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

2. 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

3. 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

5. 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

6. 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 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

7. 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

8. 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

9. 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

10. 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

11. References
1. Granberg, Gjelland, Ekerhovd. The Management of Pelvic Abscess. Best Practice & Research Clinical Obstetris and Gyncecology, 2009: 23, Hartmann KA, Lerand SJ, Jay MS. Tubo-Ovarian Abscess in Virginal Adolescents: Exposure of the Underlying Etiology. J Pediatr Adolesc Gyncecol, 2009: 22, e13-e 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-e 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, 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: