Abdominal Pain and Fever 48 Hours After Hysterosalpingography

The patient was diagnosed with bilateral tubo-ovarian abscess (TOA) likely second- ary to her HSG procedure 48 hours before. TOA is a severe infectious, inflammatory condition involving a mass of the ovaries, fallopian tubes, or adjacent tissues of the upper female genital tract. 1 Traditionally , TOAs are sequelae of undiagnosed or sub- clinical acute or chronic pelvic inflamma- tory disease (PID). This is known to occur via pathogen ascension from the lower to the upper female genital tract result- ing in cervicitis, endometritis, salpingitis, oophoritis, and if left untreated, peritoni- tis.1 About 70,000 women are diagnosed with TOAs in the US every year. These pa- tients require hospitalization as well as IV antibiotics for gold-standard treatment; however, some cases may require percuta- neous drainage based on size, severity , and location.2 Diagnostic Considerations Clinically , patients with TOAs present with fever, chills, lower abdominal pain, vagi- nal discharge with cervical motion tender - ness, and an adnexal mass on examination.3 When a TOA is suspected, a urine human chorionic gonadotropin test and testing for C trachomatis and N gonorrhoeae are war - ranted. An ED workup often reveals leu- kocytosis, elevated C-reactive protein, and elevated erythrocyte sedimentation rate. Im- aging is recommended once a TOA is sus- pected. Ultrasound is the gold-standard imaging modality and boasts a sensitivity of 93% and specificity of 98% for the detection of TOAs; however, CT has also been shown to be an effective diagnostic modality .4 Despite being common, TOAs are difficult to predict, detect, and diagnose; thus the cli- nician must often rely on thorough history taking and physical examination to raise sus- picion.5 Although most frequently associated with sexual transmission, TOAs occur in not sexually active women in adolescence and adulthood. Specifically , TOAs also can pres- ent secondary to other intra-abdominal pa- thologies, such as appendicitis, diverticulitis, and pyelonephritis, as well as a complication of intrauterine procedures, such as an HSG, or less commonly , following intrauterine de- vice (IUD) insertion.5-7 Given that sexually transmitted in- fections are the most common etiology of TOAs, C trachomatis and N gonorrhoeae are the most likely microorganisms to be iso- lated (Table).8-12 In not sexually active pop- ulations, Escherichia coli and Gardnerella vaginalis should be considered instead. Al- though rare, women with IUDs have been Abbreviation: CTAP , computed tomography arterial portography. A, Coronal CTAP with IV contrast demonstrating bilateral multilocular enlarged parauterine lesions with marginal enhancement; B, Axial CTAP with IV contrast and right parauterine mass measuring 3.70 cm in the anteroposterior diameter; C, Axial CTAP with IV contrast and left parauterine mass measuring 3.70 cm at its largest diameter. FIGURE Computed Tomography View of Bilateral Tubo-Ovarian Abscess A B C What’s Your Diagnosis? NOVEMBER 2023 • FEDERAL PRACTITIONER • 391mdedge.com/fedprac shown to have an increased incidence of PID/ TOA secondary to Actinomyces israleii rela- tive to women without IUDs. 12 In patients with TOAs secondary to intraabdominal sur- gery , anaerobic bacteria, such as Bacterioides and Peptostreptococcus species in addition to Escherichia coli, are likely culprits.11 In patients after HSG, infectious com - plications are uncommon enough that the American College of Obstetricians and Gy- necologists recommends against antibiotic prophylaxis unless there are risk factors of dilated fallopian tubes or a history of PID.13 Identifying a precise percentage of TOA as a complication of HSG is rather elusive in the literature, though, it is frequently noted that infection in general is uncommon, and the risk of developing PID is about 1.4% to 3.4%.14 However, in the retrospective study most often cited, all women who developed PID following HSG had evidence of dilated fallopian tubes. Given our patient had no his- tory of PID or dilated fallopian tubes, her risk of developing infection (PID or postproce- dural abscess) would be considered very low; therefore, the index of suspicion also was low .15 Our patient’s case of bilateral TOA also is unusual because her presentation was not entirely consistent with a TOA. She had a benign pelvic examination without cervical motion tenderness or evidence of cervicitis or cervical discharge. Given the initially low clinical suspicion, transvaginal ultrasound was not ordered. However, in the setting of tenderness to palpation in the lower abdom- inal quadrants, suprapubic tenderness, and leukocytosis, there was still concern for an acute intra-abdominal or pelvic process, and an abdominal CT was ordered as part of the workup. It was this clinical concern that led to the identification of the patient’s bilateral TOA. Following diagnosis, the patient was promptly admitted and treated with a course of IV ceftriaxone 1 g every 24 hours, IV doxycycline 100 mg every 12 hours, and a single dose of IV metronidazole 500 mg. Her leukocytosis, fever, and pain improved within 48 hours without the need for per - cutaneous drainage and the patient made a complete recovery . Complications TOAs can carry significant morbidity and mortality , and there are both acute and chronic complications associated. Even if properly treated, TOAs can rupture lead - ing to severe illness, such as peritonitis and septic shock. This often requires surgical intervention and hemodynamic pressure support in the intensive care unit setting.16 One of the most feared long-term compli - cations of TOAs is infertility secondary to structural abnormalities of the female re- productive tract. 10 Adhesions, strictures, and scarring are associated with TOAs ir - respective of medical or surgical manage- ment, and thus any women with a history of PID or TOA require advanced fertility workup if they are having difficulties with conception or implantation.17 Minimizing infectious transmission also is essential in the treatment of TOA/PID. All women who receive a diagnosis of PID or TOA should be evaluated for gonor - rhea, chlamydia, HIV , and syphilis. Women should be instructed to abstain from sexual TABLE Demographics, Risk Factors, and Associated Organisms in Tubo-Ovarian Abscesses Demographics Risk factors Likely organisms Sexually active Vaginal intercourse without barrier protection History of prior pelvic inflammatory disease or compromised immune system8,9 Chlamydia trachomatis (most common)10 Neisseria gonorrhoeae (most common)10 Group A streptococci, Gardnerella vaginalis11 Recent intrauterine procedure Recent hysterosalpingography9 Intrauterine device insertion9 Gardnerella vaginalis, actinomyces israleii12 Abdominal/pelvic trauma History of obesity Bacteroides species, Bacteroides thetaiotaomicron, Streptococcus bovis, Escherichia coli, Peptostreptococcus species12 Recent abdominal surgery History of gastrointestinal illness (bloody emesis or stool), inflammatory bowel disease, recurrent urinary tract infections, or obesity Bacteroides species, Bacteroides thetaiotaomicron, Streptococcus bovis, Escherichia coli, Peptostreptococcus species12 What’s Your Diagnosis? 392 • FEDERAL PRACTITIONER • NOVEMBER 2022 mdedge.com/fedprac intercourse until therapy is complete, symp- toms have resolved, and sex partners have been treated for potential chlamydial or gonococcal infections. All contraceptive

can be continued during treatment.

This case presented several challenges as the bilateral TOAs developed postproce- dure in a patient without risk factors. Fur - thermore, this case did not follow the classic presentation of ascending bacterial translocation to the ovaries over days to weeks. The diagnosis was complicated by a largely benign physical examination and a pelvic examination without evidence of ab- normal vaginal discharge or cervicitis. The only indicators were fever, leukocytosis, and abdominal pain in the setting of a re- cent, uncomplicated HSG procedure. Vig- ilance is required to obtain the necessary history , and the differential of TOA must be broadened to include women without a history or symptoms of a sexually trans- mitted infection (contrary to the classic association). We aim to encourage height- ened clinical suspicion for TOAs in patients who present with fever, leukocytosis, and abdominal pain after recent HSG or other intrauterine instrumentation procedures and therefore improve patient outcomes. Author affiliations aWalter Reed National Military Medical Center, Bethesda, Maryland bUniformed Services University of the Health Sciences, Bethesda, Maryland Author disclosures The authors report no actual or potential conflicts of interest regarding this article. Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitio- ner, Frontline Medical Communications Inc., the US Gov- ernment, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, con- traindications, warnings, and adverse effects before ad- ministering pharmacologic therapy to patients. Ethics and consent Consent was obtained from the patient whose information is in this case report.

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