A 40-year-old woman comes to the emergency department due to abdominal pain for the past 2 weeks. The pain has become worse over the past day and is not relieved by ibuprofen. The patient has a fever but no nausea, vomiting, diarrhea, or dysuria. She has no chronic medical conditions or previous surgeries. Her last menstrual period was 2 weeks ago; menses are regular and last 5 days, with painful cramping and heavy bleeding on the first day. The patient is sexually active with a male partner and uses condoms for contraception. She does not use tobacco, alcohol, or illicit drugs. Temperature is 38.8 C (101.8 F), blood pressure is 100/60 mm Hg, and pulse is 92/min. The abdomen has diffuse tenderness to deep palpation that is worse in the right lower quadrant. There is no rebound or guarding. Pelvic examination reveals a small, mobile, tender uterus and an enlarged, tender right adnexal mass. Leukocyte count is 22,000/mm³. Urine pregnancy test is negative. Pelvic ultrasonography reveals a large, thick-walled, multiloculated mass filled with debris obliterating the right adnexa. Which of the following is the most likely diagnosis in this patient?

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11ec25c8_d9dc_19f6_bc81_3b8c0f8c3825_MD0003_00 This patient with fever, abdominal pain, and a multiloculated, complex adnexal mass most likely has a tuboovarian abscess (TOA). TOA typically occurs in sexually active, reproductive-age women as a complication of pelvic inflammatory disease, a polymicrobial infection of the upper genital tract (ie, uterus, fallopian tubes). Patients with TOA can initially have diffuse lower abdominal pain plus uterine tenderness that gradually (over days to weeks) worsens and localizes to one side, causing unilateral adnexal tenderness with an associated mass. Because of the worsening infection, patients often develop high fever and leukocytosis. When the infection extends to the fallopian tube, it creates an inflammatory exudate, purulent fluid, and tubal wall thickening, which conglomerate into a complex adnexal mass, or pyosalpinx (ie, infected fallopian tube), visible on pelvic ultrasound. Treatment is with intravenous broad-spectrum antibiotics. (Choice A) An appendiceal abscess can cause fever, pain, and a mass in the right lower quadrant. However, patients typically have periumbilical pain that migrates to the right lower quadrant with associated nausea, vomiting, and anorexia. (Choice B) Endometriosis can present with abdominal pain and an adnexal mass (eg, endometrioma) that is typically described as having a ground-glass appearance on ultrasound. However, high fever, uterine tenderness, and leukocytosis are not typically present. (Choice C) A mature cystic teratoma may present with abdominal pain (due to mass effect or acute torsion) but does not cause fever and leukocytosis. Ultrasound typically reveals an ovarian cyst with solid components, hyperechoic nodules, and calcifications. (Choice D) Ovarian serous cystadenocarcinomas are the most common type of ovarian cancer. They can cause abdominal pain and inflammation (eg, fever, leukocytosis) due to ovarian necrosis; however, patients do not typically have both uterine and adnexal tenderness. (Choice E) Although ovarian torsion can cause abdominal pain and fever due to ovarian necrosis, the initial onset of pain is typically sudden and unilateral rather than diffuse. Ultrasound typically shows an adnexal mass with absent Doppler flow. Educational objective: A tuboovarian abscess is a complication of pelvic inflammatory disease, a polymicrobial infection of the upper genital tract. Patients typically have fever, diffuse abdominal pain that gradually worsens on one side, and both uterine and adnexal tenderness. Ultrasound typically shows a complex multiloculated adnexal mass with thick walls and internal debris. References: Pelvic inflammatory disease: diagnosis, management, and prevention. (http://www.ncbi.nlm.nih.gov/pubmed/31524362) Ultrasonography of adnexal causes of acute pelvic pain in pre-menopausal non-pregnant women. (http://www.ncbi.nlm.nih.gov/pubmed/26062637)

A 40-Year-Old Woman Comes to the Emergency Department Due to Abdominal