|Year : 2022 | Volume
| Issue : 1 | Page : 32-35
Acute salpingitis presenting with acute abdomen in a pre-pubertal girl
Thirunavukkarasu Arun Babu1, Padmapriya Balakrishnan2, Vijayan Arun Sharmila3
1 Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Mangalagiri, Andhra Pradesh, India
2 Indira Gandhi Medical College and Research Institute, Puducherry, India
3 Department of Obstetrics and Gynecology, All India Institute of Medical Sciences (AIIMS), Mangalagiri, Andhra Pradesh, India
|Date of Submission||26-Sep-2021|
|Date of Decision||31-Oct-2021|
|Date of Acceptance||22-Jan-2022|
|Date of Web Publication||25-Feb-2022|
Dr. Thirunavukkarasu Arun Babu
Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Mangalagiri, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Background: An acute abdomen in children is often a challenging scenario for clinicians as it is caused by various medical and surgical conditions. Although symptomatology and specific clinical findings point directly to few causes, thorough history and in-depth clinical examination help to systematically narrow down the differential diagnosis. Clinical Description: We report a rare case of acute salpingitis in an 8-year-old prepubertal female child presenting with acute abdominal pain and fever for 3 days. Examination revealed diffuse abdominal tenderness with guarding and rigidity along with an ill-defined, tender mass in the right iliac fossa. Management: Abdominal ultrasound showed a hyperechoic mass in the right iliac fossa and the appendix was not visualized. The child was kept nil oral and started on broad-spectrum antibiotics. However, the child developed abdominal distension and worsening of pain over the next 24 h. The child was taken up for emergency laparotomy, and a complex mass in the right iliac fossa adherent to small bowel and covered by omentum was noted. Histopathological examination of the excised right iliac fossa mass showed acutely inflamed right fallopian tube. Normal appendix was noted in the postoperative ultrasonogram. Conclusion: It is important to differentiate surgical causes from nonsurgical ones to avoid unnecessary surgery and its complications. Salpingitis may mimic acute appendicitis because of nonspecific symptomatology and radiological signs and should be considered as a differential diagnosis for acute abdomen, even in a prepubertal female child.
Keywords: Acute abdomen, appendicitis, salpingitis
|How to cite this article:|
Babu TA, Balakrishnan P, Sharmila VA. Acute salpingitis presenting with acute abdomen in a pre-pubertal girl. Indian Pediatr Case Rep 2022;2:32-5
|How to cite this URL:|
Babu TA, Balakrishnan P, Sharmila VA. Acute salpingitis presenting with acute abdomen in a pre-pubertal girl. Indian Pediatr Case Rep [serial online] 2022 [cited 2022 May 27];2:32-5. Available from: http://www.ipcares.org/text.asp?2022/2/1/32/338485
Acute abdomen is a common clinical syndrome in children which can be caused by a wide spectrum of medical and surgical conditions. The exact presentation varies with etiology, severity, age, and associated symptoms. Meticulous history-taking and focused physical examinations are vital for planning rationale investigations and establishing an early diagnosis. Common medical causes of acute abdomen in a child include gastroenteritis, mesenteric lymphadenitis, worm infestation, urinary tract infection, and colitis. The common surgical causes include acute appendicitis, ischemic colitis, perforation of the bowel, intussusception, volvulus, malrotation, blunt injury abdomen, and Meckel's diverticulitis. Gynecological conditions which present as acute abdomen such as a tubo-ovarian abscess, ovarian mass with torsion, rupture, and hemorrhage should be considered as differential diagnoses when investigating causes of surgical abdomen in a girl.
Acute salpingitis presenting as an acute abdomen is common in sexually active young women and is usually due to Neisseria gonorrhoeae or polymicrobial infection. In a prepubertal child, acute salpingitis is extremely rare. It may be caused by bacteremia due to Streptococcus pneumoniae following acute pharyngitis, acute otitis media, and/or acute pyogenic meningitis.
We report an uncommon presentation of an otherwise common condition by virtue of age-acute salpingitis in a prepubertal girl presenting as an acute surgical abdomen. It proved to be a diagnostic challenge and taught us some invaluable lessons retrospectively that we wish to share with our colleagues.
| Clinical Description|| |
An 8-year-old girl was brought to the emergency department with complaints of severe diffuse abdominal pain for 3 days and high-grade fever for 2 days. The abdominal pain was diffuse in the lower abdomen and progressively increasing in severity. She also had two episodes of bilious vomiting. There was no history of preceding abdominal trauma, altered bowel habits in the form of constipation, obstipation, or loose stools, abdominal distension, or vomiting of blood. The fever was initially low grade, which became high grade within a day and was associated with chills and rigors. There was no history of any rash, ear discharge, throat pain, headache, difficulty or painful micturition, passage of red-colored or cloudy urine, or vaginal discharge. There was no history of eating food outside the home or any other family member being similarly affected. There was no history of similar complaints in the past. The child had never been hospitalized for any serious bacterial infections or undergone any operative procedure in the past. She had not attained menarche. There was no significant family history or contact with tuberculosis.
On clinical examination, the child was sick looking, febrile with a temperature of 40°C, tachycardic, had a respiratory rate of 26/min and blood pressure of 90/70 mmHg (between 5th and 50th centile for age and sex). The child's anthropometric measurements were within normal limits. The general physical examination did not reveal any pallor, icterus, palpable purpura, or edema. The abdominal examination revealed diffuse abdominal tenderness with guarding and rigidity. An ill-defined, soft, tender mass could be palpated in the right iliac fossa, which was approximately 3 cm × 3 cm in size. The cardiovascular, respiratory, and central nervous system examinations were unremarkable. In view of the examination findings present in the right iliac fossa, the differential diagnoses that were considered were acute appendicitis, appendiceal phlegmon, typhlitis, infectious colitis, and ileocecal tuberculosis. Investigations were planned accordingly.
| Management and Outcome|| |
The child was managed with intravenous fluids and broad-spectrum empirical antibiotics. Ryle's tube aspiration was started for gastric decompression. Significant results in her complete blood count were: hemoglobin 10 g/dL, total leukocyte count 21,000 cells/mm3 with neutrophilia (80%), and a platelet count of 3 lakhs/mm3. The erythrocyte sedimentation rate was 11 mm/h and C-reactive protein was 1.9 mg/L, both being normal. The X-ray of the abdomen (erect) showed gas-filled normal bowel loops with no evidence of pneumoperitoneum. Salient ultrasonographic examination findings were a hyperechoic mass in the right iliac fossa with nonlocalization of the appendix. Uterus and bilateral ovaries were normal, thus ruling out a ruptured or torsion of an ovarian cyst.
It was decided to manage the child conservatively. The fever did not subside with antibiotics, and the vomiting and abdominal pain rapidly worsened over the next 48 h of hospitalization. The child also developed mild abdominal distension. Although the vital signs, urine output, and cardiorespiratory status were stable, we decided that rather than arranging for a computed tomography (CT, which would have taken some time, as it is not available in our institute), it would be more prudent to perform an emergency exploratory laparotomy, especially since there was rapid clinical worsening and a strong clinical suspicion of a ruptured appendicular mass.
Intraoperatively, a matted mass with distorted anatomy was noted in the right iliac fossa that was adherent to the small bowel and covered by omentum. The appendix and the right fallopian tube were obscured, with the anatomy completely distorted due to the presence of adhesions. The uterus, bilateral ovaries, and left fallopian tube were grossly normal on inspection. Gross examination showed a mass (3 cm × 3 cm × 2 cm) composed of omentum (approximately 3 cm × 2 cm × 0.5 cm) and a 2-cm long congested tubal structure that appeared to be the fallopian tube. It was open on both sides, and the lumen was filled with dark-brown material. The mass was excised after releasing surrounding bowel adhesions, fixed in 10% neutral-buffered formalin, and sent for histopathological examination. This revealed features of acute salpingitis and inflamed omentum [Figure 1] and [Figure 2]. The tubal serosal exudates or its luminal contents were not sent for culture and sensitivity.
|Figure 1: Microphotograph showing structure of fallopian tube with thickened wall and inflammatory cell infiltrates up to serosa (H and E stain, ×40)|
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|Figure 2: Microphotograph showing neutrophilic infiltrates in mucosa and wall of fallopian tube suggestive of acute salpingitis (H and E stain, ×400)|
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The final diagnosis was acute salpingitis. As this is a rare condition in a prepubertal child, the history and examination were revisited and further workup planned to identify the underlying cause or predisposing factors. Absence of suggestive symptoms and signs clinically excluded acute pharyngitis, acute otitis media, and meningitis. There was no history or clinical indicators suggestive of sexual abuse, and per vaginal examination was not performed in view of the patient's age. Urine microscopy was normal. Random blood glucose was normal. Blood culture and urine culture were sterile. Investigation for primary immunodeficiencies was not actively considered as there was no significant history of recurrent serious bacterial infections. Workup for tuberculosis, i.e., a chest X-ray, Mantoux test, and cartridge-based nucleic acid amplification assay of induced sputum were negative normal. Thus, we were unable to identify any predisposing factor. The postoperative period was uneventful, and the clinical condition improved. The total and differential white blood counts normalized. Ultrasound abdomen after 1 week showed the presence of normal appendix, colon, uterus, and bilateral ovaries. Parents were counseled regarding the long-term possibility of chronic pelvic pain, chronic pelvic inflammatory disease, and infertility. The child was discharged with a final diagnosis of acute salpingitis and is on regular follow-up.
| Discussion|| |
The various causes to be considered for abdominal pain with right iliac fossa mass in a sexually inactive prepubertal female child are mentioned in [Table 1]. Most causes are due to infections of the intestines. Acute salpingitis is rare in prepubertal children. In older sexually active individuals, it is often due to sexually transmitted diseases secondary to Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, or nonvenereal salpingitis due to Streptococcus pyogenes, Escherichia coli, etc. In these cases, acute abdominal pain due to a pelvic pathology may be picked up clinically by per vaginal and/or per rectal examination. Per vaginal examination may reveal forniceal tenderness in pelvic inflammatory disease, whereas per rectal examination may reveal any adnexal mass in pelvic inflammatory disease. Given the age of the patient, these examinations were not warranted in this case. [Table 2] summarizes the clinical and bacteriological details of similar case reports identified on a literature search.,,
|Table 1: Causes for acute abdomen pain with right iliac fossa mass in a female child|
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|Table 2: Comparison of previous cases of acute salpingitis in prepubertal girls|
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We faced certain challenges in the management of this case. One of the initial differentials was a ruptured appendicular mass. The retrocecal position of the appendix in this case could be one of the reasons for its nonvisualization in the initial ultrasound. Special positioning is needed for locating a retrocecal appendix during an ultrasonogram. Often, a retrocecal appendix will be obscured by bowel gas, leading to its nonvisualization. In this situation, the use of a three-step graded compression sonographic algorithm of sequential positioning can help to visualize retrocecal inflamed appendix when it is not visualized in the routine supine position. CT scan should be done if the appendix is still not visualized despite using this protocol, and there is a strong clinical suspicion of acute appendicitis. In addition to identify retrocecal appendicitis, its extension in subhepatic or pararenal space, free gas in ruptured appendicitis, it can help in diagnosing conditions mimicking appendicitis clinically. For instance, right-sided acute salpingitis may mimic appendicitis by forming a right iliac fossa mass in children due to the shallowness of the pelvis. A CT scan is advisable before proceeding for laparotomy on clinical grounds but could not be done. in our case due to the rapidly worsening clinical condition and practical issues related to nonavailability of CT scanning facilities in our institute.
We planned an exploratory laparotomy in view of the rapidly worsening clinical condition of the patient and our inability to arrive at a clinical diagnosis, based on the available investigations. In this case, the right iliac fossa mass comprising the inflamed right fallopian tube and omentum with small bowel adhesions obscured the visualization of the appendix intraoperatively and would have also attributed to its nonvisualization on ultrasonography.
Usually, acute salpingitis is a nonsurgical condition which is treated conservatively with antibiotic therapy. Surgical intervention is indicated in cases of pyosalpinx, rupture of the fallopian tubes, poor response to medical therapy, and when appendicitis cannot be definitely ruled out. Salpingectomy is advised when pyosalpinx leads to rupture of the fallopian tube. In this patient, the part of the right fallopian tube was removed, leaving the fimbrial end along with attached omentum. We were unable to make a bacteriological diagnosis as culture specimens from the tubal serosal exudates or its luminal contents were not sent.
Salpingitis in a prepubertal child carries a high risk of misdiagnosis, inappropriate management, and long-term sequelae-like infertility and ectopic pregnancy if delay in diagnosis leads to complications. Nonspecific symptomatology and a presentation mimicking acute abdomen secondary to supposed appendicitis contributed to the misdiagnosis in this case. The use of radiological algorithmic protocols and abdominal CT should be considered before exploratory laparotomy. Salpingitis may mimic acute appendicitis and should be always considered in the differential diagnosis of acute abdomen in a girl, even if prepubertal. All endeavors should be undertaken to establish a microbiological cause and look for predisposing causes or factors for nonsexually transmitted acute salpingitis.
Consent for publication
Signed informed consent was obtained from parents.
Declaration of patient consent
The authors certify that they have obtained the appropriate consent from the parent. In the form, the patient's parent has given his consent for the images and other clinical information to be reported in the journal. The patient's parent understands that the name and initials will not be published, and due efforts have been made to conceal the same, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Kim JS. Acute abdominal pain in children. Pediatr Gastroenterol Hepatol Nutr 2013;16:219-24.
Shafer MA, Irwin CE, Sweet RL. Acute salpingitis in the adolescent female. J Pediatr 1982;100:339-50.
van der Putten ME, Engel M, van Well GT. Salpingitis. A rare cause of acute abdomen in a sexually inactive girl: A case report. Cases J 2008;1:326.
Fein DM, Sellinger C, Fagan MJ. Acute salpingitis in a nonsexually active adolescent. Pediatr Emerg Care 2015;31:853-5.
Kulhanjian JA, Hilton NS. Gonococcal salpingitis in a premenarchal female following sexual assault. Clin Pediatr (Phila) 1991;30:53-5.
Balachandran B, Singhi S, Lal S. Emergency management of acute abdomen in children. Indian J Pediatr 2013;80:226-34.
Demetrashvili Z, Kenchadze G, Pipia I, et al
. Management of appendiceal mass and abscess. An 11-year experience. Int Surg 2015;100:1021-5.
Chang ST, Jeffrey RB, Olcott EW. Three-step sequential positioning algorithm during sonographic evaluation for appendicitis increases appendiceal visualization rate and reduces CT use. AJR Am J Roentgenol 2014;203:1006-12.
Ong EM, Venkatesh SK. Ascending retrocecal appendicitis presenting with right upper abdominal pain: Utility of computed tomography. World J Gastroenterol 2009;15:3576-9.
Magnin G. Acute salpingitis. Rev Prat 2002;52:1763-7.
[Figure 1], [Figure 2]
[Table 1], [Table 2]