Fallopian tube abscesses in asexual adolescent virgins are very rare and can present clinically with fever, chills, nausea, vomiting, lower abdominal pain, abnormal vaginal bleeding, vaginal discharge, and in severe cases can lead to diffuse peritonitis, sepsis, and infectious shock. It can also lead to distant complications such as pelvic adhesions, chronic pelvic pain, infertility and ectopic pregnancy, which can affect the quality of life in the long term. Therefore, once the above symptoms appear, early and rapid diagnosis and treatment is the key to reduce lifelong complications.
Previous studies have shown that abscesses larger than 6.5 cm and fever are independent predictors of the need for surgical treatment in patients with fallopian tube abscesses [1]. In this patient, on admission, ultrasound was performed: A 9.7×3.8 cm cystic anechoic area was seen on the posterior left side of the uterus. The repeated gynecologic ultrasound was performed: The tortuous tubular anechoic area, about 7.2×4.8cm in extent was seen in the posterior left side of the uterus. The anal examination: a cystic mass could be palpated in the posterior part of the uterus, the size was 9×8cm, the pressure pain was positive.The pelvic abscesses were not excluded and all were suggestive of greater than 6.5 cm. Other studies have shown the reliability of ESR in predicting infection in the diagnosis of fallopian tube abscesses [2]. The recommended threshold value of ESR is 61.0 mm/h [3].CRP level is the most reliable parameter for the diagnosis of pelvic infections and it represents the best criterion to assess the effectiveness of treatment for patients with pelvic infections [4]. A cutoff level of 0.330 ng/ml for PCT revealed 62% sensitivity and 75% specificity in predicting tubo-ovarian abscesses [5]。In our study, the patient was admitted with high WBC count and neutrophil percentage,CRP 124.48 mg/L, PCT 4.88ng/ml,ESR 60 mm/h, all these infection indicators suggest serious pelvic infection. In conclusion, the patient was admitted with a temperature of 39.2°C and an acute abdomen, with infection indicators suggesting severe infection, and combined with ultrasound suggesting a possible pelvic abscess larger than 6.5 cm, with indications for surgery, and laparoscopic surgery was quickly selected along with antibiotic treatment, and intraoperatively the left fallopian tube abscess was seen, and the left fallopian tube was removed, the pelvic pus was removed, and the pelvic cavity was flushed. After the operation, the patient's temperature dropped rapidly to normal. The rapid diagnosis and surgical treatment were timely and effective.
Some studies have shown that the genital tract of the prepubescent child is different from that of a woman of reproductive age. Unlike the normal acidic pH of the adult female vagina, the pH of the premenarchal vagina is neutral.[6]This creates an environment that may facilitate overgrowth of the normal vaginal flora (E.coli,Gardnerella vaginalis,Staphylococci,Streptococci,and so on). In addition, it lacks the vaginal antibodies that may appear later in life[6].These two factors may increase the susceptibility for vaginal infection in children. In this review of the literature, the most common causative organism of fallopian tube abscesses in adolescent virgins was E.coli, followed by S.pneumoniae, and occasionally Morganella morganii,Streptococcus group F,Fusobacterium nucleatum, Streptococcus anginosus, Peptostreptococcus anaerobius, Prevotella bivia.(Table 1)[7–8].The causative agent of tubal abscess in this case was E. coli. Traditionally, broad-spectrum intravenous antibiotic infusion is the preferred treatment for pelvic abscess.In this case, broad-spectrum antibiotic cefoperazone sodium and metronidazole for anaerobic bacteria were chosen and the antibiotics were effective for their treatment. The blood picture, CRP and PCT decreased to normal.
Fallopian tube abscesses in adolescent virgins are easily misdiagnosed because of the lack of many factors of ascending infection, although they exhibit clinical symptoms. In this study, literature review (up to 2022) of fallopian tube abscesses in adolescent virgins included 14 cases (Table 1) [7–8 ]. This suggests that fallopian tube abscesses rarely occur in adolescent virgins. The cause of fallopian tube abscesses in this study is unknown. Common high risk factors in the literature review are: urinary tract infection ascending infection, congenital genitourinary anomalies, crohn's disease,tonsillectomy,adjacent organs such as appendectomy、colectomy, constipation, encopresis, irritable bowel syndrome,obesity, diabetes mellitus, and so on.
In conclusion, this is the second case of fallopian tube abscess in adolescent virgins caused by E. coli in which no causative high-risk factors could be found.It is important to consider pelvic abscess in the differential diagnosis of adolescent virgins with clinical symptoms of acute abdomen.Although there are no high-risk factors.E. coli may be the causative agent, and early and timely diagnosis and treatment are essential to prevent future sequelae.
Table 1
Review of the pelvic abscess cases reported to date in virginal adolescent girls. (Revised from Maraqa et al. [ 7 ])
No.
|
Authors
|
Year of case publication
|
Age (years)
|
Symptoms
|
Postoperative diagnosis
|
Possible causal factors
|
Species
|
1
|
Sirotnak et al. [7]
|
1996
|
12
|
Right lower abdominal pain, emesis
|
FTA
|
None
|
S. pneumoniae
|
2
|
Sirotnak et al . [7]
|
1996
|
12
|
Bilateral lower abdominal pain, difficulty breathing, menstruation
|
FTA
|
None
|
S. pneumoniae
|
3
|
Pomeranz et al . [8]
|
1997
|
15
|
Abdominal pain
|
FTA
|
Relapsing Henoch-Schönlein purpura
|
Morganella morganii
|
4
|
Algren and Strickland [7]
|
2005
|
14
|
Lower abdominal pain, fever, dysuria, night sweats, nausea, vomiting, diarrhoea
|
FTA
|
None
|
Streptococcus group F, Fusobacterium nucleatum
|
5
|
Lerand and Jay [7]
|
2007
|
12
|
General abdominal pain, fever
|
FTA
|
Obesity, type II diabetes, UTIs, constipation
|
E. coli
|
6
|
Lerand and Jay [7]
|
2007
|
16
|
Right lower abdominal pain,suprapubic pain, fever, chills, anorexia
|
FTA
|
Candida vaginitis, Crohn's disease
|
E. coli
|
7
|
van der Putten et al. [7]
|
2008
|
11
|
Abdominal pain, nausea, fever
|
FTA
|
None
|
S. pneumoniae
|
8
|
Singh-Ranger et al. [7]
|
2008
|
17
|
Lower abdominal pain, back pain, appetite loss, rigours
|
FTA
|
Appendectomy
|
E. coli
|
9
|
Hornemann et al. [7]
|
2009
|
13
|
Right lower abdominal pain, fever
|
FTA
|
None
|
E. coli
|
10
|
Desai and Ward [7]
|
2011
|
12
|
Bilateral and suprapubic abdominal pain, fever, emesis, vaginal discharge
|
FTA
|
Hirschsprung's disease (colectomy), appendectomy, tonsillectomy
|
None
|
11
|
Moralioğlu et al. [7]
|
2013
|
14
|
Abdominal pain, vomiting, fever
|
FTA
|
Anal atresia with rectovestibular fistula, sigmoidectomy, uterus bicornis unicollis, septate vagina
|
E. coli
|
12
|
Kielly and Jamieson [7]
|
2014
|
11
|
Right lower abdominal pain radiating throughout abdomen, nausea, emesis
|
FTA
|
Constipation, encopresis
|
Unknown
|
13
|
Schmieg et al. [7]
|
2014
|
12
|
Lower abdominal pain, nausea, vomiting.
|
FTA
|
Appendectomy
|
E. coli
|
14
|
Maraqa et al. [7]
|
2017
|
12
|
Lower abdominal pain, fever, nausea
|
FTA
|
Obesity, UTIs, IBS, dilated vagina (Mullerian duct anomaly)
|
Streptococcus anginosus, Peptostreptococcus anaerobius, Prevotella bivia
|
15
|
Hexifeng et al.
|
2022
|
12
|
Lower abdominal pain, nausea, emesis, fever
|
FTA
|
None
|
E. coli
|
UTI urinary tract infection, FTA fallopian tube abscess, IBS irritable bowel syndrome