A postmenopausal woman with pelvic inflammatory disease misdiagnosed as an ovarian tumor: A case report.

A 62-year-old Caucasian woman was referred to a department of gynecology because of general health decline and ascites. She had had dyspnea and progressive abdominal distention for 10 days. There was a small amount of vaginal discharge. She did not have any pain nor postmenopausal blood loss. Her micturition and defecation patterns were also normal. Relevant medical history included 2 pregnancies, both with cesarean deliveries, and a laparoscopic cystectomy for a benign ovarian cyst. A Mirena intrauterine device (IUD) had been inserted 20 years previously. She had smoked 10–15 cigarettes a day for 47 years and she had a history of alcohol abuse. Her grandmother had had ovarian carcinoma. On admission, the patient was pale and cachectic with normal vital signs. Her abdomen was distended without signs of peritonitis. Bimanual examination revealed a normal uterus without tenderness of the cervix. It was not possible to palpate the adnexa because of the extensive amount of ascites. Transvaginal ultrasound showed a large uterus with normal endometrial thickness and the presence of intracavitary fluid. The IUD was visualized in the cavity. There was a lot of ascites in the pouch of Douglas, resulting in suboptimal visualization. The right ovary had a multicystic appearance with papillary formations with a Doppler color flow signal. The left ovary was not visualized. ( Fig. 1 ). Fig. 1 Transvaginal ultrasound using the GE Voluson E 10. Left: Intrauterine device in the uterus. Ascites. Right: Cystic lesion, positive Doppler signal on papillary formation. Fig. 1 Transvaginal ultrasound using the GE Voluson E 10. Left: Intrauterine device in the uterus. Ascites. Right: Cystic lesion, positive Doppler signal on papillary formation. The laboratory findings are shown in Table 1 . They revealed a mild microcytic anemia. There were no signs of infection. Serum tumor cancer antigen CA-125 was slightly elevated (297kU/L). Table 1 Laboratory test results. Unlabelled Table Analysis Value Normal value Analysis Value Normal value Hematology - Hemoglobin (g/dl) - White blood cell count - Neutrophils (%) - Platelets 10.1 8.3 73 452 11.7–16.0 g/dl 4.5–12.7 × 10^3/μL (50–70%) 150-400 × 10^3/μl Tumor markers - CEA - CA19.9 - CA125 4.5 21.4 297 0–3.0 μg/l < 37 kU/l < 35 kU/l C Reactive Protein (CRP) 5.7 <5.0 mg/l Ferritin 17 50-170 μg/dl Laboratory test results. Hemoglobin (g/dl) White blood cell count - Neutrophils (%) Neutrophils (%) Platelets CEA CA19.9 CA125 Computed tomography ( Fig. 2 ) showed a massive amount of ascites in the abdomen and a cystic-solid mass on the right ovary with a maximum diameter of 40x27mm, suspect for a cystic ovarian carcinoma. There were also signs of chronic pancreatitis with benign cysts or a cystic tumor on the pancreatic tail. Fig. 2 CT scan. Left: Coronal plane. Right: Axial plane. Fig. 2 CT scan. Left: Coronal plane. Right: Axial plane. The patient was admitted for further examination and symptom relief by administration of paracetamol and alizapride intravenously. Differential diagnoses at that time consisted of an ovarian tumor or a pancreatic tumor. A puncture for the ascites was performed. Cytological examination of the ascites showed signs of chronic inflammation little evidence of malignancy. A diagnostic laparoscopy was performed. Simultaneously a hysteroscopy was carried out to remove the IUD. After dilatation of the cervix, pus evacuated from the uterine cavity. A hyperemic endometrium was visualized. Laparoscopically, 13 l of ascites were evacuated. The ascites was seropurulent. The uterus was small, with two normal ovaries and tubes. The liver also had a normal aspect. A culture swab for general bacteriological analysis as well as PCR smear for chlamydia and gonococcus were taken. On the diaphragm there was a small white nodule, which was resected. An additional biopsy of the peritoneum was taken. There was no evidence of ovarian or peritoneal malignancy, but a high suspicion of a pelvic inflammatory disease. An abdominal lavage was carried out before closure. A drain was left in the pouch of Douglas. (See Fig. 3 .) Fig. 3 Intra-abdominal view. Hyperemic peritoneum and seropulurent secretions. Fig. 3 Intra-abdominal view. Hyperemic peritoneum and seropulurent secretions. Postoperatively, the patient was treated with metronidazole 500 mg intravenously 3 times a day in combination with oral administration of doxycycline 200 mg once a day. She was also given one dose of ceftriaxone 2 g IV. On the second postoperative day, a switch was made to amoxicillin-clavulanic acid 875 mg 3 times a day in combination with doxycycline 200 mg once a day orally because of progressively increasing levels of C reactive protein (CRP) (up to 280 mg/l). Histological examination of the biopsies of the anterior wall of the peritoneum, diaphragm dome and endometrium showed signs of a (sub)acute infection. These findings again argued against malignancy. The bacteriological and PCR analyses were negative. The patient recovered well after starting the antibiotics, with a decrease in infection parameters, and she was discharged after one week. She received oral antibiotics for 14 days in total.

In postmenopausal women, a TOA is rare. [ 1 , 3 ] The risk factors differ from those for women of reproductive age (namely unprotected sexual intercourse and multiple sexual partners). They include recent pelvic procedures, endometrial biopsies and the presence or removal of a longstanding IUD. [ 2 ] Kapustian et al. showed that patients with an IUD had significantly larger abscesses (61.6 ± 21.4 vs. 49.6 ± 20.6 mm, p  = 0.02) than patients without an IUD, but the surgical intervention rate in TOA patients with or without an IUD was similar. [ 4 ] TOA is primarily a clinical diagnosis, usually confirmed by laboratory results, imaging and microbiology results. Typical signs are abdominal pain, fever, tenderness of the uterus or cervix and abnormal vaginal bleeding or discharge. In case of rupture, an acute abdomen and signs of sepsis can be noted. Both transvaginal ultrasound and CT are sensitive and specific examinations for detection of a TOA. Although ultrasound is widely available, CT is additionally recommended to aid in differential diagnosis. Mostly, a cystic or semi-solid adnexal mass is detected, sometimes in combination with a hydro- or pyosalpinx. There are no accurate diagnostic laboratory tests, although infection parameters (white blood cells and C reactive protein) can be elevated. Tumor marker CA-125 is another diagnostic test, but increased levels are non-specific. They can be elevated in cases of malignant tumor as well as in physiological conditions, such as endometriosis and inflammatory processes, and in long-term smokers0 [ 2 , 3 , 5 , 6 ]. A recent systematic review reported that the risk of malignancy in patients with TOA is lower than initially suggested [ 2 ]. A study by Yagur et al. [ 7 ] found a prevalence of 2.4% of concurrent pelvic malignancy in postmenopausal women. Therefore, hemodynamically stable patients can be treated conservatively with broad-spectrum IV antibiotics after counseling. Further imaging needs to be performed to detect resolution of the mass. If the condition persists, surgery may be required, in which case a laparoscopic approach is preferred, with intraoperative frozen section of the excised specimen. [ 2 , 5 , 6 ] The diagnosis of a TOA in postmenopausal women should be considered especially if an IUD is still present. Conservative treatment with antibiotics is advised. If surgery is required, laparoscopy is recommended.

A tubo-ovarian abscess (TOA) is an infectious mass of the adnex that can be a life-threatening complication of pelvic inflammatory disease. It is infrequent among postmenopausal women, with a prevalence ranging from 6% to 18%. It tends to present with fewer of the typical symptoms of younger women, making it a diagnostic challenge for clinicians. The treatment is often more invasive. [ 1 , 2 ]