A 30-year-old, multiparous widow, with postpolio residual paralysis, presented with complaints of dull aching abdominal pain for 15 days. Ultrasound showed a mixed echogenic right adnexal mass with free fluid in the pelvis and abdomen. CT abdomen and pelvis revealed partially defined peripherally enhancing collection in lower abdomen and right adnexa suggestive of tubo-ovarian abscess. There was mild ileal wall thickening and few enlarged mesenteric lymph nodes. Ascitic fluid did not show acid fast bacilli and cultures were sterile. Extensive diagnostic laboratory work was done which was inconclusive. Diagnostic laparoscopy could not be performed due to non-availability of elective operation theatre in the COVID-19 pandemic. Presumptive extrapulmonary tuberculosis was clinically and radiologically diagnosed. She was started on daily anti tuberculosis treatment. This case shows us the importance of imaging as a diagnostic tool and as an alternative for laparoscopy in COVID-19 pandemic to diagnose abdomino-pelvic tuberculosis.

The aim of this study was to compare the clinical characteristics of patients with tubo-ovarian abscess (TOA) who responded to medical treatment and those who underwent surgical intervention due to medical treatment failure. Electronic medical records were evaluated retrospectively to identify patients who were diagnosed with TOA. Demographic, clinical, and laboratory data including white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were compared between the medical treatment group and the surgical intervention group. Patient age, TOA diameter, WBC count, CRP, and ESR were significantly different between the groups. On multiple regression analysis, significant correlations were identified between age (p = .001), ESR (p = .045), and failure of medical treatment. TOA diameter (p = .065) showed a borderline association with surgical intervention. The risk of needing surgical intervention in TOA patients can be predicted using ESR in addition to age and TOA size as risk factors.IMPACT STATEMENTWhat is already known on this subject? For patients diagnosed with a tubo-ovarian abscess (TOA), the size of TOA and the patient's age are helpful for early identification of patients who are likely to need surgical treatment. Inflammatory markers such as C-reactive protein and white blood cell are also associated with the risk of surgical intervention.What do the results of this study add? Erythrocyte sedimentation rate (ESR) in addition to the size of TOA and the patient's age is a useful marker in determining whether to undergo surgery in patients with TOA.What are the implications of these findings for clinical practice and/or further research? ESR combined with the patient's age and the size of TOA is clinically useful in predicting the need for early surgical intervention in patients with TOA. Large prospective controlled studies are required to establish relationship between inflammatory markers and the risk of surgical intervention.

We present the case of a 26-year-old multiparous woman who experienced rupture of a tubo-ovarian abscess during the second trimester of pregnancy. She presented with epigastric and right lower quadrant pain at 12 + 0 weeks' gestation. There were no other specific findings on the magnetic resonance imaging images. We recommended hospitalization to observe the changes in pain, but she refused confinement. About 3 weeks later, she revisited our emergency room at 15 + 4 weeks' gestation. She complained of worsening abdominal pain with fever. She underwent right salpingo-oophorectomy and appendectomy due to uncontrollable, severe abdominal pain without any obstetric abnormal condition. There was a rupture site in the right adnexa, which was covered with pus. The rupture of tubo-ovarian abscess during pregnancy is very rare. Therefore, obstetricians should carefully monitor the adnexal masses observed during pregnancy, which should be treated with caution, whether or not the patient is symptomatic.

Reproductive-age female patients commonly seek evaluation for pelvic pain in a variety of health care settings. Thus, teaching medical students how to effectively evaluate female pelvic pain is a necessary part of medical education. There are limited opportunities, however, to reinforce the needed skills for this common but sensitive presentation that can be anxiety-producing for preclinical students.

Brucellosis is a zoonotic disease located especially in Central and South America, India, the Mediterranean and the Middle East. Human brucellosis occurs as a systemic infectious disease with various clinical manifestations. We present a case of 45-year-old female patient, nulliparous, not sexually active, with a previous medical history of a treated brucellosis, and no surgical or gynecological history. The patient presented with a history of fever for 7 days of 39 degrees Celsius, chills and acute abdominal pain. She was diagnosed with diffuse peritonitis with left tubo-ovarian abscess and was admitted for an urgent diagnostic laparoscopy. A left adnexectomy was performed. The diagnosis of genital brucellosis was made. This case report discusses an unusual complication of brucellosis represented by a tubo-ovarian abscess associated with acute peritonitis, treated by a laparoscopic adnexectomy and antimicrobials. Acute peritonitis associated with a tubo-ovarian abscess is an unusual complication of brucellosis.

Introduction Pelvic inflammatory disease (PID) is a spectrum of illness ranging from mild illness to more severe forms including tubo-ovarian abscess, hydrosalpinx, pyosalpinx, oophoritis (THPO). The objective of the study was to report rates and clinical characteristics of females presenting to the ED with a diagnosis of THPO in relationship to the presence or absence of sexually transmitted infections (STIs). Methods A database of ED patient encounters occurring from April 18, 2014, to March 7, 2017 was created. Analysis of women diagnosed with THPO and who had testing for gonorrhea, chlamydia, or trichomonas by nucleic acid amplification testing or who had a vaginal wet preparation was performed. Patient demographics, ED diagnoses, laboratory tests, medications administered in the ED, and medications prescribed were examined. Categorical variables were summarized as count and percentages and analyzed using the Chi-square test. Continuous variables were summarized as the mean and standard deviation and analyzed using the t-test. All statistical tests were two-sided with a significance level of 0.05. Results THPO was diagnosed in 0.3% (56/17,905) of patient encounters. There were 50% (28/56) of women with THPO admitted to the hospital. There were 25.0% (12/48) women who received a positive test result for Neisseria gonorrhoeae, Chlamydia trachomatis, and/or Trichomonas vaginalis. Women with THPO were significantly older, more likely to be infected with gonorrhea, and more likely to be diagnosed with sepsis and PID (P<.05 for all). Conclusions THPO is an infrequently encountered entity in the ED. A diagnosis of STI, PID, and sepsis can accompany these presentations. Although an uncommon diagnosis, ED providers must be attentive to patients presenting with pelvic symptoms that could be consistent with THPO to mitigate any complications that may arise and to direct the appropriate treatment.

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.

This 5-year retrospective study aimed to investigate whether early surgical management improves outcomes in patients presenting with a tubo-ovarian abscess (TOA). Patient characteristics, investigation results and treatment outcomes were compared. 50 women were diagnosed with a TOA during the study period. Nineteen (38.0%) were treated with antibiotics (medical group) and thirty one (62.0%) were treated surgically on admission (early surgical group). The early surgical group was associated with a high success rate of 96.8% and the lowest risk of readmission within 12 months (16.1%). There was no significant difference in the length of stay between the early surgical and the successful medical group. Impact Statement What is already known on this subject? Tubo-ovarian abscess (TOA) is an inflammatory mass that forms most commonly as a complication of untreated pelvic inflammatory disease (PID). Traditionally, TOAs are treated first with broad-spectrum intra-venous antibiotics, with surgical intervention considered after 72 h. It is not known whether early surgical intervention would be beneficial to patient outcomes compared to traditional management. What do the results of this study add? In this study, we have demonstrated a high success rate with early surgical management. Readmission rate was lowest in the early surgical group compared to the medical and late surgical group. This suggests that early surgical intervention may be beneficial, compared to the standard management of trialling antibiotics and then proceeding to surgery 72 h later. What are the implications of these findings for clinical practice and/or further research? Our study suggests that early surgery may be beneficial in the management of TOAs. Although we were unable to demonstrate statistical significance, our data suggest that it would be worthwhile to investigate white blood cell (WBC) and C-reactive protein (CRP) further as a potential predictor for failure of medical management. In the future, more studies comparing early surgical management with medical and late surgical management could inform clinicians of the best mode of treatment for these patients.

Sexually transmitted infections (STIs) disproportionately affect young people, with more than half of the infections occurring in youth aged 15 to 25 years. (1)(2) This review, the second in a 2-part series on STIs, focuses on infections that may cause abnormal vaginal or penile discharge, including trichomonas, chlamydia, gonorrhea, and pelvic inflammatory disease (PID). Most infected persons, however, are asymptomatic. Nucleic acid amplification tests are the most sensitive and specific for the detection of chlamydia, gonorrhea, and trichomoniasis, and they can be performed on provider- or patient-collected swabs. Providers should have a low threshold for diagnosing and treating PID because untreated PID can have serious long-term complications for young women. Indications for hospitalization for PID include the presence of a tubo-ovarian abscess, severe illness with systemic symptoms, pregnancy, human immunodeficiency virus infection, and failure to respond to outpatient oral treatment (within 48-72 hours) or inability to tolerate the oral treatment.

is a gram-positive bacillus in the female genital tract believed to be a commensal organism that inhibits the growth of more virulent pathogens. Prevotella bivia is a gram-negative bacillus species also typically commensal in the female genital tract. Lactobacillus as the primary causative agent in perinephric abscesses and bacteremia has been documented, albeit very uncommon and opportunistic. Prevotella bivia is not classically associated with perinephric abscesses but has been implicated in rare cases of pelvic inflammatory disease and tubo-ovarian abscesses. In this report, we present a 26-year-old immunocompetent woman with a recent history of nephrolithiasis treated with lithotripsy, ureteral stent placement and removal, and antibiotics who was admitted for fever and severe right flank pain. Imaging showed a right-sided renal and perinephric abscesses colonized by Lactobacillus jensenii and Prevotella bivia. Blood cultures were also positive for Lactobacillus species. Per literature review, intravenous ceftriaxone and metronidazole were administered with successful resolution of abscesses and negative repeat blood cultures. To our knowledge, this is the first case of simultaneous renal system abscesses caused by Lactobacillus and Prevotella species. Nephrolithiasis and prior antibiotics likely contributed to the opportunistic pathogenesis in this otherwise immunocompetent patient.

Management of Pelvic Inflammatory Disease Abstract. Pelvic inflammatory disease (PID) is a common medical problem, but the diagnosis of PID can be challenging because the clinical manifestations may mimic those of other pelvic and abdominal processes. As PID might cause late complications such as infertility or chronic pelvic pain, it is of prime importance that the diagnosis of PID is made promptly to assure the early onset of an adequate antibiotic therapy. Where uncomplicated PID usually has a favorable course, complicated forms with tubo-ovarian abscess generally require surgical exploration.

We report a case of acute urinary retention in an adolescent female secondary to hematocolpos. A 13-year-old female presented to the emergency department with acute urinary retention and suprapubic abdominal pain for 24 hours. She denied menstruation or sexual history. Bedside bladder ultrasound scan revealed 1.2 L of retained urine and a Foley catheter was placed. A formal renal ultrasound detected a debris-filled structure in the abdomino-pelvic cavity. Follow-up computed tomography of the abdomen and pelvis revealed an 8.5 cm × 9.3 cm × 12.1 cm mass-like structure in the pelvis. No formal pelvic exam was completed and the patient was taken to the operating room for exploratory laparotomy due to concern for large pelvic mass versus tubo-ovarian abscess. However, upon entering the abdominal cavity, no mass was found. At that point, an external genital exam was performed, revealing an imperforate hymen. Hymenotomy resulted in the evacuation of 2.5 L of clotted blood from the vagina and uterus. Hematocolpos resulting in acute urinary retention is exceedingly rare; however, it is an important differential diagnosis that can be ruled in or out by physical exam findings. Although it may be uncomfortable for adolescent patients and physicians, external genital exams should be conducted in young females with acute urinary retention and amenorrhea to evaluate for imperforate hymen. This can ensure appropriate treatment and avoidance of unnecessary invasive procedures.

Blastomycosis is an uncommon disease caused by the dimorphic fungus, Blastomyces dermatitidis, often found in endemic regions of Midwestern America. It can be found in forested, sandy soils, decaying vegetation, rotting wood near water sources, and even in bird feces. Most commonly, blastomycosis manifests as a pulmonary infection presenting as pneumonia, or in severe cases, respiratory distress syndrome (ARDS). Dissemination to the bone is less common but osteomyelitis of the lower thoracic and lumbar spine, ribs, skull, and long bones have been most frequently reported. Disseminated infection to the genitourinary system commonly manifests as prostatitis or epididymo-orchitis in men and as an endometrial infection or tubo-ovarian abscess in women. In the nervous system, blastomycosis can manifest as meningitis or with a cranial abscess. Having a high degree of clinical suspicion and obtaining a detailed medical and social history is important for making a diagnosis. Culturing a specimen will provide a definitive diagnosis. Sputum or tissue specimens stained in 10% potassium hydroxide under microscopy will reveal the classic appearance of B. dermatitidis (broad-based budding with a double-contoured cell wall). In mild to moderate disease without dissemination, itraconazole is the treatment of choice. In severe, life-threatening cases, patients with CNS involvement or in immunocompromised individuals, amphotericin B is the preferred initial drug of choice. We present an interesting case of a 42-year-old African-American male with no significant past medical history who was admitted initially for suspicion of cellulitis/septic arthritis and was started on broad-spectrum antibiotics. However, he was eventually found to have Blastomyces osteomyelitis.

Haematogenous or direct spread of bacterial infection causing pelvic inflammatory disease of the upper female reproductive tract is uncommon. We report a diagnostically challenging case of a 41-year-old woman with a background of Stage 4 endometriosis presenting with fever, diarrhoea and abdominal pain with recent history of pyelonephritis. Initially managed for undifferentiated abdominal pain with unclear focus of infection, a broad range of investigations were undertaken. Laboratory samples confirmed the presence of Campylobacter jejuni and appropriate treatment for Campylobacteriosis was commenced. Despite treatment, her condition deteriorated and repeat radiological imaging revealed bilateral tubo-ovarian abscess requiring surgical drainage for control of severe sepsis. Sterile surgical samples of the abscess revealed Escherichia coli. This case adds to the growing body of evidence of the association between pelvic inflammatory disease, severe endometriosis and development of tubo-ovarian abscess. Sepsis associated with tubo-ovarian abscess has a mortality rate of up to 10%. Hence, we present this case to highlight severe endometriosis as a risk factor for disease and the need for prompt reassessment of the deteriorating woman with sepsis and pelvic pain to direct efforts to minimise morbidity and mortality.

The correlation between pelvic inflammatory disease (PID) and a present intrauterine device (IUD) has been debated. We aimed to evaluate the differences between IUD users and non-users among women hospitalised with a diagnosis of PID. Our hypothesis was that the role of a present IUD among PID patients is minimal, if any. We performed a retrospective cohort study during 2010-2018 in a tertiary university hospital. Overall, 474 hospitalised patients were diagnosed with PID. Of these, 121 patients were IUD users. The patients without an IUD were younger and had lower gravidity and parity. Among the patients without an IUD, higher rates of prior history of PID and fever at presentation were noticed. In 23.9% (29/121) of women, the IUD was inserted less than four weeks prior to the PID diagnosis. The patients with an IUD insertion-associated PID, had lower rates of tubo-ovarian abscess (2 (6.9%) versus 24 (26.0%), OR [95% CI] 0.18 (0.04-0.84), p = .02) at presentation, as well as a shorter length of stay (LOS) (median 4 versus 5 days, p = .05). In a patient in whom the IUD was retained, hospitalisation period was shorter (median LOS 4 days versus 5 days, p = .007). PID inpatients who carry an IUD represent a specific subset of patients with a milder disease.Impact statementWhat is already known on this subject? The correlation between pelvic inflammatory disease (PID) and a present intrauterine device (IUD) is debateable.What the results of this study add? PID inpatients who carry an IUD represent a specific subset of patients with milder disease.What the implications are of these findings for clinical practice and/or further research? Our results show that in IUD users with PID, the practice of IUD removal as part of their PID treatment is of little benefit.

Pelvic inflammatory diseases (PID) must be suspected when spontaneous pelvic pain is associated with induced adnexal or uterine pain (grade B). Pelvic ultrasonography is necessary to rule out tubo-ovarian abscess (TOA) (grade C). Microbiological diagnosis requires endocervical and TOA sampling for molecular and bacteriological analysis (grade B). First-line treatment for uncomplicated PID combines ceftriaxone 1 g, once, IM or IV, doxycycline 100 mg ×2/day, and metronidazole 500 mg ×2/day PO for 10 days (grade A). First-line treatment for complicated PID combines IV ceftriaxone 1-2 g/day until clinical improvement, doxycycline 100 mg ×2/day, IV or PO, and metronidazole 500 mg ×3/day, IV or PO for 14 days (grade B). Drainage of TOA is indicated if the pelvic fluid collection measures more than 3 cm (grade B). Follow-up is required in women with sexually transmitted infections (STIs) (grade C). The use of condoms is recommended (grade B). Vaginal sampling for microbiological diagnosis is recommended 3-6 months after PID (grade C), before the insertion of an intrauterine device (grade B), and before elective termination of pregnancy or hysterosalpingography. When specific bacteria are identified, antibiotics targeted at them are preferable to systematic antibiotic prophylaxis.

Pneumoperitoneum seen on an X-ray or computed tomography (CT) image points to a diagnosis of ruptured viscus and immediate surgery is warranted. A case of tubo-ovarian abscess (TOA) presenting with pneumoperitoneum is unusual. Very few cases have been reported where the pneumoperitoneum is caused by an abscess involving the adnexa. We present the case of a 17-year-old patient who presented with acute abdomen and raised inflammatory markers and had laparoscopy for suspected bowel perforation based on the finding of pneumoperitoneum on CT scan. Bowel perforation was ruled out and the findings were consistent with TOA. She had drainage of the abscess, subsequently received intravenous antibiotics and postoperatively recovered well. The pneumoperitoneum could have been due to coinfection with E. coli, as the patient had had a urinary tract infection due to E. coli three weeks before presentation, or slow leakage of the TOA. In conclusion, gas under the diaphragm can be related to non-bowel-related gynaecological pathology, but it vital to rule out sinister causes.