Infections caused by Salmonella remain an important public health problem, particularly in developing countries. Morbidity and mortality attributable to Salmonella infections are increasing with the emergence and worldwide spread of Salmonella strains that are resistant to most routine antibiotics. Bacteremia is a constant feature of enteric fever. Occasionally, dissemination of bacilli throughout the body results in establishment of 1 or more localized foci of persisting infection especially where a preexisting abnormality has made a tissue or organ vulnerable.1 Isolation of Salmonella species, with variety of clinical syndromes from aberrant sites, where they are hardly expected has been reported.2 However, tuboovarian abscess (TOA) is a rare manifestation of Salmonella infection. We report a case of TOA from which Salmonella paratyphi A was isolated.
A 36-year-old multiparous female patient presented in the outpatient department of a teaching and tertiary care hospital in North India, with a history of fever, off and on, for the preceding 7months. Apart from history of congestive dysmenorrhea, there was no other relevant history. The patient was investigated as a case of pyrexia of unknown origin.
On physical examination, the patient was febrile, chest was clear, abdomen was soft and nontender. Bowel sounds were normal, and there was no organomegaly or free fluids. Per vaginal examination revealed bilateral adnexal masses. There was tenderness at the cervix. Laboratory analysis revealed a hemoglobin level of 10.8g/dL, total leukocyte count was 12,600/μL with 85% neutrophils, and platelet count was 2.83 × 105/μL. Erythrocyte sedimentation rate increased (100 mm/h). A differential diagnosis of genital tuberculosis, endometriosis, and pelvic inflammatory disease was made.
Pelvic ultrasonography revealed a large complex multiloculated septated cystic mass approximately 8.5 × 6.0 cm in the right adnexal site. A calcified focus was also seen. Another thick-walled round-to-oval cystic mass 4 × 4 cm was visualized in the left side of adnexa. Papanicolaou smear tests of uterine cervix and endometrium were negative. To rule out genital tuberculosis, Mantoux skin test and enzyme-linked immunosorbent assay test to determine immunoglobulin G and immunoglobulin M antibodies in the sera of the patient against Mycobacterium tuberculosis were carried out, both of which were negative. Tumor markers were significantly elevated (CA-125, 295.05 U/mL). Ultrasound-guided fine-needle aspiration was done under all aseptic precautions. Dirty thin pus was aspirated that was sent for histopathologic and microbiological examination. Histopathologic examination revealed dense neutrophilic infiltrate, macrophages, and foreign body giant cells in a necrotic background with no malignant cells. Ziehl-Neelsen stain for acid-fast bacilli was negative. The pus was inoculated onto the plates of blood agar, MacConkey agar, and Lowenstein-Jensen medium and also passed in brain-heart infusion broth. Non-lactose-fermenting colonies were obtained on MacConkey agar after overnight incubation at 37°C. Brain-heart infusion broth was subcultured onto solid media that showed the similar growth after 24 hours of incubation. On the basis of the colony characteristics, Gram staining, motility, biochemical reactions, and agglutination with specific antisera, the isolate was identified as S. paratyphi A. The isolate was sensitive to chloramphenicol, ampicillin, cotrimoxazole, ciprofloxacin, and ceftriaxone. Blood and stool cultures were negative. Widal test revealed titers of 1:320 both for Salmonella paratyphi O (somatic) and AH (flagellar) antigens. Polymerase chain reaction and BACTEC (Becton-Dickinson, Franklin Lakes, NJ) for tuberculosis was negative. No growth was obtained on Lowenstein-Jensen medium after 6 weeks of incubation.
Exploratory laparotomy was performed by midline vertical incision in view of adnexal abscess. Tubes and ovaries of both sides were identified with difficulty only after separation of tissues because thick adhesions were present between the adnexa, gut, uterus, and pelvic wall. Pus was drained by inserting the needle into the abscess. Infected tube and ovary were not removed because patient wanted fertility sparing. Patient was given a full course of third-generation cephalosporin (ceftriaxone) intravenously. Patient responded favorably and was discharged in good condition after 2weeks of hospitalization. On follow-ups, the patient was afebrile.
Salmonellosis can result in 4 types of clinical syndromes: enteric fever, septicemia with or without local suppurative lesions, gastroenteritis, and the carrier state. Local abscess formation may occur as a complication of any Salmonella infection by either hematogenous or lymphatic spread or direct contact with the inflamed bowel wall. Salmonella proliferates within macrophages and escapes phagocytosis by neutrophils to establish a systemic infection, thus providing a means of extraintestinal dissemination.1
Tuboovarian abscess is a sequela of pelvic inflammatory disease that is composed of an infectious inflammatory complex encompassing the fallopian tube and ovary. The proposed pathophysiological mechanism for TOA development includes ascending infection and hematogenous and lymphatic routes.3 The infectious source is typically polymicrobial, and several reports have identified Escherichia coli, Neisseria gonorrhoeae, Chlamydia trachomatis, and a variety of obligate anaerobic bacteria as commonly associated microorganisms.3,4 Salmonella is rarely the causative agent, and mostly, predisposing factors such as ovarian abnormalities like dermoid cyst, endometrioma, cystadenoma, or simple cyst are present where hematogenously disseminated Salmonella tend to localize.5 In our case, both the ovaries were multicystic.
Very few cases of ovarian abscesses due to Salmonella have been reported worldwide. Out of 6250 cases of salmonellosis treated in Christian Medical College, Vellore, India, from 1981 to 1992, only 1 case of Salmonella ovarian abscess was reported.6 This indicates the rarity of the disease. Ovarian abscesses reported in literature are mostly by Salmonella typhi and nontyphoidal Salmonella (Table 1). This is probably the second case, to our knowledge, due to S.paratyphi A. The first case was reported by Sidahmed and Hassan7 in 1975 in a 19-year-old female patient having dermoid cyst. The broad differential diagnosis of an adnexal mass includes lesions of infectious origin, such as a hydrosalpinx or TOA caused by pelvic inflammatory disease hysiological or functional cysts, endometriomas, both benign and malignant neoplasms, and masses originating in organs or tissues proximal to the adnexa. Important considerations in arriving at the most probable diagnosis are the age of the patient, the history, the findings on physical examination, and the results of radiological and laboratory studies. It is best to obtain both transvaginal and transabdominal sonograms to evaluate a pelvic or an adnexal mass. A TOA is usually diagnosed based on a physical examination or pelvic ultrasound. Some abscesses are found during surgical exploration of the abdomen. Antibiotics are the first-line treatment of a TOA. Very large abscesses or abscesses that do not go away after antibiotic treatment can be drained. Drainage may be done with a large needle guided by ultrasound or by surgically cutting into the abscess. Sometimes, the infected tube and ovary also have to be surgically removed.
So, in countries like India, where Salmonella infections are endemic, differential diagnosis of Salmonella can always be kept in mind by the clinicians while managing TOAs because there is a possibility of Salmonella infection at aberrant sites, especially in patients with history of persistent fever or gastroenteritis or any preexisting abnormality like ovarian cyst or endometriosis.
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