Adnexal Mass I

One of my favorite types of blogs is the mystery case; let's see if I can do this well. Some of the details are changed for patient confidentiality.

A 25 year old woman from Mexico presents with nonspecific abdominal discomfort and bloating of several months. She cannot further characterize this pain. Otherwise, she is a G0P0, has an IUD in place, and does not have any fevers, chills, night sweats, nausea, vomiting, diarrhea, dysuria, or vaginal discharge. The physical exam is normal except the pelvic exam where a nonpainful right adnexal mass is palpated. An ultrasound confirms this adnexal mass and shows both cystic and solid components. A CT abdomen also noted this adnexal mass as well as liver hypodensities with central necrosis, lymphadenopathy, and right hydronephrosis.

Concerned for ovarian cancer, the gynecologists attempt to get a diagnosis through a percutaneous biopsy of two liver lesions. Neither lesion shows cancer; they both show inflammatory debris and one lesion biopsy grows out Bacteroides fragilis. Uncertain about the significance of this finding, the gynecologists do not treat her with antibiotics.

They decide that they need an operative diagnosis and two weeks later, hospitalize her prior for an exploratory laparoscopy or laparotomy. At this time, she complains of a cough, but otherwise she is doing well. She is non-toxic and her physical exam is unremarkable. A chest X-ray shows a right pleural effusion with atelectasis. They call an infectious disease consult. Meanwhile, a chest CT shows new peripheral nodular densities in the lungs, several of which are centrilobular or cavitary appearing. An abdominal CT shows that the adnexal mass has grown remarkably in size, and the hepatic lesions are more numerous and larger. We ruled TB out by getting two AFB negative induced sputums. The pleural fluid was tapped and was exudative with 3000 WBCs (54% neutrophils, 16% monocytes, 30% lymphocytes).

We met with the gynecology team. We couldn't think of any classic infection causing this picture, but the gynecologists couldn't think of any gynecologic cancer that appeared like this. Both of us stumped, we wanted an operative diagnosis. I'll save that for tomorrow.