{"paper_id":"6b0b5633-f72c-4886-a138-c1b97457d15c","body_text":"Tubo-ovarian abscess (TOA) is a sequela of pelvic inflammatory\ndisease (PID) that is comprised of an infectious, inflammatory complex\nencompassing the fallopian tube and ovary. The proposed\npathophysologic mechanism for TOA development includes ascending\ninfection as well as hematogenous and lymphatic routes [ 1 ].\nThe infectious source is typically polymicrobial and several\nreports have identified  Escherichia coli ,\n Neisseria gonorrhea , and  Chlamydia trachomatis \nand a variety of obligate anaerobic bacteria as commonly\nassociated microorganisms [ 1 ,  2 ].\nCases of TOA involving endometriomas have been reported in the\nliterature, and women with revised American Society for\nReproductive Medicine (ASRM) stages III-IV endometriosis [ 3 ]\nhave been found to have an increased occurrence of TOA [ 2 ].\n E coli  was more frequently cultured from aspirated\nabscesses in women with concomitant endometriosis than if no\nendometriosis was present. In addition, previous pelvic\nsurgery was found to increase the risk of TOA [ 2 ]. We report\na case of a woman with stage IV endometriosis with a TOA\ninvolving an endometrioma, in the absence of cultured organisms,\nwho had evidence of bacterial vaginosis (BV) on normal saline wet\nprep and culture.\n\nA 41-year old nulligravida presented to the University of Michigan\n(UM) Reproductive Endocrinology and Infertility clinic for an\nevaluation of a six year history of primary infertility. Her prior\nfertility evaluation and treatment history was significant for\nfour previous cycles of ovulation augmentation with clomiphene\ncitrate in conjunction with timed intercourse and a normal\nhysterosalpingogram several years earlier. Her initial workup at\nUM revealed normal ovarian reserve testing, normal values for TSH\nand prolactin, and her husband's semen analysis was normal.\nTransvaginal ultrasonography showed persistent bilateral\n3.5 cm ovarian cysts that had a ground-glass appearance\nconsistent with endometriomas [ 4 ]. The patient underwent\nlaparoscopic evaluation due to the large endometriomas at which\ntime she was diagnosed with stage IV endometriosis. Due to dense\nadhesive disease, the procedure was converted to an\nexploratory laparotomy. Three right\novarian endometriomas were removed, and the cyst wall of each was\nexcised with subsequent cauterization of the bases for hemostasis.\nThe left ovarian endometrioma was approached; however, it was not\nremoved due to severe adhesions and the patient's desire for\nfertility. The patient's postoperative course was unremarkable.\nFive weeks after surgery, the patient underwent a\nhysterosalpingogram which showed a normal uterine cavity, right\ntubal patency, and left hydrosalpinx without spillage of dye. She\nsubsequently underwent two cycles of gonadotropins in conjunction\nwith intrauterine inseminations, but had suboptimal responses.\nNine months after surgery, the patient presented to\nthe emergency room with fever and abdominal pain. Her temperature\nwas 38.7°C. Her abdominal and pelvic exams showed\nmoderate tenderness, small amount of vaginal discharge and\nbacterial vaginosis as evidenced by clue cells on a normal saline\nwet prep. Gonorrhoeae and chlamydia cultures were obtained.\nTransvaginal ultrasound showed a 7 cm left adnexal mass with\nuniform echogenicity ( Figure 1 ). Her WBC was\n16.7 K. She was admitted to the hospital for intravenous\nantibiotic administration but despite broad-spectrum coverage,\nhigh-grade fevers continued. On hospital day 3, after discussion\nof risks, benefits, and alternatives that included conservative\nmanagement, she was consented for definitive surgical management\nand underwent a modified radical hysterectomy with bilateral\nsalpingo-oophorectomy and lysis of adhesions.\nAlthough all cervical, blood, and urine cultures were negative\non hospital admission, the left ovary contained an ovarian abscess\nwith gram negative rods within the left-sided endometrioma.\nGonorrhoeae and chlamydia cultures were negative. There was an\nevidence of BV on normal saline wet prep and culture. Histology of\nthe left fallopian tube and ovary revealed an endometriotic cyst\nwith massive edema, hemorrhage, acute inflammation, and marked\neosinophilia ( Figure 2 ) with an associated pyosalpinx\nconsistent with a TOA.\n\nThe development of TOA among women with endometriomas may be due\nto an increased susceptibility to infection, [ 2 ] particularly\nin the altered immune environment seen with ectopic endometrial\nglands and stroma, [ 5 ] although there are no epidemiologic\ndata available to support this theory. Previous surgical\nprocedures involving the pelvic organs have been found to increase\nthe risk of TOA formation in patients with endometriosis [ 2 ].\nInterestingly, in this case report, the patient's surgery took\nplace nine months prior to clinical presentation and the presence\nof acute inflammatory cells in the endometrioma makes the\nprobability of a long incubation period or superinfection of a\nchronic infectious process unlikely but not out of the realm of\npossibility. There is one case report of a 7 month period of time\nfrom surgery to superinfected endometrioma [ 1 ]. Similarly, in\nterms of the timeframe of events, although an HSG performed in the\npresence of an apparently dilated fallopian tube carries an\nincreased risk of pelvic inflammatory disease, [ 6 ] this\npatient's procedure was performed eight months prior to the onset\nof her acute symptomatology and histologic findings. There was no\nknown change in partners since the patient's initial office visit\nuntil the time of presentation with symptoms of acute pelvic\ninfection.\nAlthough the association between BV and the increased risk of an\nascending PID is well established, [ 7 ] in the present case,\nthe finding of BV in the absence of isolated organisms on\ncervical, blood, and urine cultures raises the question as to\nwhether BV that has ascended to the upper genital tract is a\npredisposition to abscess formation in an endometrioma. More study\nis necessary to investigate this matter and to elucidate whether\naggressive treatment of BV in patients with known advanced stage\nendometriosis, akin to screening and treatment in patients who are\nto undergo hysterectomy to prevent vaginal cuff abscesses, should\nbe considered to prevent super-infected endometriomas.","source_license":"CC0","license_restricted":false}