{"paper_id":"3013d9cb-592d-40c2-b637-2645ebdf0772","body_text":"A tubo-ovarian abscess is commonly associated with pelvic inflammatory disease (PID) and is one of the major complications of acute PID. It occurs in 10–15 % of hospitalized women with PID [ 1 ]. Generally, tubo-ovarian abscess occurs secondary to salpingo-oophoritis. However, isolated ovarian abscesses without tubal involvement can occur as metastatic infections, especially as superinfected ovarian cysts [ 2 ]. We report a case of  Salmonella stanley  ovarian abscess without fallopian tube abscesses in a pregnant woman with endometrioma. Additionally, we reviewed previous reports of non-pregnant and pregnant women with  Salmonella  ovarian abscesses with superinfected endometriomas. Furthermore, we evaluated the relationships between  Salmonella  infections, preexisting endometriomas, and pregnancy. This report emphasizes the potential of ovarian cysts and endometriomas to become superinfected with  Salmonella , especially in pregnant women, and underscores the importance of well-timed clinical and microbiological diagnoses to prevent later infertility.\n\nA 26-year-old Japanese woman, gravida 1, para 0, at 36 weeks gestation with an unremarkable prenatal course presented with high fever, shaking chills, left lower abdominal pain, and diarrhea; therefore, she was referred to our hospital 5 days after a vaginal delivery. She had been treated with cefmetazole 1 g every 12 h for 5 days at another hospital. She presented with nausea, greenish diarrhea ( Fig. 1 A), and one vomiting episode along with the abovementioned symptoms at our hospital. She had no history of traveling abroad or contact with improperly handled foods or animals during pregnancy and fertility treatments. She had no known allergies and had not been prescribed any recent medications. Fig. 1 Stool and CT findings. (A): A sample of greenish diarrhea. (B 1-3 ): CT and magnetic resonance images showing a left adnexal mass (arrows) and fluid collection (arrow) in the pelvis. (C): CT image also showing wall thickness and fluid collection in the small intestine. CT, computed tomography. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article). Fig. 1\nStool and CT findings. (A): A sample of greenish diarrhea. (B 1-3 ): CT and magnetic resonance images showing a left adnexal mass (arrows) and fluid collection (arrow) in the pelvis. (C): CT image also showing wall thickness and fluid collection in the small intestine. CT, computed tomography. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article).\nShe was alert, and her vital signs were: body temperature, 39.3 °C; blood pressure, 123/73 mmHg; heart rate, 94 beats/minute; respiratory rate, 20 breaths/minute; and percutaneous oxygen saturation, 98 % on room air. Physical examination showed hypoactive bowel sounds on auscultation and abdominal tenderness mainly in the lower abdomen. Other examinations were unremarkable. Laboratory findings were: total protein, 5.5 g/dL; albumin, 1.8 g/dL; alanine aminotransferase, 5 IU/L; aspartate aminotransferase, 10 IU/L; lactate dehydrogenase, 122 IU/L; blood urea nitrogen, 7 mg/dL; creatinine, 0.51 mg/dL; C-reactive protein, 18.88 mg/dL; white blood cell count, 10,700/μL with 88.8 % neutrophils; hemoglobin, 9.5 g/dL; and platelet count, 30.1 × 10 4 /μL.\nSonographic examination showed a left multicystic adnexal mass measuring 8 × 7.5 cm. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a fluid collection in the pelvis and wall thickness and fluid collection in the small intestine ( Fig. 1 B, C). She was diagnosed with a left ovarian abscess with pelvic peritonitis and inflammation of the small intestine. Blood and stool cultures were taken, and intravenous ceftriaxone 1 g every 24 h and a single 2-g oral dose of azithromycin were administered. Subsequently, she underwent abdominal enucleation of the abscess with removal of the pelvic abscesses on day 4 post-admission. We found pelvic peritonitis with several abscesses; the bilateral fallopian tubes were intact. Cultures of the abscesses were positive for  Salmonella  species susceptible to ampicillin (minimum inhibitory concentration [MIC] ≤2 μg/mL), ceftriaxone (MIC ≤ 1 μg/mL), ciprofloxacin (MIC ≤ 0.06 μg/mL; susceptibility defined as MIC ≤ 0.06 μg/mL), and levofloxacin (MIC ≤ 0.06 μg/mL; susceptibility defined as MIC ≤ 0.12 μg/mL) according to E-tests (bioMérieux, Marcy I’Etoile, France) ( Table 1 ). The VITEK II system (bioMérieux) indicated the  Salmonella  group, while  S. enterica  subsp.  enterica  was identified by 16S rRNA gene sequencing. Isolate serotyping was performed by latex agglutination using mono- and poly-valent anti-sera for O and H antigens according to the Kauffman-White scheme. The serovar was determined to be  S. stanley  (O4:d:1,2). Blood and stool cultures were negative. Pathology of the left ovary revealed endometrioma with acute inflammation and abscess. She was treated with ceftriaxone for 7 days followed by oral levofloxacin 500 mg daily for 3 weeks postoperatively according to the susceptibility test ( Fig. 2 ). Consequently, the abscess was no longer visible on CT, and the patient has remained well. Table 1 Antimicrobial susceptibility test results. Table 1 Salmonella stanley Antimicrobial agents MIC (μg/mL) Interpretation of susceptibility Ampicillin ≤2 S Sulbactam/ampicillin ≤2 S Cefazolin ≤4 R Cefotiam ≤8 R Cefmetazole ≤1 R Cefotaxime ≤1 S Ceftriaxone ≤1 S Ceftadizime ≤1 S Cefepime ≤1 S Imipenem/cilastatin ≤0.25 S Meropenem ≤0.25 S Gentamicin ≤1 R Amikamycin ≤2 R Sulfamethoxazole/trimethoprim ≤1/19 S Nalidixic acid* S Ciprofloxacin ≤0.06 S Levofloxacin ≤0.06 S *Interpreted according to the disk method. MIC, minimum inhibitory concentration; S, susceptible; R, resistant. Fig. 2 Clinical course in this case. BT, body temperature; CT, computed tomography; WBC, white blood cell count; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article). Fig. 2\nAntimicrobial susceptibility test results.\n*Interpreted according to the disk method. MIC, minimum inhibitory concentration; S, susceptible; R, resistant.\nClinical course in this case. BT, body temperature; CT, computed tomography; WBC, white blood cell count; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article).\n\nThis report highlights the potential of ovarian cysts and endometriomas to become superinfected with  Salmonella  in pregnant women and the importance of timely clinical and microbiological diagnoses to prevent later infertility.\nSalmonella -infected ovarian abscesses are rare. However,  Salmonella  species can cause extraintestinal infections that may not be suspected in the setting of mild primary infection. Extraintestinal infections include orthopedic infections, endovascular infections, visceral abscesses of any organ, and ovarian endometriomas superinfection (as in our case). Nine English-language reports including pathologically diagnosed superinfected ovarian endometriomas caused by  Salmonella  infection have been published since 1963 [ [2] ,  [3] ,  [4] ,  [5] ,  [6] ,  [7] ,  [8] ,  [9] ,  [10] ]. These reports, plus this case, are summarized in  Table 2 . Blood cultures were positive in only 3 (30 %) of 10 patients. Generally,  Salmonella  infections can cause isolated ovarian abscesses without tubal involvement as metastatic infections. Therefore, we cannot exclude  Salmonella  extraintestinal infections based on negative blood cultures. Furthermore,  Salmonella  ovarian abscesses are presumed to result in hematogenous spread to endometriomas or ovarian cysts, including dermoid cysts and teratomas [ 11 ]. However, only 2 (20 %) of 10 patients were diagnosed with endometriomas before admission. Thus, diagnostic imaging (e.g., ultrasonography, CT, and MRI) is needed to diagnose superinfected ovarian cysts, including endometriomas. Here, it was probable that the patient had an undiagnosed preexisting ovarian endometrioma that predisposed her to  S. stanley  multiplication via the bloodstream following transient and undetected bacteremia. Table 2 Superinfection of endometriomas. Table 2 Authors Age (years) Comorbidity Location Preceding symptoms Positive blood cultures Positive stool cultures Pathogens Tubal involvement Pregnancy Size (cm) Antibiotic used Antibiotic duration (days) Outcome Adelman et al. [ 2 ] 28 None USA Diarrhea, abdominal pain, fever, anorexia Positive Positive S. schwarzengrund None No 12 Ciprofloxacin Metronidazole Ceftriaxone 14 A Magliulo et al. [ 3 ] 30 None Italy Abdominal pain, fever Negative Negative S. brandenburg None No 11 Chloramphenicol 10 A Ghose et al. [ 4 ] 28 None UK Bloody diarrhea, abdominal pain, vaginal bleeding Negative Negative (positive after surgery) S. stanley Yes No 10 × 8×3 Amoxicillin Cotrixazole 19 A Kemmann et al. [ 5 ] 26 Endometrioma Canada None Negative Negative Salmonella  spp. None No 7 Ciprofloxacin 14 A Li and Cohen [ 6 ] 31 SLE Hong Kong None Positive Positive S. enteritidis  (blood, stool)/ S. typhimurium  (pus) Yes No 4 Ciprofloxacin Ofloxacin 28 A Burgmans et al. [ 7 ] 16 None Netherlands Abdominal pain, fever, headache, fatigue, productive cough Negative Negative S. enteritidis None No 8.5 × 7.8 Ofloxacin 11 A Wang et al. [ 8 ] 43 None Taiwan Abdominal fullness, nausea, vomiting, diarrhea, fever Positive NA S. enteritidis None No 25 × 20 Ampicillin Ceftriaxone 35 A Thaneemalai et al. [ 9 ] 38 Endometrioma Kuala Lumpur Fever, diarrhea, vaginal discharge Negative Negative S. enteritidis Yes No 8 × 4 Cefuroxime Metronidazole 7 A Kudesia and Gupta [ 10 ] 32 None USA Fever, abdominal pain, bloody diarrhea Negative Negative S. corvalis None No 15 Ceftriaxone 42 A This case 26 None Japan Diarrhea, abdominal pain, fever, nausea, vomiting Negative Negative S. stanley None Yes 8 Ceftriaxone Azithromycin 32 A SLE, systemic lupus erythematosus; NA, not applicable; A, alive; UK, United Kingdom; USA, United States of America.\nSuperinfection of endometriomas.\nSLE, systemic lupus erythematosus; NA, not applicable; A, alive; UK, United Kingdom; USA, United States of America.\nSalmonella  gastroenteritis can cause greenish diarrhea and usually results from contact with improperly handled food. It can also be acquired via the fecal-oral route between humans and animals. However, few cases of  Salmonella  infections associated with improperly handled foods or close contact with animals have been reported. Only the cases of one patient with a history of consuming a takeaway meal [ 4 ] and another with a history of exposure to camels [ 2 ] have been published. Hence, we cannot exclude  Salmonella  infections based on a history that does not include improperly handled foods or close contact with animals. Here, we speculated that the patient had  Salmonella  superinfection of the left endometrioma according to the presentation of greenish diarrhea and preoperative CT findings, despite negative blood and stool cultures and no history of contact with improperly handled foods or animals. Additionally, we surmised that the preceding cefmetazole administration at another hospital partially accounted for the negative blood and stool culture results. Although cephamycins, including cefmetazole, may be microbiologically active (MIC ≤ 1 μg/mL here), they are not clinically effective according to the Clinical and Laboratory Standards Institute criteria [ 12 ]. Furthermore, stool cultures were positive in only two (22 %) of nine patients ( Table 2 ), indicating that we cannot exclude  Salmonella  extraintestinal infections based on negative stool cultures with or without preceding antibiotic administration. Symptom frequency in the previous reports was as follows: fever (70 %), lower abdominal pain (60 %), diarrhea (60 %), and nausea or vomiting episodes (20 %) ( Table 2 ). These symptoms may indicate adnexal infections; however, they are not specific to ovarian abscesses (e.g., pyelonephritis). Etiologies of ovarian abscesses have been reported as direct contamination by fine-needle aspiration [ 13 ], hematogenous bacterial spread from a urinary tract infection [ 14 ], and association with a gastrointestinal  Salmonella  infection [ 3 , 4 ]. Our patient’s symptoms started with abdominal pain, greenish diarrhea, and high fever, and CT revealed enteritis. Thus, we speculated that the small intestine was the most plausible infection source.\nThe salmonellosis rate in pregnant women is the same as that in the general population (i.e., 0.2 %) [ 15 ]. However,  Salmonella  species can cause more severe infections in older people, infants, those with human immunodeficiency virus infection, those undergoing treatment with immunosuppressive agents, patients with malignancy, organ transplant recipients, or pregnant women [ 15 ]. During pregnancy, the immune system must protect itself without rejecting foreign paternal antigens. The immune system resolves this dilemma by altering the Th1/Th2 cytokine level to Th2 cytokine dominance [ 16 ], which protects the fetus from the Th1-mediated immune system at the fetal-maternal interface. Nevertheless, this also makes pregnant women susceptible to  Salmonella  infections because it is an intracellular pathogen and its immunity is Th1 dependent [ 16 ].\nThree reports of  Salmonella  ovarian abscesses in pregnant women [ [17] ,  [18] ,  [19] ] plus this case are summarized in  Table 3 . All patients had ovarian abscesses in the third trimester, and two patients had been diagnosed with dermoid cysts before admission. It is unclear why all the patients had  Salmonella  ovarian abscesses in the third trimester. Generally, immune system modulation during pregnancy contributes to differential responses that depend on both microorganisms and the pregnancy stage. These findings indicate the tendency of  Salmonella  spp. to cause ovarian abscesses in pregnant women in the third trimester (as with  Listeria monocytogenes ) [ 20 ]. The symptom frequency in the patients with  Salmonella  ovarian abscess was fever (75 %), lower abdominal pain (75 %), diarrhea (75 %), and nausea or vomiting episodes (50 %). Blood cultures were positive in one (25 %) of four patients. In this review, the percentage of positive blood cultures in pregnant women with  Salmonella  ovarian abscesses was low, similar to that in patients with  Salmonella  ovarian abscesses with preexisting endometriomas (25 % vs. 30 %). Regarding serotypes, the most common serovar was Enteritidis, which was identified in 4 of 10 cases (40 %) of  Salmonella  superinfections of ovarian endometriomas ( Table 2 ). Contrastingly, there have been no reports of  S. stanley  ovarian abscesses in pregnant women ( Table 3 ). This is the first report of an  S. stanley  ovarian abscess without fallopian tube abscesses in a pregnant woman with endometrioma. Table 3 Ovarian abscesses in pregnant women. Table 3 Authors Age (years) Comorbidity Location Preceding symptoms Positive blood cultures Positive stool cultures Pathogens Tubal involvement Gestational weeks Size (cm) Antibiotic used Antibiotic duration (days) Outcome Brelje and Garcia-Bunuel [ 17 ] 26 Dermoid cyst (infected) USA Increased urinary frequency, nocturia Negative Negative S. montevideo Yes 33 16 × 12 × 12 Penicillin Terramycin 12 A Nuttall et al. [ 18 ] 23 Dermoid cyst (infected) India Weight loss, anorexia, malaise, abdominal pain, vomiting, diarrhea, fever Negative Negative S. typhi Yes 32 20 Co-trimoxazole Metronidazole 49 A Sharma et al. [ 19 ] 19 None Nepal Diarrhea, abdominal pain, fever, anorexia Positive Positive S. schwarzengrund Yes 37 12 Ciprofloxacin Metronidazole Ceftriaxone 14 A This case 26 None Japan Diarrhea, abdominal pain, fever, nausea, vomiting Negative Negative S. stanley No 36 8 Ceftriaxone Azithromycin 32 A A, alive; USA, United States of America.\nOvarian abscesses in pregnant women.\nA, alive; USA, United States of America.\nAnother clinical issue of  Salmonella  ovarian abscesses in reproductive-age women should be considered. Regarding superinfected endometriomas caused by  Salmonella  species, three cases (30 %) had tubal involvement ( Table 2 ). Furthermore, regarding  Salmonella  ovarian abscesses in pregnant women, three of four cases (75 %) had tubal involvement ( Table 3 ). Both oophoritis and tubal involvement may cause later infertility.\nA limitation of this study is that positive blood and stool findings were not proven despite repeated blood and stool cultures. The low rate of  Salmonella  ovarian abscesses with endometriomas in non-pregnant and pregnant women likely correlates with the low rate of positive blood and stool cultures. However, the involvement of  Salmonella  species can be suspected according to the clinical setting (e.g., a history of improperly handled foods or close contact with animals, preceding enteritis with greenish diarrhea, and preexisting ovarian cyst), although  Salmonella  ovarian abscesses are rare. Furthermore,  Salmonella  identification can be performed from bacterial cultures of abscesses in addition to blood and stool cultures because of a higher positivity rate. Appropriate antibiotic therapy for  Salmonella  infections, considering the potential for fluoroquinolone resistance extended-spectrum beta-lactamase production, is essential to limit the effects on later fertility.\nIn conclusion, clinicians should pay attention to  Salmonella  species involvement in superinfected ovarian cysts, particularly in pregnant women. These patients, especially those with oophoritis or tubal involvement, should be treated appropriately to prevent later infertility, considering that  Salmonella  species may be resistant to antibiotics.\n\nThis study was approved by the institutional review board and ethics committee of Japanese Red Cross Ise Hospital (approval number: ER2020−27).\n\nInformed consent was obtained from the patient for publication of this case report and accompanying images.\n\nThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\n\nHirokazu Toyoshima:  Conceptualization, Methodology, Data curation, Writing - original draft, Writing - review & editing, Visualization.  Miki Hagimoto:  Conceptualization, Methodology.  Motoaki Tanigawa:  Supervision.  Hiroyuki Tanaka:  Methodology.  Yuki Nakanishi:  Methodology.  Shigetoshi Sakabe:  Supervision.\n\nNone.","source_license":"CC0","license_restricted":false}