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Abdominal Pain and Fever 48 Hours After Hysterosalpingography

Federal Practitioner. 2023 November;40(11)a:389 | doi:10.12788/fp.0428
November 3, 2023|Federal Practitioner
CPT Andrew Evans, MD, USA;ENS Roland Kiendrebeogo, USN;CPT Grace Covelli, MD, USA;CPT Christopher Russo, MD, USAF;MAJ Caitlin Christoffel, MD, USA
Author and Disclosure Information

CPT Andrew Evans, MD, USAa; ENS Roland Kiendrebeogo, USNb; CPT Grace Covelli, MD, USAa; CPT Christopher Russo, MD, USAFa; MAJ Caitlin Christoffel, MD, USAa

Correspondence: Andrew Evans (andrewamcas@gmail.com)

aWalter Reed National Military Medical Center, Bethesda, Maryland

bUniformed Services University of the Health Sciences, Bethesda, Maryland

Author disclosures

The authors report no actual or potential conflicts of interest regarding this article.

Disclaimer

The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects before administering pharmacologic therapy to patients.

Ethics and consent

Consent was obtained from the patient whose information is in this case report.

Diagnostic Considerations

Clinically, patients with TOAs present with fever, chills, lower abdominal pain, vaginal discharge with cervical motion tenderness, and an adnexal mass on examination.3 When a TOA is suspected, a urine human chorionic gonadotropin test and testing for C trachomatis and N gonorrhoeae are warranted. An ED workup often reveals leukocytosis, elevated C-reactive protein, and elevated erythrocyte sedimentation rate. Imaging is recommended once a TOA is suspected. Ultrasound is the gold-standard imaging modality and boasts a sensitivity of 93% and specificity of 98% for the detection of TOAs; however, CT has also been shown to be an effective diagnostic modality.4

Despite being common, TOAs are difficult to predict, detect, and diagnose; thus the clinician must often rely on thorough history taking and physical examination to raise suspicion.5 Although most frequently associated with sexual transmission, TOAs occur in not sexually active women in adolescence and adulthood. Specifically, TOAs also can present secondary to other intra-abdominal pathologies, such as appendicitis, diverticulitis, and pyelonephritis, as well as a complication of intrauterine procedures, such as an HSG, or less commonly, following intrauterine device (IUD) insertion.5-7


Given that sexually transmitted infections are the most common etiology of TOAs, C trachomatis and N gonorrhoeae are the most likely microorganisms to be isolated (Table).8-12 In not sexually active populations, Escherichia coli and Gardnerella vaginalis should be considered instead. Although rare, women with IUDs have been shown to have an increased incidence of PID/TOA secondary to Actinomyces israleii relative to women without IUDs.12 In patients with TOAs secondary to intraabdominal surgery, anaerobic bacteria, such as Bacterioides and Peptostreptococcus species in addition to Escherichia coli, are likely culprits.11

In patients after HSG, infectious complications are uncommon enough that the American College of Obstetricians and Gynecologists recommends against antibiotic prophylaxis unless there are risk factors of dilated fallopian tubes or a history of PID.13 Identifying a precise percentage of TOA as a complication of HSG is rather elusive in the literature, though, it is frequently noted that infection in general is uncommon, and the risk of developing PID is about 1.4% to 3.4%.14 However, in the retrospective study most often cited, all women who developed PID following HSG had evidence of dilated fallopian tubes. Given our patient had no history of PID or dilated fallopian tubes, her risk of developing infection (PID or postprocedural abscess) would be considered very low; therefore, the index of suspicion also was low.15

Our patient’s case of bilateral TOA also is unusual because her presentation was not entirely consistent with a TOA. She had a benign pelvic examination without cervical motion tenderness or evidence of cervicitis or cervical discharge. Given the initially low clinical suspicion, transvaginal ultrasound was not ordered. However, in the setting of tenderness to palpation in the lower abdominal quadrants, suprapubic tenderness, and leukocytosis, there was still concern for an acute intra-abdominal or pelvic process, and an abdominal CT was ordered as part of the workup. It was this clinical concern that led to the identification of the patient’s bilateral TOA.

Following diagnosis, the patient was promptly admitted and treated with a course of IV ceftriaxone 1 g every 24 hours, IV doxycycline 100 mg every 12 hours, and a single dose of IV metronidazole 500 mg. Her leukocytosis, fever, and pain improved within 48 hours without the need for percutaneous drainage and the patient made a complete recovery.

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