2019 Research Forum

Applicant: Carlos D’Assumpcao MD R1 Principal Investigator: Arash Heidari MD

Tube-Ovarian Abscess on Fire

Carlos D’Assumpcao MD R1, Matthew Gilbert MS IV, Arash Heidari MD

INTRODUCTION Tubo-ovarian abscess is a complex polymicrobial adnexal infection that is a sequela of an ascending pelvic inflammatory disease. Treatment can range from total abdominal hysterectomy and bilateral salpingo-oophorectomy to conservative intravenous antibiotics and drainage. Typical microbes include gram negative and anaerobic bacteria. Corynebacterium species rarely cause tubo-ovarian abscess though there are coryneform bacteria that do.

PURPOSE This is a case of a tubo-ovarian abscess causing recurrent intraabdominal and intrathoracic abscesses due to coryneform Actinomyces europaeus.

DISCUSSION 49-year-old female with history of endometriosis and methamphetamine abuse and multiple abdominal surgeries presented with left lower quadrant abdominal pain, fever, nausea, abdominal distension and vaginal bleeding. Imaging revealed multiple pelvic and intraabdominal abscesses. Empiric ciprofloxacin, ceftriaxone and then metronidazole were started. Source control was attempted with CT guided drainage. Cultures grew Peptostreptococcus prevotii, Prevotella melaninogenica, Corynebacterium species. Vancomycin, piperacillin/tazobactam and gentamicin were added to metronidazole. Unfortunately, she left against medical advice. She returned one week later with dyspnea. Due to respiratory failure and sepsis she was intubated. Imaging showed left sided subdiaphragmatic and loculated pleuritic abscess. CT guided chest tubes and abdominal drain were placed. Cultures grew Prevotella disiens, Candida albicans and Corynebacterium species. Vancomycin, piperacillin/tazobactam, and micafungin were started. Corynebacterium species and Candida glabrata and albicans were sent for sensitivities. Due to continued septic shock she underwent exploratory laparotomy, total abdominal hysterectomy with bilateral-oopherectomy, adhesiolysis. Pathology confirmed tubo-ovarian abscess. After 18 hospital days, patient was discharged with a 14-day course of amoxicillin/clavulanate. Speciation and sensitivities of Corynebacterium species returned one week after discharge with Actinomyces europaeus sensitive to penicillin. Amoxicillin 1000mg was started with plan for 6 months course. One week later, patient returned with recurrent culture negative left pleural effusion that was successfully drained. Patient was discharged with close outpatient follow up.

CONCLUSION Physicians should be aware of fast growing aerobic coryneform bacteria like Actinomyces europaeus and others, as it can change long term clinical outcomes.

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