Pediatric Tubo-Ovarian Abscess Malika Atmakuri Pediatric Surgery, R1 1/2/2014

Case Presentation: TN 13 yo F pw worsening continuous LLQ pain x 4 weeks, n/v Afebrile, no diarrhea, no dysuria Prior Hx: April 2013: sepsis 2/2 b/l tubo-ovarian abscesses s/p laparascopic drainage and IV Abx, + for GBS, Ecoli, and Bacteroides. Rx IV ampicillin, gentamicin, clindamycin -> po doxycycline and Flagyl July 2013: lower abd pain, Rx w IV Abx then po

Medications: Micronor Fam Hx: T2DM, PCOS, HTN, Depression PMHx: Developmental delay, obesity, dysmenorrhea, hx tubo-ovarian abscesses PSgx Hx: T&A, MT, 2006 hemangioma excision Apr 2013 laparascopic drainage of b/l TOA June 2013 I&D of R shoulder abscess Medications: Micronor Fam Hx: T2DM, PCOS, HTN, Depression PE: LLQ tenderness Labs: CRP 13.5, WBC 18.7, 80% neutrophils.. U/A no nitrates or leukocyte esterase

Hospital Course IV ampicillin, Clindamycin, gentamicin x 4 days until 24h afebrile, then PO transition then d/c Abd symptoms subsided D/C PO Abx: Doxycycline and Clindamycin Outpatient f/u with Gynecology

Tubo-Ovarian Abscess Inflammatory Mass of fallopian tube, ovary, and occasionally adjacent organs Epidemiology + Risk Factors 1/3 women hospitalized with PID have TOA Most likely 15-40 years old # Sexual partners IUD use HIV Pathogenesis Most frequently arising from upper genital tract infection Likely STD or endogenous flora Inflammation and damage to epithelium predispose to infection Microbiology Common organisms: E coli, Streptococci, Bacteroides fragilis, Prevotella, Peptostreptococcus Actinomyces israelii in IUD users Rarely Candida, Pasteurella multocida, Salmonellae, S. Pneumoniae, Mycobacterium tuberculosis N. gonorrhoeae and C. trachomatis may be inciting infections

Antibiotic Therapy Alone Diagnosis Often follows diagnosis of PID Imaging: pelvic U/S, abd-pelvic CT Surgical Evaluation Suspicion of abscess rupture resulting in acute abdomen or sepsis TOA in postmenopausal women can be a result of tuboovarian malignancy Antibiotic Therapy Alone Indications: Hemodynamically stable, Abscess < 9 cm in diameter, Premenopausal IV initially, then PO Continue for approximately two weeks 48-72 hours trial of antibiotics, if no improvement then consider surgery Initially IV antibiotics is the recommendation

TOA in Virginal Adolescents As a manifestation of Crohn’s Disease 16 yo pw suprapubic and RLQ abd pain, chills, anorexia, fevers PMHx: candida vaginitis 3 months prior Diagnosed with CT scan Cx: Bacteroides uniformis, Coagulase negative staphylococcus, streptococcus milleri Laparascopy: Exudative fluid in pelvis, bowel loops adherent to uterus and fallopian tubes. Colonscopy: Crohn’s disease Etiology: hematogenous seeding of bacteria

As a manifestation of obesity, constipation, recurrent UTIs, poor hygiene 12 yo pw diffuse lower abdominal pain, n/v, fever x 1 day, anorexia, increased urinary frequency PMHx: Obesity, Type 2 DM, constipation, recurrent UTIs Diagnosed on CT scan: cystic L ovary and echogenic debris in lower pelvis Ex lap: b/l TOA + diffuse peritonitis Etiology: inadequate perineal cleansing and vaginal pooling of urine Vulvar adiposity -> recession of urethral meatus -> chronic pooling of urine in posterior vagina

Review of Literature: 9 cases 4 with E. Coli 1 from bowel translocation 1 from Crohn’s disease 2 from undetermined inflammatory process 2 from increased body habitus

References 1. Granberg, Gjelland, Ekerhovd. The Management of Pelvic Abscess. Best Practice & Research Clinical Obstetris and Gyncecology, 2009: 23, 667-678. 2. Hartmann KA, Lerand SJ, Jay MS. Tubo-Ovarian Abscess in Virginal Adolescents: Exposure of the Underlying Etiology. J Pediatr Adolesc Gyncecol, 2009: 22, e13-e16. 3. Goodwin K, Fleming N, Dumont MD. Tubo-ovarian Abscess in Virginal Adolescent Females: A case Report and Review of the Literature. J Pediatr Adolesc Gynecol, 2013: 26, e99-e102. 4. Slap GB, Forke CM, Cnaan A, et al. Recognition of Tubo-Ovarian Abscess in Adolescents with Pelvic Inflammatory Disease. Journal of Adolescent Health, 1996: 18, 397-403. 5. Vyas RC, Sides C, Klein DJ, Reddy SY, Santos MC. The Ectopic Appendicolith from Perforated Appendicitis as a cause of tubo-ovarian abscess. Pediatr Radiol, 2008: 1006-1008.