomy, and a tubo-ovarian abscess was found from which S. typhi was isolated. She had a bilateral salpingo-oophorectomy and responded to 14 days of chloramphenicol. A tubo-ovarian abscess is a rare complication of enteric fever.

Tubo-ovarian abscess in non sexually active adolescents.

A tubo-ovarian abscess is a rare presentation in non-sexually active adolescents; only 11 cases have been reported in the literature. Variable approaches for diagnosis and management are described. We present a 19-year-old, non-sexually active, medically free girl, who had an abdominopelvic mass with abdominal pain and vomiting followed by fever. She had a confusing presentation of malignancy versus tuberculosis, with the help of imaging, diagnosis and treatment with percutaneous drainage, conservative treatment was achieved. Diagnosis of a tubo-ovarian abscess is difficult in non-sexually active adolescents, a high clinical index of suspicion is important as misdiagnosis may lead to radical and aggressive management, conservative management is possible in many of these patients.

[Tubo-ovarian abscesses treatment: Faisability and results of trans-vaginal ultrasound-guided aspiration]. / Évaluation de la faisabilité du traitement des abcès tubo-ovariens par ponction trans-vaginale écho-guidée.

OBJECTIVE: Two years after the French guidelines, the objective was to assess the feasibility and efficiency of ultrasound-guided trans-vaginal drainage of tubo-ovarian abscesses (TOA) and to study the responsible germs. MATERIAL AND METHODS: All the patients with a larger abscess than 20mm were included prospectively from May 2011 to July 2014 in the university hospital of Lille. RESULTS: Sixty-nine drainages were performed among 50 patients. Success rate was 94%. No complication occurred. One germ was found in 55% of patients, the TOA was polymicrobian in 20% of cases. CONCLUSION: Ultrasound-guided trans-vaginal drainage of TOA is safe and effective with more than 90% of success rate.

Tubo-Ovarian Abscess Caused by Candida Albicans in an Obese Patient.

BACKGROUND: Tubo-ovarian abscess (TOA) arises in most cases from pelvic infection. Appropriate treatment includes use of antimicrobials and, especially in patients with increased BMI, drainage of the contents. CASE: A 44-year-old morbidly obese woman (BMI 72) had a persistent TOA despite receiving antibiotic treatment for four months. She had no history of diabetes, and denied being sexually active. Imaging demonstrated a pelvic abscess of 14.9 × 8.9 × 11.1 cm. Successful percutaneous drainage was performed yielding purulent material which grew Candida albicans. The patient recovered after drainage of the abscess and the addition of fluconazole to her antimicrobials. She had no apparent risk factor for acquiring such an opportunistic infection, other than her morbid obesity. CONCLUSION: Because morbid obesity may confer a relative immunodeficiency, morbidly obese patients may develop unusual infections such as opportunistic fungal abscesses.

Contexte : Les abcès ovario-tubaires (AOT) sont, dans la plupart des cas, attribuables à une infection pelvienne. Parmi les moyens de prise en charge adéquats, on trouve le recours à des agents antimicrobiens et, particulièrement chez les patientes qui présentent un IMC accru, le drainage des abcès en question. Cas : Une femme obèse morbide de 44 ans (IMC 72) présentait un AOT persistant malgré l'administration d'une antibiothérapie pendant quatre mois. Elle ne présentait pas d'antécédents de diabète et affirmait ne pas être sexuellement active. L'imagerie a révélé la présence d'un abcès pelvien de 14,9 cm sur 8,9 cm sur 11,1 cm. Un drainage percutané a été mené avec succès; la présence de Candida albicans a été identifiée dans le matériel purulent drainé. La patiente a récupéré à la suite du drainage de l'abcès et de l'ajout de fluconazole à ses agents antimicrobiens. À part son obésité morbide, elle ne présentait aucun facteur de risque apparent de contracter une telle infection opportuniste. Conclusion : Puisque l'obésité morbide pourrait conférer une immunodéficience relative, les patientes obèses morbides pourraient contracter des infections inhabituelles, telles que des abcès fongiques opportunistes.

Ovariectomy as treatment for ovarian bacterial granulomas in a Duvaucel's gecko (Hoplodactylus duvaucelii).

CASE HISTORY: An adult female Duvaucel's gecko (Hoplodactylus duvaucelii) from a threatened species breeding programme presented due to a prolonged gestation period and distended abdomen. CLINICAL AND PATHOLOGICAL FINDINGS: The gecko was in lean body condition with an irregularly shaped, firm mass in the coelomic cavity. Radiographically there was a diffuse radio-opacity within the coelomic cavity with cranial displacement of the right lung field. Ultrasonography revealed a round homogenous abdominal mass of medium echogenicity with an echogenic capsule. Haematology showed a leucocytosis with a moderate left shift in heterophils and toxic changes. Bilateral ovariectomy was performed to remove two ovarian granulomas and Salmonella enterica subspecies houtenae (IV) was cultured from the ovarian tissue. The gecko recovered well from the surgery, regained weight and remained in good health 3 years following the surgery. DIAGNOSIS: Pre-ovulatory stasis and ovarian granulomas associated with infection with Salmonella enterica subsp. houtenae. CLINICAL RELEVANCE: The surgery described in this case resulted in recovery of the gecko, which despite its loss of reproductive capability is of value as an education animal. This is the first report of pre-ovulatory stasis and ovarian granulomas associated with infection with Salmonella enterica in a Duvaucel's gecko and is also the first reported case of pre-ovulatory stasis in a viviparous lizard species. The case adds to knowledge regarding potential reproductive pathology in lizards, which is particularly important information for managers of captive lizard breeding programmes.

Identification of Clostridium septicum in a tubo-ovarian abscess: a rare case and review of the literature.

INTRODUCTION: Tubo-ovarian abscess (TOA) is a conglomerated mass of pelvic organs including the tube, the ovary, and the bowel. The most commonly isolated organisms from TOAs are Escherichia coli (E. coli) and Bacteroides species. CASE REPORT: We reported a case of Clostridium septicum (C. septicum) infection from a ruptured TOA with atypical clinical features. Culture of intra-abdominal free fluid obtained during surgery yielded C. septicum. VITEK II (bioMérieux, France) automated system was used for advanced identification of the bacteria. Parenteral clindamycin in combination with an aminoglycoside was used. The patient was discharged 19 days after the surgery and was clinically asymptomatic 6 months after the surgery. CONCLUSION: The differential diagnosis of TOA caused by C. septicum can be difficult, due to the lack of the symptoms. Tissues infected with C. septicum can become necrotic. A combination of early, adequate antibiotic therapy and surgery is the key point of the treatment.