Ovarian abscess in young sexually non-active girls can represent a diagnostic challenge. 15-years old girl was admitted
to the Clinic for Gynaecology and Obstetrics under the suspicion of torsion of an ovarian cyst. Her clinical status deteriorated
after the admission with development of acute abdomen. Laparoscopic exploration was performed and unilateral
ovarian abscess was found without involvement of other pelvic structures. The surgical proceedure was minimal
invasive for a young girl and Salmonella staleyville was isolated from pus. Solitary ovarian abscess can be of hematogenous
origin and the causative pathogens are different from pathogens usually involved in pelvic inflammatory disease.
To avoid later fertility problems it is of great importance to treat infections in pelvic region correctly according to the isolated
microorganism and that surgery is the least invasive

Igor But

Nina Miksić Gorišek

Slavko Orešković

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Coll. Antropol. 35 (2011) 1: 223–225Case reportSalmonella Ovarian Abscess in Young GirlPresented as Acute Abdomen – Case ReportNina Miksi} Gori{ek1, Slavko Ore{kovi}2 and Igor But31 Maribor University Medical Center, Department of Infectious Diseases, Maribor, Slovenia2 University of Zagreb, Zagreb University Hospital Center, Department of Gynecology and Obstetrics, Zagreb, Croatia3 Maribor University Medical Center, Division of Gynaecology and Obstetrics, Maribor, SloveniaA B S T R A C TOvarian abscess in young sexually non-active girls can represent a diagnostic challenge. 15-years old girl was admit-ted to the Clinic for Gynaecology and Obstetrics under the suspicion of torsion of an ovarian cyst. Her clinical status dete-riorated after the admission with development of acute abdomen. Laparoscopic exploration was performed and unilat-eral ovarian abscess was found without involvement of other pelvic structures. The surgical proceedure was minimalinvasive for a young girl and Salmonella staleyville was isolated from pus. Solitary ovarian abscess can be of hemato-genous origin and the causative pathogens are different from pathogens usually involved in pelvic inflammatory disease.To avoid later fertility problems it is of great importance to treat infections in pelvic region correctly according to the iso-lated microorganism and that surgery is the least invasive.Key words: ovary abscess, Salmonella staleyville, pelvic inflammationIntroductionPelvic inflammatory disease with abscess formation israre in sexually non-active adolescent girls. We report acase of Salmonella stanleyville unilateral ovarian abscessin 15-years old virgin presented with a clinical manifesta-tion of acute abdomen. The patient did not have any pre-vious symptoms of gastrointestinal nor clinically mani-fest bacteraemic Salmonella spp. infection.Case ReportA 15-years old girl was transferred to the Clinic forGynaecology and Obstetrics from a regional hospital un-der the suspicion of torsion of an ovarian cyst. The patientwas admitted to the regional hospital 2 days earlier withhigh fever (39.2 °C) and lower abdominal pain. Ultraso-nography of pelvis was performed on admission to the re-gional hospital and unilocular cystic structure in theright ovary was confirmed. At admission to our hospitalthe patient had high fever 38.8 °C and clinical examina-tion revealed tenderness in lower right abdomen. Rectalexamination confirmed normal sized non-tender ante-verted uterus, right adnexal area was very tender on pal-pation, although no mass was palpable. The vaginal ex-amination was not performed since she was a virgin. Theultrasound examination of the pelvic region showed hipo-echogenic cystic formation 6456 mm in the right ovarywith irregular echogenitiy inside and highly vascularizedcysts wall (Figure 1). Left ovary and uterus were normal.Small amount of free fluid was seen in the pelvic cavity.The laboratory tests performed on admission showedleucocytosis of 21.9109/L with left shift, other inflam-matory markers were only slightly elevated (C-reactivepreotein was 37 mg/L, procalcitonin 0.43 ng/L). She wasprescribed empiric parenteral antibiotic therapy withciprofloxacin and clindamycin.Her condition did not improved in the next 36 hours.She was constantly febrile with temperature above 38.5°C and right abdominal pain deteriorated with develope-ment of local contracture of the anterior abdominal wall(defence musculaire). The repeated laboratory examina-tion on the third day showed persistent leucocytosis(WBC 20.5109/L) and marked elevation of C-reactiveprotein (213 mg/L), the tumor marker CA 125 was ele-vated as well (104 U/mL).223Received for publication December 30, 2010The abdominal surgeon was consulted and bowel in-flammatory disease and perityphlitic abscess were ruledout.The explorative laparascopy was performed 44 hoursafter the admission to the hospital. We found an enlargedright ovary without torsion (Figure 2); the overlyingomentum was adhering to it. The other organs in pelvis(both falopian tubes and left ovary) were normal as wellas the appendix.The cyst in right ovary was incised and 100 mL ofwhitish-green pus was aspirated and sent for mycrobio-logical examination. The abscess cavity was rinsed and 2drains were left in pelvic cavity for abdominal lavage forthe next 18 hours.Her condition improved rapidly after the procedure.She was afebrile and clinical stabile, inflammatory mark-ers decreased, only the CA 125 marker was still elevated(320 U/mL). On the fourth postoperative day she was dis-charged from the hospital.Before the discharge we received the result of micro-biological examination of abscess fluid and nontyphoidSalmonella stanleyville was isolated. The blood cultureand urine culture were negative. The strain was suscep-tible to ceftriaxon, ampicillin, ciprofloxacin, trimetoprim/sulfametoxasole.At discharge we changed the antibiotic therapy to oralciprofloxacin alone for another 10 days.On account of this finding we performed also the mi-crobiological examination of stool, however we did notproved Salmonella spp. nor other pathogenic bacteria.After detailed questioning, the patient denied any gastro-intestinal problems or febrile ilnesses during the last 6months, all the familly members were healthy as well.She did not recall having any Salmonella infection in thepast. She did not travel abroad and does not possess anyexotic pet at home (reptiles, turtles, snakes).DiscussionOvarian abscess in young sexually non-active girlscan represent a diagnostic challenge, since it is rare andcan be unrecognized or mistaken for other pathology likecysts or tumour as reported in literuture1,2. Our preoper-ative diagnosis was ovarian cysts torsion and purulentcontent of the cyst was unexpected.Ovarian abscesses are commonly associated with pel-vic inflammation. Generally, they develop by ascendingroute as a part of salpingo-oophoritis. In contrast isolat-ed ovarian abscesses without tubal involvement are veryrare. They can follow pelvic surgery with traumatisationof ovariummost commoly3, however can be a consequenceof haematogenous or lymphatic spread of an organism dur-ing sepsis or bacteriaemia. Commonly isolated organismsin ovarian abscesses following haematogenous spreadare Enterobacteriaceae, streptoccoci, enterococci and Sta-phylococcus aureus. Salmonella spp. is a rare cause ofovarian abscess, reported in few cases in literature. Inmost cases it is of haematogenous origin, although theovary can be infected by direct propagation from in-flammed bowel wall or by ascending route.Nontyphoidal Salmonella infections are most com-mon cause of bacterial gastroenetrocolitis in developedworld. Invasive infections are rare in immunocompetentpatients. Focal metastatic infections occure in 5–10% ofpatients with invasive salmonellosis in various organs6.The presence of pre-existing disease favours Salmonellalocal infection. It is known that persons with malignancy,anatomical abnormalities, sickle cell disease, systemic lu-pus erythematosus, hemoglobinopathies etc. are at in-creased risk to develop localized infection after invasivesalmonellosis. Tumours, cysts, bone infarction and dam-aged tissue are all predilection sites for focal Salmonellainfections. Most patients with ovarian Salmonella infec-tion had pre-existing abnormalities of ovaries like cystsor endometriotic focuses4,7. In our case the patient didnot have any visible abnormality of the ovary nor anypre-existing diseaseses.N. Miksi} Gori{ek et al.: Salmonella Ovary Abscess in Young Girl, Coll. Antropol. 35 (2011) 1: 223–225224Fig. 1. Ultrasound imaging of pelvis showing hipoechogenic cysticformation 6456 mm in the right ovary with irregular echogenitiyinside and highly vascularized cysts wall.Fig. 2. Laparoscopic view of enlarged right ovary without torsion.The interesting point is the patient did not have anyhistory of gastrointestinal infection or bacteraemic epi-sode, also the stool samples, blood cultures and urine cul-tures were all negative for Salmonella.Most cases in theliterature have a history of Salmonella infection; how-ever there are also 5 reports in the literature with nega-tive history and negative stool samples4.It is well known that Salmonella can survive in a dor-mant state for a long period of time in protected locationssuch as gall-blader stones and kidney stones. Ovariancysts have been accused to be a similiar location. Thetime interval from acute salmonellosis to the clinical pre-sentation of an ovarian abscess can be from a few weeksup to 35 years8. This long interval can be explained by al-tered cell-immune response triggering proliferation ofdormant bacteria in ovary.In Salmonella focal infection in pelvic area are com-monly treated with the combination of surgery followedby 7–14 days of appropriate antibiotic treatment. We per-formed laparascopic surgery in adolescent girl which wasminimal invasive for the young patient. The antibiotic ofchoice for Salmonella infection, depending the suscepti-bility of isolated strain is ampicillin, ceftriaxon or cipro-floxacin. We continued the empirically prescribed cipro-floxacin for 14 days.Our case presents Salmonella spp. ovarian abscess asa cause of acute abdomen in young sexually non-activegirl without predisposing ovarian abnormalities. It em-phasizes the importance of microbiological diagnostics inovarian absceses, especially in sexually non-active popu-lation. To avoid later fertility problems it is of great im-portance to treat infections in pelvic region correctly andthat surgery is the least invasive.R E F E R E N C E S1. MILLER AS, HUNSTAD D, Pediatr Infect Dis J, 26 (2007) 548. —2. LATAWIEC-MAZURKIEWICZ I, JUSZKIEWICZ P, PACANOWSKI J,KWAS A, RYBKIEWICZ M, Eur J Pediatr Surg, 15 (2005) 38. — 3.VERMA A, MITTAL S, KUMAR S, Int J Gynaecol Obstet, 68 (2000) 263.— 4. BURGMANS JPJ, VAN ERP EJM, BRIMICOMBE RW, KAZZAZ BA,Eur J Ostet Gynecol Reprod Biol, 72 (1997) 2007. — 5. TOHYA T,YOSHIMURA T, ONODA C, Infect Dis Obstet Gynecol, 11 (2003) 217. —6. PEGUES D, OHL ME, MILLER SI, Salmonella species, including Sal-monella typhi. In: MANDELL GL, BENNET JE, DOLIN R (Eds)Mandell, Douglas, and Bennett’s Principles and Practice of Infectiousdiseases. 6th ed. (Philadelphia, USA, Elsevier Churchill Livingstone,2005). — 7. CHIN HY, CHIANG PC, CHEN KC, J Reprod Med, 49 (2004)762. — 8. EVANS-JONES JC, FRENCH GL, Br J Obstet Gynaecol, 90(1983) 680.S. Ore{kovi}University of Zagreb, Zagreb University Hospital Center, Department of Gynecology and Obstetrics, Petrova 13,10 000 Zagreb, Croatiae-mail: predstojnik_gin@kbc-zagreb.hrSALMONELLA OVARISJKI APSCES U MLADE DJEVOJKE SA SLIKOM AKUTNOG ABDOMENA:PRIKAZ SLU^AJAS A @ E T A KOvarijski apsces u spolno neaktivnih djevojaka mo`e predstavljati dijagnosti~ki izazov. Petnaestogodi{nja djevojkaprimljena je u Kliniku za ginekologiju i porodni{tvo pod sunjom torzije ciste jajnika. Njeno klini~ko stanje pogor{alo senakon prijama razvojem akutnog abdomena. U~injena je laparoskopska eksploracija te je na|en jednostrani ovarijskiapsces bez zahva}enosti drugih struktura zdjelice. Kirur{ki postupak za maldu djevojku je bio minimalno invazivan, aiz gnoja je izolirana Salmonella staleyville. Solitarni ovarijski apsces mo`e biti hematogenog podrijela i uzo~nici surazli~iti od patogena koji su obi~no uklju~eni u upalnu bolest zdjelice. Kako bi se izbjegli kasniji problemi plodnosti`ena, od velike je va`nosti ciljano lije~iti upale zdjeli~ne regije ovisno o izoliranom mikroorganizmu kao i primjenaminimalno invazivnog kirur{kog postupka.N. Miksi} Gori{ek et al.: Salmonella Ovary Abscess in Young Girl, Coll. Antropol. 35 (2011) 1: 223–225225

Salmonella Ovarian Abscess in Young Girl Presented as Acute Abdomen – Case Report

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