ACHAIKI IATRIKI | 2022; 41(2):98–101
Spyridon Topis, Aikaterini Marogianni, Georgios Saklampanakis, Konstantinos Toutounas, Dimitrios Koutsoulis, Charilaos Kasimis
Obstetrics and Gynecology Department of Panarkadiko General Hospital of Tripolis, Tripolis, Greece
Received: 09 Nov 2021; Accepted: 05 Mar 2022
Corresponding author: Dr. Spyridon Topis, Obstetrics and Gynecology Department of Panarkadiko General Hospital of Tripolis, Tripolis 22100, Greece, E-mail : email@example.com
Key words: Pyosalpinx, fallopian tube, hysterosalpingography, peritonitis
In this case report we will discuss the complication of pyosalpinx and peritonitis after a hysterosalpingography examination of a 38-year-old woman and the treatment used in our hospital. Pyosalpinx is an inflammatory reaction that affects the uterus, fallopian tubes and other intra-abdominal organs. The main bacterial species that are responsible are Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium and E. coli. Complications after hysterosalpingography examination are pelvic infection, loss of consciousness, spotting and iodine allergy and may occur in less than 1% of cases. We are reporting a rare case of pyosalpinx diagnosed at the district hospital of Tripolis and successful management.
Pyosalpinx is an inflammatory reaction that affects the uterus, fallopian tubes and other intra-abdominal organs. It can be acute or chronic and lead to female infertility . Approximately 1-2% of women aged 16-25 with high-risk sexual behavior have fallopian tube infection. Except for free sexual intercourse, there are other risk factors such as intrauterine device and invasive techniques (dilatation and curettage, hysterosalpigography and hysteroscopy). The main bacterial species that are responsible are Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium and E. coli [1,5]
Hysterosalpingography is a common invasive radiological examination which is used to view the interior of the cervix, uterus, and fallopian tubes. Radiolucent fluid is injected from the cervical os into the endometrial cavity in order to investigate the patency of the fallopian tubes [2, 3]. During the passage of the fluid, shots are taken through an X-ray monitor. The process is repeated 3-4 times in order to examine the full course of the liquid. Hysterosalpingography is performed on the 10th-11th day of the cycle, before ovulation and antibiotics are always given in advance [6, 9]. Although this technique is considered a safe procedure, complications such as pelvic infection, loss of consciousness, spotting and iodine allergy may occur in less than 1% of cases .
There are other techniques to evaluate tubal patency such as chromopertubation and sonohysterosalpigography . Chromopertubation is a laparoscopy assisted procedure where a dilute dye is injected transcevically in order to check tubal patency and surrounding pelvic anatomy. Sonohysterosalpingography is a similar technique but in this case tubal patency is examined via ultrasound.
A 38-year-old patient came to the emergency department of the Panarkadiko General Hospital of Tripolis with reported fever (up to 39.5 degrees Celsius) onset of 48h and abdominal pain which persisted with movement, nor did it relieve with analgesia. She reported no episodes of vomiting, dysuric disorders, sexually transmitted diseases or other gastrointestinal disorders. The medical history of the patient was free without health problems, surgeries or allergies. From her gynecological history, she mentioned menstrual cycle without irregularities, with last menstruation 12 days ago and had never been pregnant. She had undergone a hysterosalpingography exam 5 days ago for investigation of subfertility. During the clinical examination the patient’s abdomen was soft, easy to press with sensitivity in the abdomen, positive (+) intestinal sounds, positive (+) rebound tenderness, peer bilateral wheezing, negative (-) Giordano sign, and tenderness on the right gynecological examination. Her vital signs were: Blood Pressure 110 / 70mmHg, pulses 78 bpm, Sp02 98%, GCs 15/15, temperature 38.5oC. In the laboratory workup, elevated inflammatory markers were observed namely Leukocytosis 18.4 and CRP 14.98 (the rest laboratory values were within normal range), the pregnancy test was negative as well as the chest radiological examination. The findings of the intravaginal ultrasound were: a uterus with anterior flexion of 7.2cm x 5,5cm and a cystic mass near the right fallopian tube (6,5cm x 5,5cm x 4.8cm) (Figure 1, Figure 2) with low-medium fluidity fluid with no rupture points, next to the right ovary the colored Doppler showed peripheral vascularity. Therefore, a right ovarian cyst with findings of tubal infection had to be differentiated from tubo-ovarian abscess, ruptured ectopic, ruptured hemorrhagic cyst, ovarian torsion, pelvic inflammatory disease, appendicitis with absence .
Figure 1. Cystic formation 6,5cm x 5,5cm.
Figure 2. Cystic Formation 4,3cm x 4,7cm.
The patient was admitted to the Obstetrics / Gynecology Clinic of the Panarkadiko General Hospital of Tripolis where she was administered 3lt of fluids (D / W, N / S, R / L), gastroprotection, paracetamol and 2-fold antibiotic treatment (cephalosporin β΄ generation 750g x 3, metronidazole 500g x 3). Two days after admission, the patient’s clinical condition deteriorated, with clinical signs of peritonitis and ileus. On physical examination, she demonstrated increased abdominal wall rigidity, with sparse bowel sounds and vomiting, while laboratory test results were also indicative of an infection (Leukocytosis 13.7, CRP 24.4 and hypoalbuminemia 5.4). It was decided to proceed to an exploratory laparotomy on the same day. During the operation, free purulent fluid was found in the peritoneal cavity with dilated intestinal bowel, and so the cavity was washed. The right fallopian tube was ruptured and purulent fluid was found in the Douglas space (localized peritonitis). Various intestine-uterine and tubo-ovarian adhesions were found and adhesiolysis was performed. The right fallopian tube was then ligated, excised (right salpingectomy) and sent for histological examination (Figure 3).
Figure 3. Excised Right Fallopian tube.
The histological examination revealed
- Macroscopic findings: distended fallopian tube (cystic mass) 7cm length and 4cm diameter with wall thickness up to 0.5 cm.
- Microscopic findings: acute salpingitis, with no neoplastic or atypal cells.
The patient’s postoperative course ran with no complications, with a soft abdomen and positive bowel activity. Laboratory test results clearly improved including inflammatory markers (L 9.9 and CRP 11.57). The patient was discharged on the 3rd postoperative day in hemodynamically stable condition, without any discomfort and a 2-fold per os antibiotic regimen (doxycycline 100g x 2 and cephalosporin β΄ generation 750g x 2) was prescribed for 14 days at home.
As already mentioned, pyosalpinx is a condition that presents either with very specific symptoms (abdominal pain, fever and findings in gynecological examination) or with a silent clinical picture . About 50% of women present with the typical clinical picture of the disease, which is important for diagnosis. It is necessary to know the exact medical history of the patient as it will help us to rule out diseases during differential diagnosis. In this case, we do not know what caused the peritonitis, whether there was a pre-existing fallopian tube infection or rupture of an ovarian cyst during the hysterosalpingography or the pyosalpinx was created through this invasive procedure. The ultrasound exam is useful, because it provides information about internal genitalia and helps us reach a diagnosis. Thus, the finding of a cystic mass near the ovary should be evaluated appropriately in order to exclude other diseases such as endometriosis, hemorrhagic ovarian cyst, extrauterine pregnancy, etc. When there is a differential diagnostic problem, it would be recommended to perform other auxiliary radiological examinations such as MRI which shows all lower abdomen structures with greater clarity and reliability. Disease management varies depending on the severity of each case from intravenous antibiotic treatment to surgical resection of the diseased organ followed by histological examination as in the current case. Pelvic inflammation (defined as Pelvic Inflammatory Disease – PID) is caused, as already reported, by sexually transmitted diseases that spread from the vagina to the cervix and through the uterus to the adnexa. The main bacteria responsible for the disease are Chlamydia trachomatis and Neisseria gonorrhea. PID is a condition with high morbidity and mortality if left untreated.
In literature, there is a similar case report  from a non-tertiary hospital where a 29-year-old woman presented with pyosalpinx after hysterosalpigography for infertility evaluation. Although her medical history was complicated (HIV positive, PID with pelvic and peri-hepatic adhesions), management was approximately the same with our case. Salpingectomy was performed in both cases through different surgical approaches (laparoscopy vs laparotomy). The antibiotic treatment during hospital stay in the first case  was ofloxacin 400mg x 2 + metronidazole 500mg x 2, whereas in the second was cephalosporin β’ generation 750mg x 2 + metronidazole 500mg x 3. Despite the differences mentioned above, both patients were discharged 72h postoperative without complications.
In conclusion, it is challenging for every specialist in ob/gyn to make the diagnosis of acute abdomen due to tubal infection based on medical history and patient’s clinical picture. This way the appropriate treatment plan will be developed. It turns out that any invasive examination of the internal genitals should be done with great precision, abiding by all sterilization protocols, as this complication that we analyzed may be considered rare, but it may be life-threatening for patients. Every patient with PID has lower chances of natural conception and high risk of ectopic pregnancy. More specifically, our patient was advised to in vitro fertilization for getting pregnant due to the fact that an extra factor was added in her infertility investigation process which is a major surgery (salpingectomy and pelvic adhesions).
Conflict of interest disclosure
None to declare
Declaration of funding sources
None to declare
ST, AM: conception and design; ST, AM: analysis and interpretation of the data; ST, AM: drafting of the article; CK: critical revision of the article for important intellectual content; CK: final approval of the article. GS, KT, DK, CK: critical revision of the article for important intellectual content and final approval of the article.
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