Acute Diffuse Peritonitis Due to Spontaneous Rupture of an Infected Endometrioma: A Case Report

Abstract

Background. Endometriosis is defined as a chronic, inflammatory, estrogen-dependent gynaecologic disease. It affects approximately 5–10% of reproductive-age women worldwide. Ovarian endometriosis is the most frequent form of this condition. Endometriotic cysts are found in about 17–44% of women diagnosed with endometriosis. It is well known, that ovarian endometriomas can cause infertility and chronic pelvic pain. Enlarging cysts can also cause ovarian torsion. In addition, ovarian endometriosis slightly increases the risk for ovarian cancer. The rupture of endometriotic ovarian cysts is an exceptional complication. According to the literature, the prevalence is less than 3% among women with endometriosis. The rupture of an ovarian endometrioma can cause acute peritonitis, which can lead to sepsis, septic shock and can be lethal. The occurrence of abscesses within an ovarian endometrioma is an extremely rare complication. Generally, the origin of infected endometriotic ovarian cysts is related to the previous invasive procedures involving pelvic organs or the use of intrauterine devices. Also, ovarian abscesses can be caused by the hematogenous or lymphatic spread of bacteria. Although, the literature points out that infection of endometriotic ovarian cysts can develop spontaneously. In these rare cases, reservoir and route of infection remains an enigma.Case report. A 49-year-old female was brought to the emergency room with severe generalized lower abdominal pain (6/10) and three days lasting fever. Abdominal examination revealed diffuse abdominal pain with anterior abdominal wall muscle tension. Painful solid masses were felt on both sides of the uterus during the pelvic examination. Cystic masses were detected in both ovaries during transvaginal sonography. Computer tomography (CT) of the abdomen and pelvis revealed abnormal changes in both ovaries. A small amount of free fluid was found in the pelvic cavity along with thickened pelvic peritoneum. Suspecting acute peritonitis and bilateral tubo-ovarian abscesses, surgical treatment was performed. Lower midline laparotomy with bilateral adnexectomy and abdominal lavage with 4000 ml normal saline were done. The outcome of peritonitis was evaluated using the Mannheim peritonitis index (MPI=17 – low risk of morbidity and mortality). The histopathological examination revealed the diagnosis of bilateral endometriotic cysts complicated with acute inflammation, with associated acute inflammation of both fallopian tubes. Microbiological cultures from the purulent fluid were negative.Conclusions. Although the occurrence of abscesses within an ovarian endometrioma is an extremely rare finding in clinical practice, it has to be considered by gynaecologists because it might result in a surgical emergency that can be life-threatening. Being aware of the risk factors of abscesses within an endometrioma can lead to an early diagnosis of this rare condition and help to avoid serious complications.

Multimodality imaging findings of infected endometriomas: “T1 signal reversal” as a potential diagnostic sign?

“…Infected endometrioma is a rare entity, and current literature is limited to a small number of case reports [ 1 , 6 , 8 , [9] , [10] , [11] , [12] , [13] ]. Lower abdominal pain and fever are generally expected clinical findings.…”

“…However, in some cases, the insidious onset of symptoms may cause patients to be admitted to the hospital late with signs of peritonitis in a preseptic state. Early detection of infection is vital, as it may be complicated by rupture and can be fatal [ 1 , 8 ].…”

“…Endometriosis is a chronic and inflammatory gynecologic disease characterized by the extrauterine presence and growth of endometrial tissue. It is one of the leading causes of chronic pelvic pain and infertility, with a prevalence of approximately 10% in women of reproductive age [1] , [2] , [3] . The ovary is one of the most frequently affected organs in endometriosis (20%-40% of cases) [2] .…”

“…Even though endometriomas cause chronic symptoms, they may rarely present with acute symptoms when complicated due to rupture or superinfection and can lead to diagnostic confusion [1] . This article aims to discuss the multimodality imaging findings and management of a patient diagnosed with bilateral infected endometriomas.…”

Acute abdominal pain in women of reproductive age: keys to suggest a complication of endometriosis

“…This complication most commonly occurs during pregnancy, because of the rapid growth of endometrioma due to hormonal stimulation [ 28 , 29 ]. Clinically, endometrioma rupture may mimic the rupture of a hemorrhagic ovarian cyst with findings ranging from symptoms of inflammation, such as fever, leukocytosis, and elevated c-reactive protein, to acute abdominal pain and signs of hypovolemic shock [ 30 , 31 ].…”