A Case-Report on Diverticulitis Misdiagnosed As Tubo-Ovarian Abscess

Background - A tubo-ovarian abscess is a complex infectious mass of the adnexa manifested with multiple clinical conditions such as fever, elevated WBC count, lower abdominal-pelvic pain, vaginal discharge and gastrointestinal findings. It can be a complication of PID, which is an inflammatory mass involving the fallopian tube, ovary, and, occasionally, other adjacent pelvic organs. On the other hand, Diverticulosis occurs when small, bulging pouches (diverticula) develop in digestive tract. The inflammation (swelling) and infection in one or more diverticula leads to Diverticulitis. Its symptoms include abdominal pain, fever, nausea and a change in bowel habits.

Herein, a case report is presented where a complicated diverticulitis was misdiagnosed as TOA, owing to overlapping genital involvement. The patient underwent surgery due to lack of response to pharmacological treatment and intra operative finding showed complicated diverticulitis.

Case presentation – A 45 year old woman complained of chronic abdominal pain in the LLQ (left lower quadrant) along with dyspareunia, fever and chills. The patient had no gastrointestinal and urinary symptoms and had normal menstruation without any history of vaginal discharge and dysmenorrhea. 

The ultrasound findings showed a heterogeneous cyst mass of adnexal origin along with adjacent inflammatory changes and loculated fluid adjacent to the iliac fossa, indicative of peduncle degenerative myoma. MRI also showed the evidence of tubo-ovarian abscess. Antibiotics were administered and the follow-up showed positive results. Later, follow-up ultrasound was performed that bared a large lesion. Due to recurrence, patient underwent laparotomy where multiple adhesions were seen. Pathology revealed multiple sigmoid diverticula and fistulized ovaries along with acute inflammation and the presence of multinuclear giant cells.

Conclusion - This study revealed a case of acute diverticulitis showing symptoms and adnexal mass with the involvement of gynecological organs. In this case, diverticulitis was the most common causes of gastrointestinal manifestations. This complication revealed symptom similar to those of genital tract. Furthermore, due to the lack of inflammatory sign and proximity to genital organ, it was misdiagnosed as genital diseases/anomalies. 

Source: Seyyedeh Neda Kazemi, Masoomeh Raoufi, Majid Samsami, Hamidreza Didar, Hanieh Najafiarab; A case-report on diverticulitis misdiagnosed as tubo-ovarian abscess; Annals of Medicine and Surgery, Volume 72; Elsevier; 2021.