SRP Discussion
Case Takeaways
This was a complex case involving a 14-year-old female patient with pelvic inflammation and a tubo-ovarian abscess. The surgical team discussed the diagnostic process, including imaging findings and surgical intervention, which revealed a large fibroinflammatory cystic lesion originating from the ovary. The case was challenging due to its rarity in nonsexually active adolescents, the lack of clear response to antibiotics, and the need for extensive surgery, with the team considering various differential diagnoses and ultimately preserving the patient's left ovary.
Challenging Pediatric Inflammatory Case
Moderator Dr. Sherif Emil intorduced a challenging case involving a 14-y-o female patient with a fever, vaginal discharge, and elevated inflammatory markers. Despite the patient's obesity and initial concerns about a perforated appendix, the physical exam was benign, leading to an ultrasound to further investigate the inflammatory process. He emphasized the difficulty of the case and invited input on how others might have managed it.
Tubo-Ovarian Abscess Imaging Findings
The surgical team presented ultrasound and CT scan findings of a complex right lower quadrant mass with cystic and solid components, preserved vascularity, and surrounding inflammation, consistent with a tubo-ovarian abscess. The CT scan showed a larger lesion extending deeper with tubular structures likely representing an inflamed or obstructed fallopian tube. Given the patient's fever and symptoms, the diagnosis of a tubo-ovarian abscess was highly likely, with no signs of appendicitis or ovarian torsion. PID in Non-Sexually Active Adolescent Ray discussed a case of a young, non-sexually active woman with PID and ovarian abscess. Despite initial improvement with IV antibiotics, the patient's symptoms persisted, and imaging showed no change despite multiple courses of antibiotics. The case was complex due to the rarity of PID in nonsexually active adolescents and the lack of clear response to treatment.
Complex Ovarian Mass Surgical Case
A pelvic mass was initially explored via laparoscopy, but required an open procedure because of unclear origins and extensive infiltration of surrounding structures. The surgical team, including a gynecologist, worked for several hours to remove the mass, which was ultimately determined to be originating from the ovary, though they could not completely excise it due to its infiltrative nature. Postoperatively, the patient did well, and the pathology report revealed a large, complex mass measuring 12.8 by 2.5 centimeters, with no obvious ovary or Fallopian tube identified grossly.
Fibro-inflammatory Cystic Lesion Analysis
A detailed histopathological analysis of a fibroinflammatory cystic lesion showed areas of acute and chronic inflammation, including neutrophils, plasma cells, and foamy macrophages. The cytopathology sample from the pelvic cyst was diagnosed as an abscess, with abundant bacteria present. The diagnosis remained descriptive, characterizing the lesion as a fibroinflammatory, ruptured cystic lesion with elements of inflammation.
Chronic Pelvic Inflammation Case Review
The presented findings of fibrous stroma encasing fallopian tube and ovarian tissue, with no necrosis, granulomas, or foreign bodies identified. They considered several differential diagnoses including PID, tuberculosis, diverticular disease, IBD, and endometriosis. The patient had been on multiple courses of antibiotics with no improvement, and while glucose levels were normal during hospitalizations, undiagnosed diabetes was suggested as a possibility. The patient's left ovary was preserved and she is now symptom-free with normal menstrual cycles. The pathologist considered but ruled out inflammatory fibroblastic tumor as a diagnosis, noting the absence of typical mass formation and plasma cells.