CASE REPORT

Tubo-Ovarian Abscess Caused by

Candida Albicans in an Obese Patient
Valerie To, MDCM, Joshua Gurberg, MDCM, Srinivasan Krishnamurthy, MD, FRCSEd, FRCOG
Department of Obstetrics and Gynaecology, McGill University Health Centre, Montreal QC

Abstract Conclusion : Puisque lobsit morbide pourrait confrer une

immunodficience relative, les patientes obses morbides
Background: Tubo-ovarian abscess (TOA) arises in most pourraient contracter des infections inhabituelles, telles que
cases from pelvic infection.. Appropriate treatment includes des abcs fongiques opportunistes..
use of antimicrobials and, especially in patients with
increased BMI, drainage of the contents..
J Obstet Gynaecol Can 2015;37(5):426429
Case: A 44-year-old morbidly obese woman (BMI 72) had a
persistent TOA despite receiving antibiotic treatment for four
months.. She had no history of diabetes, and denied being INTRODUCTION

A
sexually active.. Imaging demonstrated a pelvic abscess of 14..9
8..9 11..1 cm.. Successful percutaneous drainage was
performed yielding purulent material which grew Candida
pproximately 800000 women develop pelvic
albicans. The patient recovered after drainage of the abscess and inflammatory disease annually in the United
the addition of fluconazole to her antimicrobials. She had no States, corresponding to approximately an incidence of
apparent risk factor for acquiring such an opportunistic infection, 0.05%, which is similar to the Canadian incidence. 13 Tubo-
other than her morbid obesity.. ovarian abscess is reported to complicate 10% to 15% of
Conclusion: Because morbid obesity may confer a relative cases of PID, especially if the initial episode was
immunodeficiency, morbidly obese patients may develop inadequately treated.4 Appropriate management is crucial,
unusual infections such as opportunistic fungal abscesses.. because there are potentially severe short-term consequences
(such as abscess rupture and ensuing peritonitis and sepsis)
Rsum and long term consequences (such as infertility, ectopic
pregnancy, and chronic abdominal/pelvic pain). Risk factors
Contexte : Les abcs ovario-tubaires (AOT) sont, dans la plupart for TOA development include having had a previous episode
des cas, attribuables une infection pelvienne.. Parmi les of PID, having multiple sexual partners, having an
moyens de prise en charge adquats, on trouve le recours des intrauterine device, and immunosuppression.4 PID is thought
agents antimicrobiens et, particulirement chez les patientes qui to arise from vaginal or cervical pathogens ascending into the
prsentent un IMC accru, le drainage des abcs en question.. sterile endometrial cavity, fallopian tubes, and peritoneal
Cas : Une femme obse morbide de 44 ans (IMC 72) prsentait un AOT cavity.5 A TOA can also result from other causes, such as
persistant malgr ladministration dune antibiothrapie pendant diverticulitis, appendicitis, inflammatory
quatre mois.. Elle ne prsentait pas dantcdents de diabte et bowel disease, and gynaecologic or obstetric surgery.4
affirmait ne pas tre sexuellement active. Limagerie a rvl la The infection is usually polymicrobial; microorganisms
prsence dun abcs pelvien de 14,9 cm sur 8,9 cm sur 11,1 cm.. involved can include
Un drainage percutan a t men avec succs; la prsence de
N. gonorrhoea, C. trachomatis, Bacteroides
Candida albicans a t identifie dans le matriel purulent drain.
La patiente a rcupr la suite du drainage de labcs et de lajout species, Peptococcus, Peptostreptococcus, and E.
de fluconazole ses agents antimicrobiens. coli. 6 Nearly all causative pathogens are bacteria, and can
part son obsit morbide, elle ne prsentait aucun facteur de include rare microorganisms such as
risque apparent de contracter une telle infection opportuniste..
Edwardsiella tarda and Pasteurella Multocida.7,8
TOA caused by a fungus has been described in only three
Key Words: Female, pelvic infection, opportunistic case reports to date; in all three cases the causative organism
infection, Candida albicans, drainage, obesity, morbid was Candida glabrata, and the patients either had an
Competing Interests: None declared.. IUD or were immunocomprised.9-11 We report here a case of
Received on June 3, 2014 TOA caused by Candida albicans, in a non-diabetic 44-
Accepted on August 5, 2014 year-old woman with no apparent risk factors except morbid
obesity.

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 Tubo-Ovarian Abscess Caused by Candida Albicans in an Obese Patient

THE CASE CT scan showing large gas-containing fluid collection

extending into the uterus and anterior abdominal wall
A 44-year-old woman, gravida 1 para 1, presented to her
community hospital with bilateral lower abdominal pain,
fever, and chills. Her past gynaecological history was
characterized by regular heavy menstrual flow and
dysmenorrhea, normal Papanicolaou smears, no history of
sexually transmitted infections, and no notable intrauterine
device use. Her past medical history included venous
thromboembolic events (a deep vein thrombosis and a
pulmonary embolism), urolithiasis, recurrent urinary tract
infections, chronic obstructive pulmonary disease, gout,
asthma, and morbid obesity (BMI 72). She was not diabetic.
Her surgical history included cholecystectomy, a Caesarean
section at term, and surgery for renal calculi. Her current
medications were warfarin, allopurinol, ferrous sulfate, and
fluticasone and salbutamol inhalers.
After the patient was found on CT scan to have a tubo-ovarian was 37.4C. Her hemoglobin concentration was 88 g/L,
abscess measuring 12712cm, she began intravenous and white blood cell concentration was 12.2giga/L. A CT
antibiotic treatment with clindamycin, gentamicin, and scan of her abdomen and pelvis revealed a 15 9 11cm
ampicillin. Two weeks later, she was transferred to a tertiary care
gas-containing fluid collection extending into the
hospital because her condition was not improving. A repeat CT
uterus and anterior abdominal wall, consistent with an
scan showed a 161314cm multiloculated pelvic abscess.
abscess, as shown in the Figure.
Her white blood cell concentration was 17giga/L. She received
intravenous Tazocin and oral doxycycline. After a few days of Treatment was switched to intravenous Tazocin (4.5 g at
defervescence, and after consultation with an infectious disease 8-hour intervals). She subsequently developed
specialist, this treatment was switched to oral metronidazole C.difficile colitis and was given oral vancomycin.
(500mg 3 times daily) and oral levofloxacin (750mg daily). Concurrently, she developed a cutaneous fistula in her
Her blood and urine cultures were negative, as well as a lower abdomen, confirmed by CT scan, and this
gonorrhea and Chlamydia PCR. An interventional radiologist drained purulent fluid which was not cultured. Despite
attempted percutaneous drainage of the abscess, but was this treatment, the patient continued to have fever,
unsuccessful. One week later, the abscess size had decreased to persistent left lower quadrant rebound tenderness, and
859cm on repeat CT. The patient felt better, and her level leukocytosis. Urine and blood cultures showed no growth
of pain had decreased significantly. She was discharged of pathogens throughout each of her hospitalizations. A
from hospital two weeks after admission (four weeks since her vaginal culture, however, was positive for Candida
first presentation) to take oral antibiotics for three weeks. albicans, but because the patient had no vaginal
symptoms, no antifungal treatment was given. Three days
At three weeks after discharge from hospital, the patient
after readmission to hospital, an interventional radiologist
presented back to her community hospital with
was able to perform ultrasound-guided drainage of the
recurrent lower abdominal pain, increasing over four
abscess despite the patients body habitus, and inserted a
days, with accompanying fever (up to 40C) and chills.
pig-tail catheter for continuous drainage:
She began treatment with meropenem and was
200mL of purulent, blood tinged fluid were
transferred again to our tertiary care hospital.
drained. She had been on antibiotics at that point for
On initial assessment, she had rebound tenderness in the approximately three months.
left lower quadrant of the abdomen, and her temperature
Microscopy of the abscess fluid showed numerous hyphae,
and culture resulted in growth of Candida albicans
and
ABBREVIATIONS mixed enteric organisms. Treatment with oral fluconazole
PID pelvic inflammatory disease (400mg daily) was added, and the patient showed rapid
TOA tubo-ovarian abscess clinical improvement. A repeat ultrasound examination nine
days after abscess drainage showed interval resolution. The
patients level of pain improved, her white blood cell count
normalized, and she remained continuously afebrile.
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Case Report

The patient was transferred to her community hospital The patient in our case did not wish to preserve her
two weeks after admission on intravenous Tazocin, oral fertility, but to assist in counselling women who do,
fluconazole, and oral vancomycin. She several case series have reported on pregnancy outcomes
continued to receive Tazocin and after the different modalities used in treatment of an
fluconazole for a total of four weeks, until a repeat unruptured TOA. In a review by Rosen et al., only 4% to
CT scan showed complete resolution of the abscess. 15% of women treated with antibiotics alone subsequently
She then stopped her antibiotic therapy and was finally became pregnant, a rate similar to those who required a
able to return home. laparotomy and antibiotics, but pregnancy rates reached
62% to 53% following laparoscopic drainage and
DISCUSSION antibiotic therapy.17 These authors advocated for
emergency laparoscopy and medical management in all
In patients hospitalized with severe PID or who have PID women presenting with a TOA who wish to conceive in
that is not responding to antibiotic therapy, tubo-ovarian the future. It is hypothesized that this management
abscess should be ruled out by means of imaging by decreases the exposure of the adnexa to purulent material,
ultrasonography or computed tomography. Once the thereby minimizing scarring and fibrosis.17 A
diagnosis of TOA is made, management options include retrospective study reported pregnancy rates of
treatment with intravenous antibiotics alone, antibiotic approximately 50% after transvaginal ultrasound-guided
therapy with imaging-assisted drainage of the abscess, or drainage of TOA.18
antibiotic therapy combined with surgery. Antibiotic We had hoped initially that a prolonged course of antibiotics
regimens include a broad spectrum beta-lactamase agent alone would be sufficient treatment for our
(usually a third-generation cephalosporin) with oral patient, because her high BMI and comorbidities made her
doxycycline, or clindamycin plus gentamycin. These a very poor candidate for surgery; percutaneous drainage of
regimens have been shown to have the abscess was deemed to be almost impossible because of
comparable efficacy and response rates the thickness of her abdominal wall. However, weeks of
(defined as decreased pain, decreased white antibiotic therapy did not result in resolution, and she
cell concentration, and loss of fever) of 63% to 75%. 6,12 improved only with the combination of ultrasound-guided
However, a study by McNeeley et al. found that a triple drainage (to decompress the abscess and allow
therapy regimen (using ampicillin, clindamycin, and identification of the causative organism) and appropriate
gentamycin) was significantly more effective antimicrobial treatment (with the addition of antifungals to
her therapy). Curiously, yeast is an opportunistic
(87.5% response) than cefotetan plus doxycycline (34%
microorganism and is not known to cause severe infection
response) or clindamycin plus gentamicin (47%
and form abscesses unless the patient is
response).13 Treatment failure may well be related to the 9,19
immunocompromised or has an IUD, as in two other case
size of the abscess, as shown in a study by Reed et al., in
reports.10,11 It is possible that the prolonged antibiotic
which 60% of women with an abscess diameter of 10 cm
therapy before transfer to our hospital could have suppressed
or more required surgical intervention compared with 30%
the detection of bacteria in culture media.
of those measuring 7 to 9cm and 15% of those measuring
4 to 6cm.12 The patient did not have any of the known risks for
immune suppression; she was not diabetic and was
Patients with a TOA who fail to respond to antibiotic
presumed to be HIV-negative because she had not been
treatment alone within 48 to 72 hours should be
sexually active for many years (she declined testing at that
considered for abscess drainage or surgery.14 Many
time). Other conditions known to be associated with
patients treated successfully with antibiotics may still immune suppression include use of immunosuppressive
require surgery for recurrence in the long term. 6 drugs, renal or hepatic insufficiency, certain
Alternatively, if the patient is not responding to antibiotic autoimmune diseases, malignancy and asplenia.20 It
therapy or if the abscess is large, imaging-guided drainage is possible however that her morbid obesity
can be considered and has been shown in several studies to contributed to a relative immunodeficiency
be well-tolerated and efficacious.15,16 It can be guided state, resulting in an opportunistic fungal infection
by CT scanning or by ultrasound, via the transabdominal, ascending from the vagina. Obesity is a state of low-grade
transvaginal, transrectal, and transgluteal routes. Surgical chronic inflammation, with altered circulating
treatment is reserved for ruptured, severe, or refractory levels of nutrients and hormones.21
cases of TOA, and includes laparoscopy or possibly
Epidemiological data have shown that obese individuals
laparotomy for drainage of an abscess, adhesiolysis,
are more prone than individuals of normal weight to
salpingo-oophorectomy, and/or hysterectomy.4
infections, including postoperative and nosocomial
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 Tubo-Ovarian Abscess Caused by Candida Albicans in an Obese Patient

5.Lareau SM, Beigi RH. Pelvic inflammatory

disease and tubo-ovarian abscess. Infect Dis Clin
North Am 2008;22(4):693708, vii.
infections.22 Physiologically, this can be
6.Landers DV, Sweet RL. Tubo-ovarian abscess:
correlated with an altered immune response contemporary approach to management. Rev Infect
to infection, such as impaired lymphocyte Dis 1983;5(5):87684.
proliferation.23 However, more studies are
required to better understand why obese
people are more prone to infections and if and
how they respond differently to treatment
(e.g., requiring higher doses of antibiotics).

CONCLUSION

An unruptured tubo-ovarian abscess should

be drained, especially if it is large or not
responding well to antibiotic therapy, or if
future fertility is a concern. Drainage can
be performed either percutaneously with
imaging guidance or by surgery. Both
approaches can be challenging in an obese
patient. Draining the abscess allows
antibiotics to better penetrate it and allows
antibiotic therapy to be tailored
appropriately to the organisms cultured.
Causative agents may include yeast,
necessitating the use of antifungal agents.
Obese individuals may have impaired
immunity compared with lean individuals,
and they may have a different response to
antibiotic therapy.

ACKNOWLEDGEMENTS

The woman whose story is told in this case

report has provided written consent for its
publication.

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