At the recommendation of her primary care physician, a 53-year-old perimenopausal woman sought care at the emergency department for the fever, abdominal pain, and pyuria that had persisted for 4 days despite outpatient treatment for pyelonephritis. On physical examination, she was febrile and tachycardic with abdominal tenderness of the left lower quadrant. Genitourinary examination revealed copious brown vaginal discharge, left adnexal tenderness, and no cervical motion tenderness.
Laboratory testing revealed leukocytosis but otherwise normal electrolytes, liver function tests, and lactate levels. Urine culture obtained when she presented to an urgent care facility 3 days earlier had been negative. Computed tomography (CT) was performed and was read by Radiology as “closed loop small bowel obstruction in the left lower abdomen” (FIGURE 1). The patient was taken emergently to the operating room where her entire length of bowel was run without any obstruction found. Instead, the surgeons identified a mass in the left iliac fossa originating from the left ovary and fallopian tube (FIGURE 2).