Tubo-ovarian abscess (TOA) is a serious complication of pelvic inflammatory disease associated with high morbidity. Although TOA is not uncommon, it presents a diagnostic challenge in emergency department. Its classic presentations of lower abdominal pain, fever and vaginal discharge, are rarely present. In our emergency department (ED), bedside ultrasound is commonly performed on patients presented with abdominal symptoms.
We present three cases of TOA diagnosed in ED, who initially had other provisional diagnosis. The first case involved a 44-year-old lady who was referred from primary care clinic for urosepsis. She presented with 2 days history of fever and bilateral loin pain. Abdominal examination showed suprapubic tenderness. UFEME was positive for urinary tract infection. Bedside ultrasonography revealed presence of cystic collection posterior to the uterus with presence of intrauterine contraception device. The second case was a 31-year-old lady who was referred from a private hospital for acute gastroenteritis. She presented with history of fever with vomiting and diarrhea of four days duration. Examination revealed tenderness over lower abdomen. The initial diagnosis was infective gastroenteritis. Bedside ultrasonography showed presence of multiple lesion of mixed echogenicity over adnexal region. The third case was a 27-year-old lady who presented with fever, diarrhea and abdominal pain. Again, the provisional diagnosis was gastroenteritis. Bedside ultrasonography revealed presence of multiloculated collection over right adnexa. All three cases had a change in diagnosis to TOA and were referred to gynaecology team which later confirmed the diagnosis.
TOA is not an easy diagnosis to make, especially if the complaint is not gynae in nature. ED doctors usually perform targeted history and focused examinations. This has the potential to missed certain diagnosis. In all our patients, the presenting complaints were not suggestive of TOA. These cases further emphasized the benefit of point-of-care ultrasound in improving diagnostic accuracy in the ED.
point-of-care ultrasound, tubo-ovarian abscess
Richard. Epidemiology, clinical manifestaion and diagnosis of tubo-ovarian abscess. 2017. https://www.uptodate.com/contents/epidemiology-clinical-manifestations-and-diagnosis-of-tubo-ovarian-abscess (Accessed 23/5/2018)