{"paper_id":"39f26c2b-bd15-47f8-91bd-aca08467f967","body_text":"NOVEMBER 2023  • FEDERAL PRACTITIONER • 389mdedge.com/fedprac\nAuthor affiliations  \ncan be found at the  \nend of this article.\nCorrespondence:  \nAndrew Evans  \n(andrewamcas@gmail.com)\nFed Pract. 2023;40(11).\nPublished online November 15.\ndoi:10.12788/fp.0428\nWHAT’S YOUR DIAGNOSIS?\nAbdominal Pain and Fever 48 Hours \nAfter Hysterosalpingography\nCPT Andrew Evans, MD, USAa; ENS Roland Kiendrebeogo, USNb; CPT Grace Covelli, MD, USAa;  \nCPT Christopher Russo, MD, USAFa; MAJ Caitlin Christoffel, MD, USAa\nA \n37-year-old woman presented to \nthe emergency department (ED) \nwith 12 hours of fever and lower \nabdominal cramp pain. She had a his-\ntory significant for hypothyroidism, in-\nfertility , and dysmenorrhea and had a \nhysterosalpingography (HSG) 48 hours \nprior for a comprehensive infertility \nworkup. \nOn examination, the patient’s vital \nsigns were a 94 bpm heart rate; 109/64 \nmm Hg blood pressure; 14 breaths per \nminute respiratory rate; 99% oxygen sat-\nuration on room air; and 101.2 °F tem -\nperature. The patient reported pain in \nthe bilateral lower abdominal quadrants \nand no history of sexually transmitted \ninfection, pelvic inflammatory disease, \nvaginal discharge or bleeding, dysuria, \nhematuria, melena, or bright red blood \nper rectum. A human chorionic gonado-\ntropin urine test was negative on intake. \nThe HSG 48 hours prior showed no con-\ncerning findings with normal uterine \ncavity and normal caliber fallopian tubes \nbilaterally . \nOn physical examination, the pa-\ntient’s abdomen was nondistended, non-\nperitonitic, and without evidence of \nacute trauma or surgical scars. On pal-\npation, the patient was tender in her su-\nprapubic region and lower abdominal \nquadrants without evidence of guard-\ning or rebound tenderness. At rest, the \npatient rated her abdominal pain 4 out \nof 10 and 7 out of 10 upon palpation. \nOn pelvic examination, there was nor -\nmal appearing external genitalia without \nevidence of discharge or bleeding. Her \nvaginal vault was atraumatic with a min-\nimal amount of physiologic discharge. \nHer cervix was normal in appearance \nwithout evidence of cervicitis. We ob-\ntained swabs for Neisseria gonorrhoeae (N \ngonorrhoeae) and Chlamydia trachomatis \n(C trachomatis), which were negative. On \nbimanual pelvic examination, the patient \nhad no cervical motion tenderness, and no \nadnexal masses were palpable. However, \non palpation of the adnexa, she endorsed \na localized dull, nonradiating 6 out of 10 \nright-sided pain/tenderness.\nThe patient’s initial laboratory tests \nwere as follows: white blood cells, \n20.1 × 10 3/μL (reference range, 4-11 × \n103/μL); hemoglobin, 12.1 g/dL (ref-\nerence range, 12.1-15.1 g/dL); he-\nmatocrit, 37.1%, (reference range, \n36%-48%); alanine aminotransferase, \n84 U/L (reference range, 7-56 U/L); as-\npartate aminotransferase, 66 U/L (ref-\nerence range, 8-33 U/L); and lipase,  \n25 U/L (5-60 U/L). Urinalysis was no-\ntable for only 5 red blood cells and neg-\native for white blood cells, leukocyte \nesterase, and nitrites. The patient’s pain \nand fever were controlled with 1 g IV \nacetaminophen.\nThe patient’s fever, leukocytosis, and \nphysical examination were concerning \nfor possible intra-abdominal processes, \nso a computed tomography (CT) of her \nabdomen and pelvis with IV contrast \nwas obtained for further evaluation. \nThe CT showed bilateral tubular rim-  \nenhancing fluid collections within bilat-\neral adnexa with the right fluid collec-\ntion measuring 3.7 × 3.5 × 4.0 cm and \nthe left 4.8 × 3.5 × 3.2 cm with associ-\nated fat stranding and trace-free fluid in \nthe abdomen (Figure).\n \n n  What is your diagnosis?\nn  How would you treat this patient?\n\nWhat’s Your Diagnosis?\n390 • FEDERAL PRACTITIONER  •  NOVEMBER 2023 mdedge.com/fedprac\nDISCUSSION\nThe patient was diagnosed with bilateral \ntubo-ovarian abscess (TOA) likely second-\nary to her HSG procedure 48 hours before. \nTOA is a severe infectious, inflammatory \ncondition involving a mass of the ovaries, \nfallopian tubes, or adjacent tissues of the \nupper female genital tract. 1 Traditionally , \nTOAs are sequelae of undiagnosed or sub-\nclinical acute or chronic pelvic inflamma-\ntory disease (PID). This is known to occur \nvia pathogen ascension from the lower \nto the upper female genital tract result-\ning in cervicitis, endometritis, salpingitis, \noophoritis, and if left untreated, peritoni-\ntis.1 About 70,000 women are diagnosed \nwith TOAs in the US every year. These pa-\ntients require hospitalization as well as IV \nantibiotics for gold-standard treatment; \nhowever, some cases may require percuta-\nneous drainage based on size, severity , and  \nlocation.2  \nDiagnostic Considerations\nClinically , patients with TOAs present with \nfever, chills, lower abdominal pain, vagi-\nnal discharge with cervical motion tender -\nness, and an adnexal mass on examination.3 \nWhen a TOA is suspected, a urine human \nchorionic gonadotropin test and testing for \nC trachomatis and N gonorrhoeae are war -\nranted. An ED workup often reveals leu-\nkocytosis, elevated C-reactive protein, and \nelevated erythrocyte sedimentation rate. Im-\naging is recommended once a TOA is sus-\npected. Ultrasound is the gold-standard \nimaging modality and boasts a sensitivity of \n93% and specificity of 98% for the detection \nof TOAs; however, CT has also been shown \nto be an effective diagnostic modality .4 \nDespite being common, TOAs are difficult \nto predict, detect, and diagnose; thus the cli-\nnician must often rely on thorough history \ntaking and physical examination to raise sus-\npicion.5 Although most frequently associated \nwith sexual transmission, TOAs occur in not \nsexually active women in adolescence and \nadulthood. Specifically , TOAs also can pres-\nent secondary to other intra-abdominal pa-\nthologies, such as appendicitis, diverticulitis, \nand pyelonephritis, as well as a complication \nof intrauterine procedures, such as an HSG, \nor less commonly , following intrauterine de-\nvice (IUD) insertion.5-7\nGiven that sexually transmitted in-\nfections are the most common etiology of \nTOAs, C trachomatis and N gonorrhoeae are \nthe most likely microorganisms to be iso-\nlated (Table).8-12 In not sexually active pop-\nulations, Escherichia coli and Gardnerella \nvaginalis should be considered instead. Al-\nthough rare, women with IUDs have been \nAbbreviation: CTAP , computed tomography arterial  \nportography.\nA, Coronal CTAP with IV contrast demonstrating \nbilateral multilocular enlarged parauterine lesions \nwith marginal enhancement; B, Axial CTAP with \nIV contrast and right parauterine mass measuring \n3.70 cm in the anteroposterior diameter; C, Axial \nCTAP with IV contrast and left parauterine mass \nmeasuring 3.70 cm at its largest diameter.\nFIGURE Computed Tomography View of Bilateral Tubo-Ovarian Abscess\nA B\nC\n\nWhat’s Your Diagnosis?\nNOVEMBER 2023  • FEDERAL PRACTITIONER • 391mdedge.com/fedprac\nshown to have an increased incidence of PID/\nTOA secondary to Actinomyces israleii rela-\ntive to women without IUDs. 12 In patients \nwith TOAs secondary to intraabdominal sur-\ngery , anaerobic bacteria, such as Bacterioides \nand Peptostreptococcus species in addition to \nEscherichia coli, are likely culprits.11 \nIn patients after HSG, infectious com -\nplications are uncommon enough that the \nAmerican College of Obstetricians and Gy-\nnecologists recommends against antibiotic \nprophylaxis unless there are risk factors of \ndilated fallopian tubes or a history of PID.13 \nIdentifying a precise percentage of TOA as \na complication of HSG is rather elusive in \nthe literature, though, it is frequently noted \nthat infection in general is uncommon, and \nthe risk of developing PID is about 1.4% to \n3.4%.14 However, in the retrospective study \nmost often cited, all women who developed \nPID following HSG had evidence of dilated \nfallopian tubes. Given our patient had no his-\ntory of PID or dilated fallopian tubes, her risk \nof developing infection (PID or postproce-\ndural abscess) would be considered very low; \ntherefore, the index of suspicion also was \nlow .15\nOur patient’s case of bilateral TOA also is \nunusual because her presentation was not \nentirely consistent with a TOA. She had a \nbenign pelvic examination without cervical \nmotion tenderness or evidence of cervicitis \nor cervical discharge. Given the initially low \nclinical suspicion, transvaginal ultrasound \nwas not ordered. However, in the setting of \ntenderness to palpation in the lower abdom-\ninal quadrants, suprapubic tenderness, and \nleukocytosis, there was still concern for an \nacute intra-abdominal or pelvic process, and \nan abdominal CT was ordered as part of the \nworkup. It was this clinical concern that led \nto the identification of the patient’s bilateral \nTOA. \nFollowing diagnosis, the patient was \npromptly admitted and treated with a \ncourse of IV ceftriaxone 1 g every 24 hours, \nIV doxycycline 100 mg every 12 hours, and \na single dose of IV metronidazole 500 mg. \nHer leukocytosis, fever, and pain improved \nwithin 48 hours without the need for per -\ncutaneous drainage and the patient made a \ncomplete recovery . \nComplications \nTOAs can carry significant morbidity and \nmortality , and there are both acute and \nchronic complications associated. Even if \nproperly treated, TOAs can rupture lead -\ning to severe illness, such as peritonitis and \nseptic shock. This often requires surgical \nintervention and hemodynamic pressure \nsupport in the intensive care unit setting.16 \nOne of the most feared long-term compli -\ncations of TOAs is infertility secondary to \nstructural abnormalities of the female re-\nproductive tract. 10 Adhesions, strictures, \nand scarring are associated with TOAs ir -\nrespective of medical or surgical manage-\nment, and thus any women with a history \nof PID or TOA require advanced fertility \nworkup if they are having difficulties with \nconception or implantation.17\nMinimizing infectious transmission also \nis essential in the treatment of TOA/PID. \nAll women who receive a diagnosis of PID \nor TOA should be evaluated for gonor -\nrhea, chlamydia, HIV , and syphilis. Women \nshould be instructed to abstain from sexual  \nTABLE Demographics, Risk Factors, and Associated Organisms in Tubo-Ovarian Abscesses \nDemographics Risk factors Likely organisms \nSexually active Vaginal intercourse without barrier protection \nHistory of prior pelvic inflammatory disease or  \ncompromised immune system8,9 \nChlamydia trachomatis (most common)10  \nNeisseria gonorrhoeae (most common)10 \nGroup A streptococci, Gardnerella vaginalis11 \nRecent intrauterine \nprocedure \nRecent hysterosalpingography9 \nIntrauterine device insertion9 \nGardnerella vaginalis, actinomyces israleii12\nAbdominal/pelvic \ntrauma\nHistory of obesity Bacteroides species, Bacteroides thetaiotaomicron, \nStreptococcus bovis, Escherichia coli,  \nPeptostreptococcus species12 \nRecent abdominal \nsurgery \nHistory of gastrointestinal illness (bloody emesis or stool),  \ninflammatory bowel disease, recurrent urinary tract  \ninfections, or obesity \nBacteroides species, Bacteroides thetaiotaomicron, \nStreptococcus bovis, Escherichia coli,  \nPeptostreptococcus species12 \n\nWhat’s Your Diagnosis?\n392 • FEDERAL PRACTITIONER  •  NOVEMBER 2022\nmdedge.com/fedprac\nintercourse until therapy is complete, symp-\ntoms have resolved, and sex partners have \nbeen treated for potential chlamydial or \ngonococcal infections. All contraceptive \nmethods can be continued during treatment.\nCONCLUSIONS\nThis case presented several challenges as \nthe bilateral TOAs developed postproce-\ndure in a patient without risk factors. Fur -\nthermore, this case did not follow the \nclassic presentation of ascending bacterial \ntranslocation to the ovaries over days to \nweeks. The diagnosis was complicated by a \nlargely benign physical examination and a \npelvic examination without evidence of ab-\nnormal vaginal discharge or cervicitis. The \nonly indicators were fever, leukocytosis, \nand abdominal pain in the setting of a re-\ncent, uncomplicated HSG procedure. Vig-\nilance is required to obtain the necessary \nhistory , and the differential of TOA must \nbe broadened to include women without \na history or symptoms of a sexually trans-\nmitted infection (contrary to the classic \nassociation). We aim to encourage height-\nened clinical suspicion for TOAs in patients \nwho present with fever, leukocytosis, and \nabdominal pain after recent HSG or other \nintrauterine instrumentation procedures \nand therefore improve patient outcomes.\nAuthor affiliations\naWalter Reed National Military Medical Center, Bethesda, \nMaryland\nbUniformed Services University of the Health Sciences, \nBethesda, Maryland \nAuthor disclosures\nThe authors report no actual or potential conflicts of interest \nregarding this article.\nDisclaimer\nThe opinions expressed herein are those of the authors \nand do not necessarily reflect those of Federal Practitio-\nner, Frontline Medical Communications Inc., the US Gov-\nernment, or any of its agencies. This article may discuss \nunlabeled or investigational use of certain drugs. Please \nreview the complete prescribing information for specific \ndrugs or drug combinations—including indications, con-\ntraindications, warnings, and adverse effects before ad-\nministering pharmacologic therapy to patients.\nEthics and consent\nConsent was obtained from the patient whose information is \nin this case report.\nReferences\n  1.   Gkrozou F , Tsonis O, Daniilidis A, Navrozoglou I, Pas-\nchopoulos M. Tubo-ovarian abscess: exploring op-\ntimal treatment options based on current evidence. \nJ Endometr Pelvic Pain Disord. 2020;13(1):10-19. \ndoi:10.1177/2284026520960649\n  2.   Taylor KJ, Wasson JF , De Graaff C, Rosenfield AT, Andri-\nole VT. Accuracy of grey-scale ultrasound diagnosis of \nabdominal and pelvic abscesses in 220 patients. Lancet. \n1978;1(8055):83-84. doi:10.1016/s0140-6736(78)90016-8\n  3.   Bridwell RE, Koyfman A, Long B. High risk and low preva-\nlence diseases: tubo-ovarian abscess. Am J Emerg Med. \n2022;57:70-75. doi:10.1016/j.ajem.2022.04.026\n  4.   Lambert MJ, Villa M. Gynecologic ultrasound in \nemergency medicine. Emerg Med Clin North Am. \n2004;22(3):683-696. doi:10.1016/j.emc.2004.04.016 \n  5.   Munro K, Gharaibeh A, Nagabushanam S, Martin C. Diag-\nnosis and management of tubo-ovarian abscesses. Obstet \nGynaecol. 2018;20(1):11-19. doi:10.1111/tog.12447\n  6.   Fink D, Lim PPC, Desai A, Stephans AB, Wien MA. \nRecurrent tubo-ovarian abscess in a nonsexually \nactive adolescent. Consultant. 2022;62(1):e26-e28. \ndoi:10.25270/con.2021.04.00010\n  7.   Hiller N, Fux T, Finkelstein A, Mezeh H, Simanovsky N. \nCT differentiation between tubo-ovarian and appendiceal \norigin of right lower quadrant abscess: CT, clinical, and \nlaboratory correlation. Emerg Radiol. 2016;23:133-139. \ndoi:10.1007/s10140-015-1372-z\n  8.   Kairys N, Roepke C. Tubo-ovarian abscess. In: StatPearls. \nTreasure Island (FL): StatPearls Publishing; June 12, 2023.\n  9.   Gao Y , Qu P , Zhou Y , Ding W. Risk factors for the \ndevelopment of tubo-ovarian abscesses in women \nwith ovarian endometriosis: a retrospective matched \ncase-control study. BMC Womens Health. 2021:21:43. \ndoi:10.1186/s12905-021-01188-6\n10.   Curry A, Williams T, Penny ML. Pelvic inflammatory dis-\nease: diagnosis, management, and prevention. Am Fam \nPhysician. 2019;100(6):357-364.\n11.   Landers DV, Sweet RL. Tubo-ovarian abscess: con -\ntemporary approach to management. Rev Infect Dis. \n1983;5(5):876-884. doi:10.1093/clinids/5.5.876\n12.   Burkman R, Schlesselman S, McCaffrey L, Gupta PK, \nSpence M. The relationship of genital tract actinomy-\ncetes and the development of pelvic inflammatory dis-\nease. Am J Obstet Gynecol. 1982;143(5):585-589. \ndoi:10.1016/0002-9378(82)90552-x\n13.   Armstrong C. ACOG releases guidelines on antibiotic pro-\nphylaxis for gynecologic procedures. Am Fam Physician. \n2007;75(7):1094-1096.\n14.   Pittaway DE, Winfield AC, Maxson W, Daniell J, Herbert \nC, Wentz AC. Prevention of acute pelvic inflammatory dis-\nease after hysterosalpingography: efficacy of doxycycline \nprophylaxis. Am J Obstet Gynecol. 1983;147(6):623-626. \ndoi:10.1016/0002-9378(83)90438-6\n15.   Committee on Practice Bulletins—Gynecology. Prevention \nof Infection After Gynecologic Procedures: ACOG Practice \nBulletin, Number 195. Obstet Gynecol. 2018;131(6):e172-\ne189. doi:10.1097/AOG.0000000000002670\n16.   Tao X, Ge SQ, Chen L, Cai LS, Hwang MF , Wang CL. \nRelationships between female infertility and female \ngenital infections and pelvic inflammatory disease: \na population-based nested controlled study. Clinics \n(Sao Paulo) . 2018;73:e364. Published 2018 Aug 9. \ndoi:10.6061/clinics/2018/e364\n17.   Fouks Y , Azem F , Many A, Cohen Y , Levin I, Cohen A. \nFertility outcomes in patients with tubo-ovarian ab -\nscesses after an oocyte retrieval: a longitudinal cohort \nanalysis. Arch Gynecol Obstet. 2019;300(3):763-769. \ndoi:10.1007/s00404-019-05230-9","source_license":"CC0","license_restricted":false}