This paper was read at a joint meeting of the Association of Surgeons and Physicians of Malta and the Fifth Army Surgeons Travelling Club at a meeting in Malta, in May 1968.  Typhoid Fever has been notorious over the decades for the variety of complications that may arise from it, and numerous references are to be found in the medical literature devoted partly or exclusively to discussion of these complications. Abscess involvement of the ovaries or Fallopian tubes is one of the rarest of complications. A patient who developed this rare complication is here described and a short review of the literature made. Factors that may have contributed to this complication are furthermore discussed. A particular aspect of typhoid management which this case study illustrates is the relationship of relapse to dosage of Chloramphenicol. It is strongly believed that the complication of tubo-ovarian abscess in the present case would not have arisen had a fully adequate dose of Chloramphenicol been given at home from the start.peer-reviewe

Attard, Raphael

Vassallo, Luis A.

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CAM1LLER1, A.P., and CREMONA, V. (1969): J. Obstet. Gynaec. Brit. Cwlth., in press. CONE, T.E. (1961): Paediatrics, 28, 490. CREMONA, V. (1967): Chest-Piece, Malta, I, 3I. FRACCARO, M. (1956): Ann. hum. Genet., 20, 282. FRACCARO, M. (1958): Hum. Bio!., 30, 142. GREGERSEN, N.F. (1937): Acta obstet. gynec. Scand., n, 75· HOLL1NGSWORTH, M.F. (1960): West Afr. med. J., 9 (n.s.), 256 . KARN, M.N. and PENROSE, L.S. (1951): Ann. Euge-nics, Lond., 16, 147. 131 KOSKELA, O. (I965): Ann. Chir. Gynec. Fenn., 54, 462 . LEE, C. (1948): Chinese med. J., 66, 153· McKEowN, T., and GIBS ON, J.R. (195 1): Brit. J. soc. Med., 5, 98 . ROEDERER, J .G. (I753): Commentaries of the Royal Society of G6ttingen, p. 410. Cited by Cone, 196I. SHAW, M.M. (1933): East Afr. med. J., ID, 32 . UTTLEY.. K.H. (1940): Chinese med. J., 58, 582 . W.H.O. (1961): Wld. Hlth. Org., Tech. Rep. Ser., No. 217. TU BO-OVARIAN ABSCESS AS A COMPLICATION OF TYPHOID FEVER LUIS VASSALLO B.sc., M.D., M.R.C.P. (LOND.), M.R.C.P. (ED1N.), M.R.C.P. (GLASG.) R<APHAEL A TIIARD B.Sc., M.D., F.R.C.S. (ENG.) St. Luke<'s Hospital. Th1s paper was read at a joint meeting of the, Association of Surgeons and Physi-cians of Malta and the Fi,fth Army Surgeons Travelling! Club at a meet!ng in Malta, in May 1968. Typhoid Fever has been notorious over the decades for 1Jhe, varie;ty of complicart'ions that may arise from it, and numerous re-ferences are to be found in the medical lite-rature devoted partly or exclusively to dis-cussion of these complications. (Keen, 1898; Osier, 1901; Rowland, 1961; Gadehoh & Madsen, 1963). In spite of the great variety and fre-quency of complications that have been des-cribed, abscess involvement of the ovaries Or Fallopian< tubes is one of the rarest of complications. A patient who developed this rare com-plication is here described and a short review of the literature' made. Factors that may have contributed to this complication will also be discussed. Case Report A 30 year old unmarried Maltese wo-man was referred to hospital on 3-9-65 by her doctor for fever of unknown origin. For the previous two months, the patient had been running an irregular fever reaching at times 102°F in the mornings and 105°F in the eV\3nings. She had complained of fre-quent frontal headaches, and dizziness. She had not experienced epistaxis. She admitted to having an occalsional dry cough, but had no expectoration. Her most prominent symptoms apa'rt from the pyrexia had been frequent moderately severe rigors. She: had no abdominal pain, but had had an episode of loose stools la,sting three days, 1lhough she had been generally constipated through-out her illness. She also complained of ge-neral weakness, though she did not look to-xic or very ill. Her appetite: was poor. An-other feature was frequency of micturition and moderate nocturia. She a,lso had mild dysuria. She gave a history of dysmen-132 orrhoea since her menarche. Her menstrual periods were regular occurring every 28 da,ys an:d lasting 7 days. She denied any vaginal discharge. She had no past history of typhoid or brucellosis. She was questioned as to the drugs she had been halving. She admitted having had five separa>te courses of chloram-phenicol, each lasting 3 - 5 days. Chloram-phenicol had been prescribed in a dose of one tablet (250 mgm.) every four hours. On every occasion the temperature had subsided by the end of the course and s!he would feel subjectively better. Pyrexia and rigors would however recur after a, few days. Her doctor had carried out slide agglu-tination tests for typhoid and brucellosis, which had been negative. X-ray chest and urinalysis had been reported as normal. On examination she appeared to be an excited plump young woman who did not look toxic or very ill. Her tongue was dry and coated with whitish fur. Her throat look-ed normal. There was no lymphadenopathy. Her B.P. was normal, and she had a regular, good volume, pulse of 100/min. Her abdomen moved on respiration. The liver and spleen were, not palpable. ~here was no rigidity but mild tenderness was present in the right up-per abdominal quadrant. No masses were present. Her temperature on admission was 102.4°F. Laboratory investigations gave the fol-lowing results: Hb. 13 g./"IOO ml.(88%). White cell count: 6,900 per. c.mm. (Poly.: 45%; eosinophils: 3<;101; Iymphocytes: 40%; monocytes: 12%). Urina:lysis: Fa'im traces of protein; few pus cells; no casts. Ehrlich's di'azo reaction was not carried out. Her blood urea was 30 mgm. per cent. From the Bacteriology Laboratory at St. Luke's Hospital serum a'gglutination tes,ts against Safm typhi 0 were reported positive at 1 in 20 and against Saifm. typhi H up to 1/ 320; negative against Bruc. me{it. and a blood culture carried out on the day of ad-mission (3-9-65) was reported five days la-ter to have yie,Ided a' growth of Sa1m. typhi'. It was decided to start her again on chloramphe,nicol 500 mgm. every four hours on the first day followed by 500 mgm. every six hours for another fourteen days. Her temperature rapidly subsided to norma'l ex-cept for an occasional rise and she, improved clinically and denied any symptoms. As three successive faeces cultures for Sa1m. typhu~ were negative at the end of three weeks and as, there was no abnormal features, she was discharged home. She was rea,dmitted to hospita'l as an acute emergency on 30-9-65, 2 days a,tte'r be-ing discharged, because severe central abdo-minal colicky pain had developed. A typhoid relapse: wa,s suspected. ~here wa's no nausea or vomiting. There, was no radiation of pain elsewhere. She: had passed a normal stool. Her temperature was 101 ° F. Her menstrual period was due, on 3-10-65. On exami'nation her general condi-tion was good. Her pulse rate was 84/min. and her B.P. wa's 115/70. Her tongue was moist and only slightly furred. Her abdomen moved with respiration. It was not distend-ed. The,re was doubtful, tenderness over the ri,ght iliac fossa with some guarding. The pa-tient was however difficult to examine, a's she would not relax properly. Bowel sounds were present. She was started 0111 Penbritin 500 mgm. every six hours; kept on fluids on-ly by mouth and closely observed. As she seemed to be developing more rebound ten-derness the next day, it was decided to carry out a laparotomy the same' evening. At ope-ra'tion (Surgeon R.A.), the' peritoneal ca-vity was opened through a right lower para-medianlincision. No free fluid was pre'sent. The appendix appeared normal. The coils of intestine were also healthy. ~he uterus and left adnexa were also normal. On the right side~ a tuboovarian abscess was present to-gether with fibrinous exudate. A swab for cultul'e was taken from the site and a right salpingo-oophorectomy was performed. No drainage was instituted and the abdomen was then closed in layers. She was put on Penbritin 500 mgm. every six hours for fifteen days. Penbritin was then continued in a dose of 250 mgm. every six for another three, weeks. Her post-operative course was essenti:ally uneventful. Safmoneflal typhj was grown from a swab taken from the operation site. The patient was regularly followed up at intervals for over a year, but no further com-plications were observed. Discussion A typhoid infected tubo-ovarian abscess is surprisingly one o,f the rare'st of typhoi1d complications. In a review of 2647 cases of typhoi,d and paratyphoid fever (Gadeholt and Madsen 1963) no gynaecological compHca-ations were found though 2.6% had urinary tract infections, the frequency of urinary tract infections being twice as high in females as in males. About one fifth of the 530 patients with typhoid described by Rowland (1961) developed one or more complications but no mention is made of tubo-ovarian involve-ment. Again this complication was not found in Pathania's and Sachar's series (1965) of 340, patients. The first description in medical literature of an ovarian complication is generally held to have beel1l given by Werthin 1893 when he described the suppuration of a typhoi,d ovarian abscess occurring ei'ght months after typhoid ,fever. In France, Widarl and Ravault described the first French case in 1902. T:he most complete work on the subject has been done by Feldstein (1937) who in his thesis for the University of Lyons was able to collect forty-one cases from the world literarture - by far the great majority of cases occurring in already disea'sed ovaries. Thirty-three, o·f the cases collected by Feldstein were de,finitely due to Salmo-nelfa' typhi, while four abscesses werer at-tributed to Paratyphoid B organisms. Staemmler (1950,) described two ca-ses. In his first case acute le,ft sided abdo-minal pain occurred four months a,fter typhoid fever ina 53 ye'ar old' woman and at operation an infected dermoid cyst was found. The second case in a 39 year old wo-man was due to paratyphoid B. He also analysed twenty-nine' cases in the literature and attr:ibuted to Kummel the, description of the first case' in 1890 and not to Werth as was generally held. Poustochkine (1952) in the Dutch lirte-rature described two personal cases, and discussed the' vexed question as to whether an infection with typhoid could give rise to abscess formation in healthy ovaries. One of his patients had a diseased ovary, and the other a dermoid cyst. The pa'tient described by Bertrand e't al. (1957) is perhaps of particular interest, as 133 the initial clinicarl course prior to operation resembles closely that ,in the, patient des-cribed this paper. Their fourtyfour-year old patient had suffered from intermittent pyrexiar ,for 2 months and Chloramphenicol had also been given repeatedly with poor e'f-fect. An infected ovarian cyst was found and cut open, but the patient's condition ra-pidly deteriorated post operative,ly and she died of an "EncephaUe typho.'dique('. The authors rightly stress t1he, possibility of endo-toxin liberate,d from the cyst. The surgical complications regarding operative technique and the dangers of liberating endotoxin by cutting open such abscesses at opera,tion are thereforer obvious as being the, major factor leading to their patient's death. A case de'scribed by Detlefsen (1954) is especially unusual as the typhoid infected ovarian cyst perforated. Another aspeCt of typhoid management which our case i.flustrates is the relationship of relapse to dosage of Chloramphenicol. T:he physician has to steer a course between inadequate dosage with a consequently higher danger of relapse and the, worse" though fortunately rarer possibility, of haema-tological toxici,ty from chloramphenicol itself. A dist,inction must be made between the re-lapse, rate! of the untreated case and that of the' Chloramphenicol treated case. Among ther 28057 patients with typhoid fever in the European and American literature, Osier found that the relapse rates varied in differ-ent series from 3% to 18%. This, of course, refers to the prer-chloramphenicol era, before the dramatic effect of chloramphenicol in the treatment of typhoid fever was first des-cribed by Woodward and his colleague in 1948. According to numerous authors includ-ing John & Vinayagam (1952) and El Ramli (1953) treatment wivh chloramphenicol for an inadequate period of time leads to a much higher relapse rate than in cases not treated with Chloramphenicol. Smadel, Woodward and Bailey (1949) found a de1finite relation between chloramphenicol treatment and re-lapse rate. The relapse was over 501%' in cases treated for eight days or less. Good and MaCkenzie (1950) found a similar re'-lapse, rate. El, Ramli (1950) found thart, on an a,ver-134 a,ge, 28% of treated cases relapsed, but that relapse was 33% in those' patients treated for six to ten days into convalescence and 81% ,in those' treated for 11-15 days. The therapeutic lesson was therefore clear and his further figures in 1953 illustrate this. In 1953 he found that the relapse rafte in patients who had continued with chloram-phenical for twe'lve days aher a, normal tem-perature had been reached was only 4%, while it was 26% in those whose, treatment had been stopped on the third day of con-va,lescense. Huckst€1p (1962) in his excel-lent review on the subject concludes there-fore that in typhoid fever chloramphenicol should be continued for at least 14 days. The '15 days course) given to our patient. when she was first admitted to hospital shoul,d ha,ve been adequate for the ordinary case' of typhoid. The implications that may be derived from the case 'IS that if pre,viously inadequate courses of chloramphenicol have been given, then there is the' increased risk of a typlhoid complication. The' possibiHty of local abscess formation somewhere ,in the' body should be held in mind. Such cases al-so suggest that consecuti,ve treatment with Ampicillin should be considered in these cir-cumstances. It is strongly believed that thel complic-a:tion of tubo-oavrian abscess -in the present casei would not have' arisen had a, fully ade-quate dose of Chloramphenicol been given at home from the start, and Bertrand's simi-lar experience) in 1957 lends suppOrt to this belief. We vvfiSh to' thank Prof{, A P. Camjfleri who read the; manurscript and gave us val-uarb/'e' advice. References BERTRAND, L., BAUMEL, H., BERTRAND, A., MAY DERMENGHEN (r957), Montpellier med., 52, 91. DETLEFSEN, M. (r954) Zbl. gyn., 76, 8. EL RAMLr, A.H. (r950) Lancet, I, 6r8. EL RAMLI, A.H. (1953), Lancet, I, 927. FELDSTEIN, R. (1937), Les Suppurations typhoidi--ques et Paratyphoidiques des Kystes de l'Ovaire. These de Lyon, no. 451. GADEHOLT, H., and MADsEN, S.T. (1963), Acta med. Scand, I74, 753· GOOD, R.A., and MACKENZIE, R.D. (r950), Lancet, I, 611. HUCKSTEP, R.L. (1962) Typhoid Fever and Other Salmonella Infections. London. E. & S. Living-stone Ltd. ]OHN, A.T., and V1NAYAGAM, V.S. (r952), Lancet, 2, 757. KEEN, W.W. (r898), Surgical Complications and Sequelae of Typhoid Fever. Philadelphia. W.B. Saunders Co. KUMMEL, L. (r890). Quoted by Staemmler, H.]. (r950). OSLER, W. (1901), Studies in Typhoid Fever. Editor. ]ohns Hopkins Hosp. Baltimore. ]ohns Hopkins Press. PATHAN1A, N.S., and SACHAR, R.S. (1965), Amer. ]. Trop. Med. Hyg., I4, 419. POUSTOCHKINE, 1. (1952), Ned. tschr. geneesk., 96, 35· ) RowLA:m, H.A.K. (1961), ]. Trop. Med. Hyg., 64, 143· SMADEL, ].E., "'v\"OODWARD, T.E., BAILEY, C.A. (1949), ]. Amer. med. Ass., I4I, 129. STAEMMLER, H.]. (1950), Geburtsh, u. Fauenh., IO, 341. WERTH, F. (1893), Dtsch. med. Wschr., 489. WOODWARD, T.E., SMADEL, ].E., LEVY, H.L., GREEN, R., MARKHAM, D.S. (1948), Ann. Int. Med., 29, 131. 

Tubo ovarian abscess as a complication of typhoid fever

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Tubo ovarian abscess as a complication of typhoid fever

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