Tubercular Pyosalpinx Mimicking Ovarian Torsion

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1 Indian Medical Gazette FEBRUARY Case Report Tubercular Pyosalpinx Mimicking Ovarian Torsion Debraj Basu, RMO cum Clinical Tutor, Dept. of Gynae. & Obst., R. G. Kar Medical College, Kolkata. Samrat Chakrabarty, Asst. Professor, Dept. of Gynae. & Obst., Murshidabad Medical College, Murshidabad. Prasad Mondal, PG Trainee, Dept. of Gynae. & Obst., R. G. Kar Medical College, Kolkata. Vidyasagar Sau, PG Trainee, Dept. of Pathology, R. G. Kar Medical College, Kolkata. Abstract Ovarian torsion is a gynecological emergency that requires prompt recognition and treatment. It may present with nonspecific signs and symptoms, and should be considered in any female with acute abdominal pain. The diagnosis is based on an awareness of the relevant risk factors, the clinical presentation, and a high index of suspicion. Timely investigation and management can make the difference between ovarian loss and salvage an outcome of great importance in the population of reproductive age females. Whereas Tuberculosis is a chronic infectious disease, and the morbidity associated with it has major health implications. When tuberculosis affects the genital organs of young females, it has the devastating effect of causing irreversible damage to their fallopian tubes, resulting in a possible tubercular pyosalpinx and infertility. However, the disease often remains silent. In this case study, suspecting the diagnosis of genital tuberculosis and of establishing the differential diagnosis with ovarian tumors in the presence of large pyosalpinges is highlighted. Keywords ovarian torsion, adnexal torsion, gynecologic emergency, genital tuberculosis, pyosalpinges Introduction Ovarian torsion, first described by Kuestner in 1891, results from partial or complete rotation of the ovarian pedicle on its long axis, is infact 5th most common gynaecological emergency comprising 2-3% of acute surgical emergencies 1,2. The diagnosis of ovarian torsion can sometimes be difficult because the presenting signs and symptoms, abdominal pain, nausea and vomiting, are common to many causes of acute abdomen, including appendicitis, bowel obstruction, ruptured ovarian cyst, ectopic pregnancy, pelvic inflammatory disease. Tuberculosis is a chronic infectious disease which when affects the genital organs of young females causes irreversible damage to the fallopian tubes, resulting in infertility that is difficult to cure. However, the disease mostly remains silent or may present itself with very few specific symptoms. In about 18% cases genital TB causes uni- or bilateral Hydrosalpinx 3.17 and it remains to be an incidental finding. GTB can be confused with different gynecological pathologies, such as PID, ovarian torsion, ectopic pregnancy or with non-gynecological pathologies, such as acute appendicitis. In this case we report a case of bilateral Tubercular Pyosalpinx Mimicking Ovarian Torsion. Case Report An 21-year-old woman, primiparous, who had been Address for correspondence: Dr. Debraj Basu, C/o S. S. Das, Aparajita Apts., Flat - 06, 13/4 K. B. Sarani, Mall Road, Kolkata debrajbasu@hotmail.com

76 Indian Medical Gazette FEBRUARY 2015 sexually active for 5 years with last child birth 4 years back by caesarean section was transferred from the general emergency department to emergency of

She had been seen at a private clinic a week before due to repeated episodes of pain abdomen; she underwent an ultrasonography examination on 2nd May,2014 perhaps related to the presence of pain

2 76 Indian Medical Gazette FEBRUARY 2015 sexually active for 5 years with last child birth 4 years back by caesarean section was transferred from the general emergency department to emergency of Gynaecology department on 10th May She had been seen at a private clinic a week before due to repeated episodes of pain abdomen; she underwent an ultrasonography examination on 2nd May,2014 perhaps related to the presence of pain abdomen which revealed presence of one cm septated Rt. Adnexal lesion at the Right adnexa and pouch-of-douglas with right ovary not seen separately, suggesting Right ovarian cyst. On 10th May, 2014 as a consequence of persistent discomfort followed by severe pain in her lower abdomen associated with vomiting she was admitted to the General Septic Ward of Department of Gynaecology, R.G.Kar Medical College. At Gynae. Septic Ward her gynecological examination findings show uterus normal sized and anteverted, but over right fornix a soft cystic mass of about 8 6 cm felt, suggesting ovarian tumour and with associated symptoms of vomiting and severe pain abdomen diagnosis of ovarian torsion was made. As there were no clinical improvement after conservative management, a surgical intervention was proposed. On that day, emergency laparotomy was performed (10th May, 2014) and revealed omental adhesions probably long term complications of previous caesarean section along with bilateral huge pyosalpinx. Small deposits found all over uterus and ovaries and pouchof-douglus. Her ovaries showed some adhesions but seemed healthy. Drainage, adhesiolysis and bilateral Fig. 1 Bilateral Pyosalpinx (a) (b) Fig. 2 (a) depicting presence of granuloma with langhans giant cell, (b) Depicting tubal anatomy with presence of granuloma within salpingectomy (Fig. 1) were performed.pus from pyosalpinx collected for bacterial culture and sensitivity. Bilateral salpingectomy done. Sterile intraperitoneal wash given. After achieving haemostasis, abdomen was closed in layers. Later culture and sensitivity report shows no growth of any pathogen. Sections from bilateral fallopian tubes show histopathological features of chronic granulomatous salpingitis of Koch s etiology (Fig. 2). Patient was discharged after 7 days and advised to visit Revised National Tuberculosis Control Programme (RNTCP) unit at R. G. Kar Medical College and is now under anti-tubercular drug therapy comprising of Isoniazid, Rifampicin, Pyrazinamide, Ethambutol of Category 1 of RNTCP. She has already successfully completed Intensive phase and currently under continuation phase with Isoniazid and Rifampicin. Discussion Ovarian torsion, that is partial or complete rotation of the ovarian pedicle on its long axis, potentially compromising venous and lymphatic drainage 2. Adnexal torsion is rarely bilateral and is more common on the right side 3,6, perhaps because the sigmoid colon leaves limited space for left adnexal mobility 7. Torsion occurs more commonly in young women, with the greatest incidence in the 20 to 30 year age group 8. Ovarian tumours or adnexal masses can act as fulcrums, resulting in torsion. Benign ovarian neoplasms carry an 11% risk, and dermoid tumours (a.k.a. benign cystic teratomas), the most common ovarian neoplasms in young females, are a relatively common antecedent of adnexal torsion 3. Malignant ovarian tumours are more likely to adhere to or invade other pelvic structures, hence carry a lower risk of

3 Indian Medical Gazette FEBRUARY torsion only 2% 3. Because of the anatomy of the broad ligament, both the ovary (or adnexal mass) and the fallopian tube are usually involved in the torsion; it is uncommon for these structures to be involved in isolation 6. Predisposing factors for torsion are hypermobile adnexa due to hydrosalpinx or an elongated mesosalpinx, pregnancy, patients undergoing ovulation induction. The diagnosis of ovarian torsion can be difficult because the presenting signs and symptoms of abdominal pain, nausea and vomiting, are common to many causes of acute abdomen, including appendicitis, bowel obstruction, gastrointestinal infection, ruptured ovarian cyst, ectopic pregnancy, pelvic inflammatory disease, cystitis and renal colic. Therefore, the diagnosis of adnexal torsion must be kept in mind in attending female patient presenting with lower abdominal pain, which, classically in patients with ovarian torsion will present as severe, progressive unilateral abdominal or pelvic pain that is crampy or colicky in nature. Pain may radiate to the thigh or lower back on the affected side 7. Incomplete or intermittent torsion may be characterized by bouts of severe pain separated by asymptomatic periods as the ovary twists and untwists 6. Nausea and vomiting is common 1,3, and low grade fever (<38.0 C) may occur 8. The physical exam may reveal a soft abdomen with lower quadrant tenderness; however, if the torsion is longstanding, the abdomen may be diffusely tender with peritonitis and rigidity 7. Bi- manual pelvic exam may demonstrate uterine shift toward the affected side. Adnexal tenderness is typical and up to 50% of women have a palpable adnexal mass 8. Few investigations are sensitive or specific for adnexal torsion, a negative b-hcg can rule out causes such as ectopic pregnancy, and a urine dipstick and microscopy should be performed to assess the possibility of urinary tract infection or stone. Studies have demonstrated elevated white blood cell counts in 16% to 38% of cases 1,8, but this result is non-specific. In cases of suspected torsion, ultrasound is the investigation of choice, and >93% of patients with ovarian torsion will have abnormal ultrasound findings 8 with the most common finding ovarian enlargement 6. In cases of incomplete ovarian torsion, ultrasonography may show massive ovarian edema due to compromise of lymphatic drainage, without ischemic necrosis 5. Free fluid is found in the cul-de- sac in a small number of patients from ovarian capsule transudate secondary to lymphatic and venous obstruction 11. With prolonged and complete torsion, infarction may appear as cystic, clotted areas 2. Colour Doppler Sonograpy (CDS) has been used increasingly in recent years to evaluate ovarian viability. Abnormal flow on CDS increases the likelihood of torsion 6,9. Diagnostic laparoscopy is indicated when there is a high suspicion of ovarian torsion and the need for surgical intervention remains unclear 13. In the past, oophorectomy was considered the standard of care, because of concern that untwisting of the adnexa might precipitate pulmonary embolism from a thrombosed vein 3. Several studies have shown that only in the absence of a grossly necrotic ovary, untwisting of the adnexa can be performed, and the ovary salvaged 10. As indicated above, ovarian torsion mostly present as a surgical emergency but pyosalpinx due to Genital TB(GTB) often remains silent or may present with very few specific symptoms so its diagnosis is more difficult and is delayed if clinicians do not consider it a possibility. Moreover most common presentation of GTB is primary infertility 11 which is not present in this case.the case report described here presents several interesting facts that should be considered and discussed: 1) the lack of TB predisposing factors, the uncommon form of presentation, and the difficulty of its diagnosis and of differential diagnosis led to GTB not being considered; 2) the bilateral large pyosalpinx findings, most probably by super imposed PID, and their confusion with ovarian tumors that too after ultrasonography. Regarding the first point, the patient did not have a personal nor family history that could suggest a TB infection. She also did not have the known risk factors for GTB (AIDS, immigration or drug addiction). In the case studied here, the TB symptoms were also limited to lower abdominal discomfort followed by severe pain abdomen which is very uncommon in cases of pyosalpinx due to GTB. Primary infection of the genital tract by TB is extremely unusual and it is almost always secondary to other infections 12 that mostly is the pulmonary infectious TB. This primary infection, in most cases, is controlled by the immune response; the damage caused by the infection tends to be fibrosis and calcification. However, in the 2 or 3 weeks that it takes for the specific

4 78 Indian Medical Gazette FEBRUARY 2015 T-cell-mediated response to develop, asymptomatic hematogenous spread of the bacilli can occur. The bacilli preferentially spread to places including lung vertices and the female genital tract, especially the fallopian tube, where they may remain in a latent state for a long time. Secondary TB occurs due to the re-activation of this latent infection or, more rarely, due to re-infection 13. The TB bacilli can reach the female genital tract through hematogenous routes, which occurs in 90% of cases from a primary infection of the lungs, lymph nodes or skeletal system 12. Infection of the female genitourinary tract can also occur through the lymphatic system or directly from the gastrointestinal tract, mesenteric nodes or peritoneum or, rarely, by sexual transmission 12. Because of the few symptoms of GTB 14,15, only 50% of cases are diagnosed without surgery. Most frequently, the diagnosis becomes apparent as a salpingitis that expresses itself by primary infertility, which is not the case her. Sometimes GTB is initiated with pelvic pain, by menstrual disorders or, less frequently, the presence of fever and the decline of a general physical state. In the most advanced cases, there are involvement of the fallopian tubes, uterus and ovaries, and can lead to pelvic peritonitis 16. In our case, the pelvic pain was marked. Subsequently, symptoms presented after the USG was performed, and we assumed that these symptoms were due to the torsion of the ovarian mass. As TB is considered one of the greatest imitators of other diseases, other inflammatory purulent processes such as endometritis and salpingitis, a ruptured ectopic pregnancy or an acute appendicitis, must be ruled out. Regarding the second point in the discussion, the finding of a large bilateral pyosalpinx and its confusion with ovarian tumors has been mentioned in other publications. In effect, GTB can present with adnexal tumors, ascites and elevation of the serum CA- 125<500UI/mL; it is difficult to establish the differential diagnosis from ovarian cancer. The clinical findings are of little utility because both pathologies can present with the same vague symptoms; but usually symptoms of ovarian torsion remains different from pyosalpinx due to GTB. Conclusion Ovarian torsion is a surgical emergency that often presents a difficult diagnostic challenge. A detailed history and physical, including a pelvic exam is crucial, and tests such as α-hcg are useful to exclude some other possibilities. Ultrasound with or without Doppler imaging may be helpful. Genital TB(GTB) has insidious onset which is why clinicians do not typically consider GTB in forming differential diagnosis of ovarian torsion. The need to remember the risk of pyosalpinx due to GTB and to distinguish it from ovarian tumors must be highlighted. Histopathological study and cultures are the gold standard for a definitive diagnosis. References 1. Martin C. and Magee K. Ovarian torsion in a 20 yrs old. CJEM: JCMU, 8(2), March Hibbard L.T. Adnexal torsion. Am J Obstet Gynecol. 152, Gascón and Acién:lateral bilateral tubercular pyosalpinx in a young woman with genitourinary malformation:a case report, Journal of Medical Case Reports. 8:176, Varma T.R. Genital tuberculosis and subsequent fertility. Int J Obstet Gynaecol. 35(1):1-11, Bapna N., Swarankar M., Kotia N. Genital tuberculosis and its consequences in subsequent fertility. J Obstet Gynecol India. 55(6): , Albayram F., Hamper U.M. Ovarian and adnexal torsion: spec-trum of sonographic findings with pathology correlation. J Ul- trasound Med. 20: , Nichols D.H., Julian D.J. Torsion of the adnexa. Clin Obstet Gy-necol. 28: , Houry D., Abbot J.T. Ovarian torsion: a fifteen year review. Ann Emerg Med. 38: , Cappell M.S., Friedel D. Abdominal pain during pregnancy. Gas-troenterol Clin North Am. 32:1-58, Cohen S.B. Laparoscopic detorsion allows sparing of the twisted ischemic adnexa. J Am Assoc Gynecol Laparosc. 6: , 1999.

5 Indian Medical Gazette FEBRUARY Ghosh K., Ghosh K., Chowdhury J.R. Tuberculosis and female reproductive health. J Postgrad Med. 57(4): , Akbulut S., Arikanoglu Z., Basbug M. Tubercular tubo-ovarian cystic mass mimicking acute appendicitis: a case report. J Med Case Reports. 5:363, SEGO, Protocolos Asistenciales en Ginecología. Protocolo 51: Tuberculosis genital femenina. Progr Obstet Ginecol. 46(11): , Aliyu M.H., Aliyu S.H., Salihu H.M. Female genital tuberculosis: a global review. Int Fertil Womens Med. 49(3): , Mondal S.K. Histopathologic analysis of female genital tuberculosis: a fifteen-year retrospective study of 110 cases in eastern India. Turk Patoloji Derg. 29(1):41 45, Ilmer M., Bergauer F., Friese K., Mylonas I. Genital tuberculosis as the cause of tuboovarian abscess in an immunosuppressed patient. Infect Dis. 17. Kulshrestha V., Kriplani A., Agarwal N., Singh V.B., Rana T. Genital tuberculosis among infertile woman and fertility outcome after antitubercular therapy. Int J Gynecol Obstet. 113(3): , 2011.

Richmond, Virginia. I ve have this terrible pain

Richmond, Virginia. I ve have this terrible pain Acute Pelvic Pain A Practical Approach Christine Isaacs, MD Associate Professor Department of Obstetrics & Gynecology Virginia Commonwealth University School of Medicine Richmond, VA Richmond, Virginia