{"paper_id":"643d0275-f16b-43aa-9605-d00884709306","body_text":"Journal of Case Reports and Images in Obstetrics and Gynecology, Volume 9, Issue 1, 2023; Pages 28–30. ISSN: 2582-0249\nJ Case Rep Images Obstet Gynecol 2023;9(1):28–30. \nwww.ijcriog.com\nHorvath et al. 28\nCASE REPORT  OPEN ACCESS  \nUnusual presentation of a case of endometriosis diagnosed \nwithout laparoscopy\nDavid Horvath, Utkarsh Pandey\nCASE REPORT\nA 27-year-old nulliparous female was referred for \nobstetric and gynecological services due to a four-year \nhistory of progressively worsening pelvic pain, pelvic \nfullness, and dyspareunia. On several occasions, she \nhad experienced significant post-coital abdominal \npain leading to nausea and vomiting. Additionally, she \ncomplained of nausea, diarrhea, bilateral lower limb pain, \nand lower back pain in the last week of the luteal phase \nof the menstrual cycle, which resolved within the first few \ndays of menstruation. Her personal female history was \nmenarche at age 10, heavy and regular periods lasting five \ndays, bacterial vaginosis on and off in the last year, and \ninfertility. There was no family history of endometriosis.\nHer vital signs were within normal limits. Physical \nexamination revealed an abdomen that was not distended, \nsoft, without tenderness, and without masses. On a \npelvic exam, the patient complained of bilateral adnexal \ntenderness. No masses were palpable. Other than the \naforementioned complaints, the patient reports she is in \ngood health.\nUltrasound of the abdomen with a follow-up computed \ntomography (CT) scan with and without contrast was \nobtained in the prior month. The ultrasound identified \na 3.2 × 2.7 × 2.0 cm circumscribed ovoid mass with \ninternal heterogeneous material located between the \novaries in the pouch of Douglas at the level of the lower \nuterine segment (Figure 1). A CT scan was ordered to \nfurther characterize this mass, rule out other causes of \nabdominopelvic pain, and assist with surgical planning \nDavid Horvath 1, Utkarsh Pandey 1\nAffiliation: 13rd year medical student, Lincoln Memorial Uni -\nversity DeBusk College of Osteopathic Medicine, Harrogate, \nTN, USA.\nCorresponding Author: David Horvath, 402 W. Bowne Blvd., \nClarksville, IN, USA; Email: david.horvath@lmunet.edu\nReceived: 31 January 2023\nAccepted: 24 February 2023\nPublished: 05 March 2023\nif this became a prospect in the future. Furthermore, the \npatient opted for a CT scan due to the time and financial \nbarriers of magnetic resonance imaging (MRI). On axial \nCT with contrast, the ovoid structure had high noncontrast \nattenuation suggesting products of hemorrhage, a finding \ncommonly seen with endometriomas (Figure 2). Axial CT \nalso demonstrated enlarged ovaries, positioned in close \nproximity to each other in the pouch of Douglas, with \neach ovary containing irregular cystic lesions (Figure 2). \nThis juxtaposition of the ovaries is sometimes referred to \nas “kissing ovaries” sign, which is highly associated with \npelvic endometriosis [1]. Similarly, the coronal CT with \ncontrast showed both ovaries as multicystic structures \nin close proximity (Figure 3). The aforementioned \nendometrioma was inferomedial to the ovaries in the \ncoronal plane and tangential to the anterior rectal wall in \nthe axial frame (Figures 2 and 3).\nThe patient declined both laparoscopy for definitive \ndiagnosis and referral for fertility treatment due to \nfinancial and time constraints. Cancer antigen 125 \nlevels were obtained to partly circumvent the limitation \ncreated by a foregone laparoscopy. Laboratory results \ndemonstrated a cancer antigen 125 level of 52 U/\nmL (reference value: <35 U/mL), supporting either a \ndiagnosis of endometriosis or endometrial cancer. A \nprovisional diagnosis of endometriosis was made based \non the above report.\nThe daily oral contraceptive, levonorgestrel and \nethinyl estradiol combination (0.15 mg/0.03 mg), was \nprescribed along with over-the-counter 200 mg of \nCLINICAL IMAGE  PEER REVIEWED | OPEN ACCESS \nFigure 1: (A) An US demonstrating kissing sign. (B) An US \nshowing a heterogeneous cyst resembling an endometrioma \nbudding off the right ovary.\n\nJournal of Case Reports and Images in Obstetrics and Gynecology, Volume 9, Issue 1, 2023; Pages 28–30. ISSN: 2582-0249\nJ Case Rep Images Obstet Gynecol 2023;9(1):28–30. \nwww.ijcriog.com\nHorvath et al. 29\nIbuprofen four times daily if needed to help manage her \nendometriosis-related pain. On follow-up, the patient \ncontinued to endorse the same intensity of endometrial \npain, despite strict compliance with the prescribed \nregimen. The decision to perform laparoscopy for diagnosis \nand treatment was discussed and declined again.\nDISCUSSION\nBecause of the varied symptoms and clinical \npresentation, it is important to keep endometriosis in \nthe differential diagnosis of women of child bearing age \nwith chronic pelvic pain. Despite the fact that laparoscopy \nis key to the definitive diagnosis of endometriosis; due \nto its invasive nature, the successful diagnosis is largely \ncontingent upon appropriate clinical acumen and \njudgment. One of the major shortcomings and resultant \npatient complaints of current clinical practice and \nmanagement is the delay in diagnosis due to the difficulty \nin efficiently applying the current diagnostic criteria. To \nthat end, it is important that we continually work to expand \nour knowledge of all potential markers of the condition \nso that the diagnosis can be made in a quicker timeframe \ngoing forward.\nIn the case of this patient, there were two relatively \nunique symptoms exhibited. The first was post-coital \nnausea and vomiting and the second was bilateral lower \nlimb pain. Due to the direct connection between the pelvis \nand peritoneal cavity in women, the theory of retrograde \nmenstruation posits that endometriosis can spread to the \nperitoneal space. It is possible that due to excess physical \nstimulation during intercourse, irritation of inflamed \nectopic endometrial sites could trigger feelings of nausea \nand cause vomiting. In the case of the second symptom; \nectopic endometrial tissue in the lower extremities could \ncontribute to bilateral lower limb pain; similarly to how it \ncan cause pelvic and abdominal pain.\nCONCLUSION\nIn this patient with a four year history of endometriosis, \nseveral non-laparoscopic symptoms were crucial to arriving \nat her ultimate diagnosis. She had some very classical \nclinical symptoms such as dyspareunia, progressively \nworsening pelvic pain, pelvic fullness, and lower back pain \nthat began leading up to the menstrual cycle and resolved \nshortly after menstrual flow. On CT scan, she had what is \nknown as the “kissing ovaries” sign and an endometrioma, \nwhich are well known to be associated with endometriosis. \nIn addition to the more typical signs above, she also had \ntwo uncommon findings: post-coital symptoms and \nbilateral lower limb pain. Future work from a diagnostic \nand data-gathering standpoint could focus on identifying \nhow common these signs are in other patients with a \ndiagnosis of endometriosis. Overall, identification of the \nwider array of symptoms, laboratory values, and imaging \nfindings associated with endometriosis is important to \nmaking the diagnostic process more efficient and helping \npatients with the condition get appropriate care sooner \nthan they currently do.\nKeywords: Endometrioma, Endometriosis, Kissing \novaries, Pelvic pain\nHow to cite this article\nHorvath D, Pandey U. Unusual presentation of a case \nof endometriosis diagnosed without laparoscopy. J \nCase Rep Images Obstet Gynecol 2023;9(1):28–30.\nArticle ID: 100140Z08DH2023\n*********\nFigure 2: Axial CT with contrast showing multicystic, juxtaposed \novaries in the pouch of Douglas (“kissing sign”). Although \ndifficult to discern, part of the endometrioma is tangent to the \nanterior rectal wall.\nFigure 3: Coronal CT with contrast showing multiloculated \novaries. Inferomedial to the ovaries is a homogenous appearing \ncyst likely to represent an endometrioma.\n\nJournal of Case Reports and Images in Obstetrics and Gynecology, Volume 9, Issue 1, 2023; Pages 28–30. ISSN: 2582-0249\nJ Case Rep Images Obstet Gynecol 2023;9(1):28–30. \nwww.ijcriog.com\nHorvath et al. 30\ndoi: 10.5348/100140Z08DH2023CI\nREFERENCE\n1. Ajayi A, Ajayi V, Oyetunji I, Biobaku O, Aikhuele \nH, Afolabi BM. Abdominal scar endometriosis and \nhemothorax in a Nigerian woman: A case report. \nGynecol Obstet (Sunnyvale) 2017;7(2):430. \n*********\nAuthor Contributions\nDavid Horvath – Conception of the work, Acquisition of \ndata, Analysis of data, Interpretation of data, Drafting the \nwork, Revising the work critically for important intellectual \ncontent, Final approval of the version to be published, \nAgree to be accountable for all aspects of the work in \nensuring that questions related to the accuracy or integrity \nof any part of the work are appropriately investigated and \nresolved\nUtkarsh Pandey – Design of the work, Drafting the work, \nRevising the work critically for important intellectual \ncontent, Final approval of the version to be published, \nAgree to be accountable for all aspects of the work in \nensuring that questions related to the accuracy or integrity \nof any part of the work are appropriately investigated and \nresolved\nGuarantor of Submission\nThe corresponding author is the guarantor of submission.\nSource of Support\nNone.\nConsent Statement\nWritten informed consent was obtained from the patient \nfor publication of this article.\nConflict of Interest\nAuthors declare no conflict of interest.\nData Availability\nAll relevant data are within the paper and its Supporting \nInformation files.\nCopyright\n© 2023 David Horvath et al. 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