Tubo-Ovarian Abscesses in Nonsexually Active Adolescents: A Rare but Consequential Miss

Abstract

A tubo-ovarian abscess (TOA) is an emergent and potentially life-threatening illness. Rapid administration of antibiotics, interventional radiology abscess drainage, and/or gynecologic surgery are critical interventions. The goal is to prevent abscess rupture, which can lead to peritonitis, severe sepsis, recurrent hospitalizations, and, in rare circumstances, death [1]. Although mortality from TOA in the U.S. is uncommon, the result of an untreated TOA can have lasting damaging effects to pelvic organs and increase the risk of infertility, ectopic pregnancy, ovarian vein thrombosis, and chronic pelvic pain [2].TOAs are typically a complication of pelvic inflammatory disease (PID) in a sexually active female. PID is defined as an infection of the upper genital tract involving the uterus, fallopian tubes, and ovaries. The vast majority of PID cases in the U.S. are secondary to sexually transmitted infections, such as Chlamydia trachomatis and Neisseria gonorrhea [3]. A TOA typically forms when PID evolves into an inflammatory mass. Although Chlamydia trachomatis and Neisseria gonorrhea are rarely isolated from the TOA, they seem to facilitate the invasion of the upper genital tract by lower genital tract flora, increasing the risk of progressive infection [3].The article by Hakim et al. in this issue of the Journal of Adolescent Health forces us to reevaluate our preconceived notion that the diagnosis of a TOA, similar to that of PID, is restricted to sexually active females [4]. Hakim et al. present the largest case series to date of TOAs in nonsexually active adolescent females. All patients presented to the emergency department for care and the majority presented with abdominal pain, fever, or vomiting. The mean age was 14.6 years, and all patients tested negative for Chlamydia trachomatis and Neisseria gonorrhea. Approximately, three quarters of patients had anatomic abnormalities and/or other disease processes that increased their risk of TOA, such as renal agenesis, appendicitis, and renal or urinary tract anomalies. The authors concluded that TOAs are not limited to sexually active females.Prior case reports of TOA in nonsexually active women are consistent with the findings of Hakim et al. Two literature reviews summarize 11 cases of TOAs in nonsexually active adolescents [5,6]. Isolated organisms included Escherichia coli, Bacteroides fragilis, Bacteroides species, Peptostreptococcus, Peptococcus, and aerobic Streptococcus. Although mechanisms of 1054-139X/