Case presentation:
A 66-year-old female patient presented to the surgical department with a past medical history of hypertension in the last five years and complained of a two-year right lower quadrant pain and severe swelling. The pain had been vague for the first six months and increased gradually. The pain had increased sharply in the last three days before hospitalization, and it was positional and got worse by bending forward or lying down. The pain has been persistent and mild at first and had nothing to do with painkillers, and it had nothing to do with feeding or defecation. The patient had nausea and vomiting three times which contained food eaten, but she did not complain of constipation. She had normal defecation and gas passing. Due to the patient’s symptoms, she was referred to the surgical clinic and admitted to the surgical ward for more investigation. The patient had stable vital signs at the time of admission, and she did not have a fever. Her weight increased gradually in the past two years and was uncontrollable, but she had not seen a doctor during that period. On the physical examination, the stomach was symmetric but fatty and had mild to moderate distension. Epigastric and right lower quadrant tenderness were found, but rebound or gardening were not detected. The patient has used 25 mg Losartan tablet daily, and her blood pressure was under control. She also had a history of cesarean section with a low-midline incision 40 years ago. For more investigation, she was asked to do abdominal ultrasonography. Sonography revealed a huge cystic area with approximate dimensions of 245 x 205 x 121 mm and an approximate volume of 3235 cc, extending most of the abdominal area from the gastric area to the top of the uterus. Adjacent to the anterior area of the mentioned area, the image of a hypoechoic, heterogeneous and mass-like lesion with no vascularity measuring 33 by 80 cm was seen. On the other hand, multi-hypoechoic, heterogeneous and irregular areas were seen in the right lip of the liver. The most significant lesions were 27 by 27 mm in the 6th liver segment and 23 by 13 mm in the 7th liver segment, respectively. The patient was asked to do an upright chest X-ray and supine abdominal X-ray for more investigation. Upright chest X-ray revealed nothing, as can be seen in Figure 1, but a dense mass-like lesion was seen in the left lower quadrant of the abdomen in supine abdominal X-ray, as can be seen in Figure 2. So, the patient was asked to do an abdominal computed tomography (CT) scan for more investigation, as can be seen in Figure3. The CT scan report was as follows: The image of a large lesion with a diameter of 247 x 126mm containing fat, cystic, calcification, and teeth, as well as a solid 34 x 19mm except in the lower, left posterior part at the beginning of the pelvic cavity extending to the abdominal cavity to the epigastrium is seen preferably on the left and midline of the abdomen. Dislocation of the small intestine loop is anterior and, according to the above evidence, can suggest cystic teratoma of the ovary (possibly from the left ovary). Moderate free fluid is found in the peripheral and paracolic gutters and pelvis. Multiple hypodense lesions are seen in the liver parenchyma with a maximum diameter of 30 mm. Delayed images show a compressive effect of the cystic lesion on the right middle ureter. Blood test analysis presented leukocytosis (white blood cell [WBC] = 17400 mg/dl with neutrophil ratio of 90 % and lymphocyte ratio of 7 %), hemoglobin = 11.9 mg/dL, a high level of erythrocyte sedimentation rate (ESR) = 33 (usually should be under 15 in female), positive C-reactive protein (CRP), aspartate aminotransferase (AST) = 85 (normally should be under 31 in female), alanine aminotransferase (ALT) = 95 (normally should be under 31 in female), and metabolic acidosis, probably caused by decreased tissue perfusion. Other factors were in the normal range. In continuance, general tenderness was detected in physical examination during the patient’s hospitalization. So, due to suspicion of a massive abdominal lesion and according to the clinical presentation and the results of blood tests and imaging reports, the patient underwent laparotomy. An abdominal midline incision was performed. After opening the patient’s abdomen, approximately two liters of free fluid in the abdomen, containing pus and debris, which turned gray, was seen in the abdominal cavity and drained by suction. As can be seen in Figure 4, A large mass of right ovarian origin was seen sticking around. The adhesions were released, and the mass was completely removed from the patient’s abdomen by salpingo-oophorectomy. The mass was huge and about 10 kg. On the other hand, as can be seen in Figure 5, multi liver lesions were seen in the right and left liver lips, and multi biopsies were provided and sent to a laboratory for more investigation. After providing necessary hemostasis, the abdomen area was washed with 10 Lit normal salines, a single drain was performed, and the abdomen was closed. The huge mass contains hair grafts and teeth, as can be seen in Figure 6. After the operation, the patient was transferred to the ICU and transferred to the surgery ward after three days. Ceftriaxone and metronidazole treatment was started for her and continued for ten days. The patient was discharged from the surgery department in good general condition after PO tolerance and defecation. There was no complication in the one-month follow-up. Finally, the pathology report revealed that the mass was mature cystic teratoma and was negative for malignancy, as can be seen in Figure7 and 8. Furthermore, the report approved that the liver lesions did not contain any malignant tissue or cell; they just contained hyalinized tissue without any specific cells, as can be seen in Figure 9.