tubo - ovarian abscess ( toa ) is a sequela of pelvic inflammatory 
 disease ( pid ) that is comprised of an infectious , inflammatory complex 
 encompassing the fallopian tube and ovary .
the proposed 
 pathophysologic mechanism for toa development includes ascending 
 infection as well as hematogenous and lymphatic routes . 

the infectious source is typically polymicrobial and several 
 reports have identified escherichia coli , 
 neisseria gonorrhea , and chlamydia trachomatis 
 and a variety of obligate anaerobic bacteria as commonly 
 associated microorganisms [ 1 , 2 ] .
cases of toa involving endometriomas have been reported in the 
 literature , and women with revised american society for 
 reproductive medicine ( asrm ) stages iii - iv endometriosis 
 have been found to have an increased occurrence of toa . 

e coli was more frequently cultured from aspirated 
 abscesses in women with concomitant endometriosis than if no 
 endometriosis was present . in addition , previous pelvic 
 surgery was found to increase the risk of toa .
we report 
 a case of a woman with stage iv endometriosis with a toa 
 involving an endometrioma , in the absence of cultured organisms , 
 who had evidence of bacterial vaginosis ( bv ) on normal saline wet 
 prep and culture .
a 41-year old nulligravida presented to the university of michigan 
 ( um ) reproductive endocrinology and infertility clinic for an 
 evaluation of a six year history of primary infertility .
her prior 
 fertility evaluation and treatment history was significant for 
 four previous cycles of ovulation augmentation with clomiphene 
 citrate in conjunction with timed intercourse and a normal 
 hysterosalpingogram several years earlier .
her initial workup at 
 um revealed normal ovarian reserve testing , normal values for tsh 
 and prolactin , and her husband 's semen analysis was normal . 

transvaginal ultrasonography showed persistent bilateral 
 3.5 cm ovarian cysts that had a ground - glass appearance 
 consistent with endometriomas .
the patient underwent 
 laparoscopic evaluation due to the large endometriomas at which 
 time she was diagnosed with stage iv endometriosis . due to dense 
 adhesive disease , the procedure was converted to an 
 exploratory laparotomy .
three right 
 ovarian endometriomas were removed , and the cyst wall of each was 
 excised with subsequent cauterization of the bases for hemostasis . 

the left ovarian endometrioma was approached ; however , it was not 
 removed due to severe adhesions and the patient 's desire for 
 fertility .
five weeks after surgery , the patient underwent a 
 hysterosalpingogram which showed a normal uterine cavity , right 
 tubal patency , and left hydrosalpinx without spillage of dye .
she 
 subsequently underwent two cycles of gonadotropins in conjunction 
 with intrauterine inseminations , but had suboptimal responses .
nine months after surgery , the patient presented to 
 the emergency room with fever and abdominal pain .
her abdominal and pelvic exams showed 
 moderate tenderness , small amount of vaginal discharge and 
 bacterial vaginosis as evidenced by clue cells on a normal saline 
 wet prep .
transvaginal ultrasound showed a 7 cm left adnexal mass with 
 uniform echogenicity ( figure 1 ) .
her wbc was 
 16.7 k. she was admitted to the hospital for intravenous 
 antibiotic administration but despite broad - spectrum coverage , 
 high - grade fevers continued . on hospital day 3 , after discussion 
 of risks , benefits , and alternatives that included conservative 
 management , she was consented for definitive surgical management 
 and underwent a modified radical hysterectomy with bilateral 
 salpingo - oophorectomy and lysis of adhesions .
although all cervical , blood , and urine cultures were negative 
 on hospital admission , the left ovary contained an ovarian abscess 
 with gram negative rods within the left - sided endometrioma . 

histology of 
 the left fallopian tube and ovary revealed an endometriotic cyst 
 with massive edema , hemorrhage , acute inflammation , and marked 
 eosinophilia ( figure 2 ) with an associated pyosalpinx 
 consistent with a toa .
the development of toa among women with endometriomas may be due 
 to an increased susceptibility to infection ,   particularly 
 in the altered immune environment seen with ectopic endometrial 
 glands and stroma ,   although there are no epidemiologic 
 data available to support this theory .
previous surgical 
 procedures involving the pelvic organs have been found to increase 
 the risk of toa formation in patients with endometriosis . 

interestingly , in this case report , the patient 's surgery took 
 place nine months prior to clinical presentation and the presence 
 of acute inflammatory cells in the endometrioma makes the 
 probability of a long incubation period or superinfection of a 
 chronic infectious process unlikely but not out of the realm of 
 possibility .
there is one case report of a 7 month period of time 
 from surgery to superinfected endometrioma .
similarly , in 
 terms of the timeframe of events , although an hsg performed in the 
 presence of an apparently dilated fallopian tube carries an 
 increased risk of pelvic inflammatory disease ,   this 
 patient 's procedure was performed eight months prior to the onset 
 of her acute symptomatology and histologic findings .
there was no 
 known change in partners since the patient 's initial office visit 
 until the time of presentation with symptoms of acute pelvic 
 infection .
although the association between bv and the increased risk of an 
 ascending pid is well established ,   in the present case , 
 the finding of bv in the absence of isolated organisms on 
 cervical , blood , and urine cultures raises the question as to 
 whether bv that has ascended to the upper genital tract is a 
 predisposition to abscess formation in an endometrioma .
more study 
 is necessary to investigate this matter and to elucidate whether 
 aggressive treatment of bv in patients with known advanced stage 
 endometriosis , akin to screening and treatment in patients who are 
 to undergo hysterectomy to prevent vaginal cuff abscesses , should 
 be considered to prevent super - infected endometriomas .
( a ) transvaginal ultrasound image , shortly 
 after initial evaluation , of persistent bilateral ovarian masses 
 adjacent to uterus ( ut ) . ( b ) ultrasound image of left 
 ovarian cystic structure after patient presented with symptoms of 
 acute pelvic inflammatory disease . endometrioma with associated edema , hemorrhage , 
 acute inflammation , and marked eosinophilia ( h & e , 40 ) .
 background . tubo - ovarian abscess involvement of an endometrioma has been reported in cases of 
     patients with polymicrobial sources such as neisseria gonorrhoeae , chlamydia trachomatis , 
     and obligate anaerobic bacteria ; however , bacterial vaginosis ( bv ) predisposing to abscess formation in 
     an endometrioma has not been reported to date . 
 case . 
 superinfection of an endometrioma was surgically diagnosed in a patient with known advanced - stage endometriosis after she presented with acute pelvic inflammatory disease symptoms and was unresponsive to antibiotic therapy .   
 gram - negative rods were cultured from the endometrioma .   on admission , cervical , blood , and 
 urine cultures were negative ; bv was diagnosed on normal 
     saline wet prep and gram stain . 
 conclusion . 
 this case raises the possibility of bv ascension to the upper genital tract predisposing to abscess formation in endometriomas .   
 therefore , aggressive treatment of bv in patients with known advanced - stage endometriosis may be considered to prevent superinfected endometriomas . 
INTRODUCTION
CASE
COMMENT
Figures and Tables