A 16-year-old girl with no previous health problems came to the emergency room after several days of severe abdominal pain. The pain started around her belly button and then moved to her right lower abdomen. The pain was constant and prevented her from sleeping or even standing up straight. He also had nausea and vomiting. Although her period usually came every month, she told us that her last period started 6 weeks early and she has not had another. In the emergency room, the triage nurse discovered that he had a high fever of 103°F. The first doctor on the scene tried to examine her and found that her lower right abdomen was extremely tender.

What caused this teen’s symptoms? Abdominal pain can be due to many things; some are more serious than others. Appendicitis had to be considered immediately. The appendix is ​​a small organ attached to the large intestine in the right lower abdomen. When the appendix is ​​blocked, bacteria overgrow and the appendix becomes infected. Appendicitis usually presents with right lower abdominal pain, fever, nausea and vomiting. Caught early, it can sometimes be treated with antibiotics. But if the appendix ruptures, the infection can spread quickly. An abdominal ultrasound only showed us that he had too much inflammation in the area to clearly see the appendix. When this happens, an MRI or CAT scan is done for better visualization. Pending these tests, other solutions had to be considered.

Another possibility was an ectopic pregnancy. This happens when a fertilized egg implants outside the uterus – often in the fallopian tubes, but it can also implant in an ovary or abdomen. An ectopic pregnancy is a surgical emergency, but that wasn’t the issue here because her pregnancy test was negative.

Ovarian torsion is another surgical emergency. Ovarian torsion occurs when an ovary twists, cutting off its blood supply. Symptoms include sudden onset of lower abdominal pain and vomiting. Torsion can occur when an ovarian cyst or mass makes the ovary misshapen and prone to twisting. Additionally, an ovarian cyst is a fluid-filled sac or tissue in the ovary that can burst and cause abdominal pain. But we wouldn’t know if an ovarian problem was causing her pain until further imaging tests were completed.

Kidney conditions, including kidney stones, urinary tract infections, and kidney infections (pyelonephritis) can also cause severe lower abdominal pain, but have been ruled out as suspicious when the patient’s urinalysis and blood function tests renal function returned to normal.

Gastrointestinal infections involving the stomach or intestines are common culprits. Symptoms of gastroenteritis include nausea, vomiting, diarrhea and abdominal pain. Most cases of gastroenteritis improve within a few days of rest and hydration. Our patient’s pain was getting worse, however, and was more severe than is usually the case with gastroenteritis.

Another culprit behind such pain can be pelvic inflammatory disease (PID), an infection of the ovaries, fallopian tubes, and/or uterus. Initial blood tests showed an elevated white blood cell count, which often suggests a bacterial infection. But our patient disclosed that she had never had intercourse, leaving a sexually transmitted infection such as PID off the list of possible diagnoses. .

Solution

The most telling clues were in the abdominal MRI. She showed a tubo-ovarian abscess involving the right ovary as well as an enlarged and inflamed appendix. This type of abscess is usually a complication of pelvic inflammatory disease, so it was not at all what we expected.

Here’s how I connected the details: bacteria from the infected appendix leaked and infiltrated the nearby right ovary, causing a TOA.

Mystery solved, he was immediately given two intravenous antibiotics for the two conditions, either of which could have ruptured at any time and required surgery. Over the next 24 hours, our patient began to improve enough to continue with oral antibiotics to treat both infections.

Health care providers typically try to fit patients’ symptoms into a single diagnosis—and that’s appropriate, because that’s usually what happens. But this adolescent patient provided a valuable reminder that medical detectives must remain alert to the possibility of co-occurring conditions so that both can be addressed promptly.

Jonathan Ghaul is a pediatric resident and Rima Himelstein is a specialist in adolescent medicine at Nemours Children’s Hospital of Delaware.