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Clinical Case 110: Sepsis, Scans and Surgeons

Here is a case that may keep you guessing.  One for the US nerds.  Here we go:

25 year old tourist – visiting the town, she has been backpacking for 6 months and the history is a little vague… but basically she thinks she may have had a miscarriage about 5 months ago.

She had a positive pregnancy test and two weeks later developed pain and PV bleeding.  Didn’t see a doctor as she had no travel insurance…  the pain settled and she thinks she may have passed some large clots  – anyway the symptoms settled and she carried on her travels.  No imaging was done.

Fast forward to now – 5 months later.

The history is of 24 hours of lower ado pain. The pain started in the left iliac fossa.  Was well localised but has since become more generalised – on examination she is guarding and has clear peritonism across the lower belly.  Certainly she is more tender on the left.  She is febrile (39.8 C = 103.6 F), tachycardia 110 and has a BP of 90/60.  She denies any recent PV loss, discharge or urinary symptoms.  Her bowels were OK until yesterday – no motion since the pain started.  A VBG shows a mild, compensated metabolic acidosis, normal lactate.

He UA shows some pyuria but no nitrites.  And the B-hCG is…..   [drum roll] .. negative.

So in summary – a 25 yo lady who may have had a spontaneous miscarriage 5 months ago now presents with a sepsis picture, left iliac fossa pain and peritonism.  We need a scan!  So I will show you a series of 6 TV US images now and let you interpret them…  here we go.   [I have added captions to orient you if you are not familiar with TV scan which can look a bit weird to the uninitiated ]

I think I will let this case linger here for a few days.  Would really love to hear your thoughts on these images, the possible diagnoses and where to next!

Of course I will tell you what the final outcome and diagnosis was – but first lets see what you think of these images in this scenario.

Comments please.  Are you a super sleuth with a scanner?

Casey

Right ovary on TV

Right ovary on TV

Longitudinal pelvis view

Longitudinal pelvis view

Left pelvis adnexa

Left pelvis / adnexa

Left ovary

Left ovary

Left pelvis mass long.

Another look at the left pelvic mass

And so what happened in this case? What was the diagnosis?

After some fluid resuscitation and empirical antibiotics we headed off to the OT. Gynae started with a laparoscope – which showed: – a lot of purulent fluid – a long inflamed appendix which was adherent to theft anterior pelvic peritoneum, wrapped in omentum. – the appendix had a terminal abscess which contained a sac of frank pus in a strange casing! – Presumably a partially walled off appendix abscess in an odd location. Moral of the story: an unusual appearance of a common disease is commoner than the usual appearance of a rare disease ! The pregnancy was “noise” unhelpful clinical data

Comments

  1. Vahe Ender says:

    I’m a Paramedic, so my U/S experience is limited to eFAST views, not TV. Could this be a molar mass? I know the hcg was negative, but it would be a negative assay feasibly due to hook effect. Respectfully, Vahe

  2. Ewen McPhee says:

    Impression
    Acute internal haemorrhaging.
    USS -- free intraperitoneal fluid with unusual calcified annual lesion in eth left adnexa
    Evidence of ? fronding and almost fetus like appearance in the pelvis near left ovary
    DDX
    Intraperitoneal gestation
    Cyst complication (Ovarian Dermoid) Torsion, Bleed etc…
    Ectopic pregnancy
    Needs Resuscitation and a laparotomy

  3. I don’t agree that she needs a scan -- this is a woman who is septic from a presumed intraabdominal cause. I think she needs a diagnostic laparoscopy, washout, +- laparotomy, done with both general surgery and gynaecology in the room.

    Is this tubal RPOC with superimposed tuboovarian abscess?

  4. The left sided pain threw me a bit -- she’s a bit young to have diverticulitis, and the story really isn’t a good one for appendicitis.

    Something I’ve noticed is that the way I think depends on what choices I have -- so in this case, I wouldn’t be too fussed about making a diagnosis off the scan, because she’s heading toward a laparoscopy either way.

    • Yes -- IT threw us too!
      This case really shows how we need to be clinicians rather than sonographers -- we are treating a patient, not the images!
      Although bedside US is really cool and has greatly enhanced practice -- it still remains a part of the picture.

      The most important piece of kit is between your ears (intrasound?)
      C

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