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

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