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
And so what happened in this case? What was the diagnosis?
About The Author
Casey Parker
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact
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
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
I forgot about the fever -> Pelvis Appendicitis, Tubal-Ovarian abscess, Meckles
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?
YEp. Its a curious thing the way we think. The recent pregnancy is overweighted by our brains.
If I phrased this case as: 25 yo F, non-pregnant presenting with sepsis and lower ado pain / peritonism – it is a much easier diagnosis.
Ah yes, the “Framing Effect”!
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