Salmonella Ovarian Abscess: A Case Report*

Salmonella Ovarian Abscess: A Case Report*
Eileen G. Aniceto, M.D.,** Adrian C. Pena, M.D.,*** Adelia M. Quijano, M.D.**** and Charito
Saludades, M.D. *****
(*From the University of the East Ramon Magsaysay Memorial Medical Center (UERMMMC) University Hospital;
**Chief Resident, Department of Medicine; ***Assistant Professor of Medicine and Chief, Section of Infectious
Diseases, Department of Medicine; ****Consultant, Department of Obstetrics and Gynecology; *****Senior
Resident, Department of Obstetrics and Gynecology)
ABSTRACT
Ovarian abscesses are rare conditions. Ovarian abscesses secondary to Salmonella spp. are even rarer entities.
This is a report of a 23-year old primigravid who developed ovarian abscess, pelvic inflammatory disease (PID) and
peri-appendicitis three weeks after an episode of typhoid fever. [Phil J Microbiol Infect Dis 1990; 19(2):68-71]
Key words: ovarian abscess, salmonella infection, pelvic inflammatory disease
INTRODUCTION
Ovarian abscesses are rare conditions. Ovarian abscesses secondary to Salmonella spp.
are even rarer entities. Localization of infection may occur at any site after salmonella bacteremia
irrespective of the associated clinical syndrome. Although bacteremia can be assumed to develop
in all patients with typhoid fever, localized infections actually occur only in 1% of cases.
Localization of the infection in the ovaries occurs even less frequently. We report a case of a 23year
old G1P0 (0070) primigravid who developed left ovarian abscess, PID and peri-appendicitis 3
weeks after an episode of typhoid fever .
Case History
A 23-year old female, G1PO (0010) was admitted for the third time because of severe
continuous hypogastric pains. of 2 days duration. She was first admitted to this center 25 days
prior to admission because of a five day history of moderate to high grade fever, malaise and bifrontal
headache. There were also severe crampy hypogastric pains followed by vaginal spotting
noted 2 days after.
On admission, physical examination revealed a febrile patient with essentially normal
findings except that the uterus was enlarged to 8 weeks size, and the cervix was soft, closed, and
non-tender with no adnexal masses. Work-up revealed WBC count of 4.8 x 10 9 /1 with a normal
differential count; urinalysis showed 4-6 WBC/HPF; ultra sound examination showed a
gestational sac with no fetal pole; Widal test showed positive titers at 1/320 for Salmonella D.
Blood culture was positive for Salmonella typhi. Diagnosis then was typhoid fever, intrauterine
pregnancy, blighted ovum 9-2/7 weeks. Patient was started on chloramphenicol at 3 grams per
day. A dilatation and curettage was performed on the first hospital day. The patient was
discharged asymptomatic after one week with instructions to continue chloramphenicol for 2
weeks.
Eight days prior to admission, the patient developed intermittent mild to moderate
crampy hypogastric pains without associated fever. Internal examination then revealed slight
tenderness at left adnexae. She was admitted with an impression of pelvic inflammatory disease
(PID), rule out ectopic pregnancy. Work up showed a negative monoclonal pregnancy test and a
culdocentesis showed only serosanguinous fluid. WBC and differential count showed 9 x 10 9 /L
with 52% neutrophils, 47% lymphocytes and 1 % eosinophils. Penicillin G was given. The patient
was discharged asymptomatic after 3 days of hospitalization.

Two days prior to admission, severe hypogastric pains developed. This was associated
with nausea, vomiting, diarrhea, and undocumented fever. Physical examination on admission
showed a fairly nourished, fairly developed individual who was not in distress. A low-grade fever
of 37.8 O C was noted. Abdominal examination showed voluntary guarding, direct and rebound
tenderness on both lower quadrants. Internal examination showed an ill-defined tender mass
about 2 centimeters in its widest diameter with exquisite tenderness of the cervix on wriggling.
No discharge was noted. Admitting impression was acute abdomen, rule out ectopic pregnancy.
On admission, an exploratory laparotomy was done which revealed mucopurulent
discharge in the pelvic cavity amounting to 250 cc. The left ovary was cystic, measured 4 x 3 x 2
cm, and with a mucopurulent discharge oozing from a point of rupture at its superior pole, Figure
1. The right ovary was grossly normal except for the presence of a follicular cyst. Both fallopian
tubes were slightly edematous, although the uterus was grossly normal. The appendix was
edematous and hyperemic. There was no point of rupture. However, there was fibrin coating the
whole structure. A left oophorectomy and appendectomy was performed with pelvic drainage.
The patient was started on intravenous preparations of metronidazole 500 mg q 8h and
clindamycin 300 mg IV q 6h for three days after whic h therapy was changed to oral preparations.
Culture of the ovarian discharge showed a heavy growth of Salmonella typhi. Oral ciprofloxacin
500 mg q 8 hours for ten days was given and metronidazole was continued at 500 mg tablets q 6
hours for possible co-existing anaerobic infection. The patient remained afebrile and was
discharged asymptomatic.
Figure 1. Schematic representation of operative findings showing the left ovarian abscess and its point of
rupture
DISCUSSION
Localization of salmonella infection following a bacteremia is not very common. It has
been said to commonly follow salmonella bacteremia although it may occur after enteric fever or

gastroenteritis. 1 Abscesses secondary to salmonella infection was reported by Saphra et al (1957)
as occurring in 1% (136/7779) cases of salmonellosis. These were frequently directly or indirectly
connected with the gastrointestinal tract as peri-proctal, perineal, subphrenic or appendiceal. 2
Salmonella infections of the liver, spleen, peritoneum and bone associated with enteric fever have
been reported but localized ovarian abscesses are very rare. Since 1893, when it was first
reported, there have only been 41 cases reported. 3,4,5
Clinical manifestations of localized Salmonella infection would largely depend on the
structures involved. The usual presenting symptoms in ovarian abscesses were abdominal pain,
nausea and vomiting. Purulent cervical discharge was seen only in 16% of cases. 5 Fever is also a
consistent symptom seen in all patients in whom temperatures were recorded. These symptoms
would occur from several weeks to months after the initial salmonella infection.
Physical examination usually reveals abdominal pain or pelvic tenderness, and/or
palpable adnexal masses. Laboratory data in over half the patients had leukocytosis, 2/7 had
bacteremia, 3/9 had positive stool cultures. In females, the most common serotype seen was
Salmonella typhi. 6 Bacteriologic diagnosis can usually be obtained from the material taken in situ.
Ovarian abscesses, in general, are usually associated with tubal or pelvic infections, when
the normal ovary is involved by direct spread of organisms from the lower genital tract. In such
cases, the infecting organisms are usually normal vaginal flora or gonococci. 5 Isolated ovarian
abscesses are much less common and in these patients some abnormality of the ovary encourages
the seeding of an organism during a septicemia. 7
It can be noted from previous reports that almost all typhoid infections had been noted in
dermoid cysts with the minority occuring in cystadenomas. From 1893 to 1971, 2 of 20 patients
reported by J.C. Evans-Jones occurred in normal ovaries. 8 In the report of Cohen et al (1987),
anatomic abnormalities were noted in 4/12 women (3 were dermoid cysts and 1 with
cystadenoma). 5
Three mechanisms by which salmonella spread to uterine adnexae are: organisms in the
abdominal cavity gain access during ovulation; an inflamed bowel may have adhered to an ovary
and allowed direct extension of the infection; and spread via blood stream or lymphatics.
The surface of the ovary is damaged during ovulation and in the process any organism
present in the peritoneal cavity will gain access and may proliferate causing abscess formation.
Any infection in the surrounding adnexae or intestine may, by direct extension, involve
the ovaries. Intra-ovarian abscesses are characteristically seen in patients with pelvic
inflammatory disease associated with an intrauterine device (IUD). 10 IUD causes colonization of
the female genital tract by bacteria, which then gain access to the peritoneum through the
fallopian tube. 11 The patient, however, had no history of IUD use. Ovarian abscess may also be
seen after a pelvic surgical procedure, especially if there had been ovarian trauma. 10 The most
common type of purulent infection of the ovary is a tubovarian abscess due to ovarian
involvement secondary to acute salpingitis. 11 In contrast, ovarian abscesses unrelated to tubal
disease is very rare. 12 With the history of dilatation and curettage done during the time the patient
had typhoid fever, it is highly likely that PID developed as a consequence with subsequent
ovarian abscess formation.
Early in the course of salmonella bacteremia, the ovaries with a collection of stagnant
blood would have been a likely site for salmonella to establish themselves. 9 The presence of preexisting
disease resulting in necrotic scarred or hyperplastic tissue favors localization of blood
borne organisms. Localized salmonella infections have been seen in many types of benign and
malignant tumors, cysts, aneurysms, bone infarctions and effusions in serous cavities. 13 The
presence of hair, bone, teeth or other tissues in a dermoid cyst or the mucus of a cystadenoma
may act as a similar protected site with chronic infection which may develop into an ovarian
abscess many months or years after the initial septicemic illness. 3
The development of salmonella ovarian abscess in our patient can be explained on the
basis of two hypotheses. First, she had enteric fever during the time that a gynecological

procedure was performed. Salmonella infection may have set in resulting in PID, periappendicitis
and ultimately ovarian abscess formation in a pre-existing ovarian cyst. Hence, the
condition may be nosocomially acquired. Second, she may have had salmonella secondarily
infecting an ovarian cyst during the bacteremic phase of typhoid fever, producing a latent
infection, which was activated by a more recent infection.
Salmonella genital infections are difficult to eradicate with medical therapy alone,
presumably because of the abscess formation requiring surgical intervention. Surgical drainage of
the localized collection of purulent material and antibiotic coverage are the cornerstones of
therapy. Common antibiotics proven effective in treating salmonella infection are ampicillin,
chloramphenicol, trimethoprim-sulfamethoxazole and amoxicillin. 6 Ampicillin or
chloramphenicol is commonly used for extra intestinal salmonella infections. Trimethoprimsulfamethoxazole
is generally used for organisms resistant to the above two drugs. Evans-Jones
used chloramphenicol successfully in the treatment of salmonella ovarian abscess given at a dose
of 4 gms/day iv for 5 days followed by 2 gms/day PO for 5 more days. 3 Salztsmann et al used
chloramphenicol in combination with ampicillin for 14 days. 14 Ghose et al on the other hand
combined amoxycillin with cotrimoxazole successfully for 2 weeks. 9 These antibiotics had been
used either alone or in combination in the treatment of salmonella ovarian abscess, with varying
degrees of success.
Salmonella isolates have become increasingly resistant to these antibiotics. Outbreaks of
salmonella resistant to multiple antibiotics are being reported with increasing frequency. 15,16,17
Since typhoid fever remains an important health problem especially in the Philippines emergence
of resistance makes it necessary to develop potential therapeutic alternatives.
Ciprofloxacin, a quinolone carboxylic acid derivative, has a greater antibacterial activity
than earlier compounds such as nalidixic acid, pipemidic acid, or norfloxacin. Its bactericidal
activity against members of the Enterobacteriaceae, to which salmonella belongs, suggests its
usefulness in the treatment of typhoid fever. Several studies have shown its success in the
treatment of patients with uncomplicated typhoid fever. 18,19,20
There have been no reports however, on the use of ciprofloxacin in localized infections.
The use of ciprofloxacin in this patient may be a precedent for future therapy of salmonella
ovarian abscess.
CONCLUSION
Although salmonella ovarian abscess is a rare condition, it should be considered in the
differential diagnosis of patients with pelvic inflammatory disease who have had a history of
typhoid fever. Treatment must be surgical and suitable antibiotics must be started.
Chloramphenicol is still the drug of choice for uncomplicated typhoid fever.
The onset of complications while on chloramphenicol therapy should make one consider
clinical resistance inspite of in vitro sensitivity of S. typhi. It has also been shown in this report
that ciprofloxacin may be used successfully in the treatment of salmonella ovarian abscess.
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