Investigations and treatment
Trans-abdominal ultrasound showed a pelvic thick-walled multilocular
complicated cyst containing echogenic debris, measuring 70*6.8*56 cm in
the left adnexa. Magnetic resonance image revealed a unilateral complex
multilocular thick-walled fluid-filled ovarian mass with an irregular
thick uniform enhancing wall and septa at the left side of the pelvic,
causing pressure on the adjacent uterus associated with surrounding
pelvic fat haziness. The above mentioned lesion in MRI demonstrated
heterogeneous intermediate and hyper signal intensity on T2-weighted
images, low signal intensity on T1-weighted images, high signal
intensity on diffusion-weighted imaging (DWI), and low signal intensity
on apparent diffusion coefficient (ADC) indicated restricted diffusion.
These observations indicated the presence of tubo-ovarian abscess(Fig. 1) .
Additionally, a high T2 signal intensity track with enhancement was seen
between the left anterior wall of the lower rectum and the left
posterior wall of the vagina with surrounding fat haziness, in favor of
the rectovaginal fistula (Fig. 2) .
Due to persistent fever, abscess drainage was performed under an
ultrasound guide. Puncturing of the swollen left ovary revealed internal
pus and pus was collected for bacterial culture and the abscess was
excised without any substantial compromise to the ovary. The culture was
positive for Escherichia coli . Clindamycin 900 mg IV every 12
hours and Gentamicin loading dose IV (2 mg/kg) followed by 1.5 mg/kg
every 8 hours was administered.
The rectovaginal fistula was managed conservatively according to the
colorectal surgeon’s recommendation. She was discharged after 6 days;
the CRP level on the day of discharge was 4.12 mg/dL. Oral Clindamycin
at 900 mg/BID was continued for 14 days. Finally, imaging performed one
month after the procedure showed no recurrence of ovarian abscess.
Written informed consent was obtained from the patient and her mother
for the publication of the report.