Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tokyo 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Abstract |
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Key words: appendicitis/ectopic pregnancy/ovarian hyperstimulation syndrome/peritonitis
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Introduction |
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Case report |
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On admission, she had severe abdominal distension, which made it difficult to localize pain or tenderness. Her temperature was 38.8°C associated with tachycardia (138/min) and decreased O2 saturation (96.5%). Her blood pressure was kept normal. A chest X-ray demonstrated mild right hydrothorax. Although total leukocyte count (7700/mm3) was in the normal range, differential count revealed a marked left shift (48% band neutrophils and 4% segmented neutrophils). Blood chemistry showed hypoproteinaemia (4.7 g/dl), hypoalbuminaemia (2.4 g/dl) and elevated C-reactive proteins (18.6 mg/dl).
Paracentesis for alleviation of abdominal distension revealed turbid, foul-smelling fluid, in which numerous bacteriae were detected under microscope. Emergency laparotomy was performed with the diagnosis of infectious panperitonitis of unknown origin. At laparotomy, a total of 4500 ml foul-smelling ascites and massive pus all over the abdomen were found. The abdominal cavity was thoroughly examined and perforation of a swollen appendix at the proximal portion was found. In addition, we found an enlarged isthmus of the right tube, in which villous tissues were detected. With the diagnosis of perforated appendicitis and right tubal pregnancy, appendectomy and right tubectomy were performed. After vigorous irrigation, five drains were placed in the abdominal cavity. The diagnosis of both appendicitis and tubal pregnancy was histologically confirmed. Bacteriae in the ascites were identified to be Group F streptococci, E.coli and bacteroides.
After operation, the patient's urine HCG titre decreased promptly. Although she had intra-abdominal abscesses in the Morisson pouch and cul-de-sac post-operatively, they were conservatively treated with antibiotics. Having had a complete recovery, she was discharged on post-operative day 37.
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Discussion |
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Generally, the pain associated with appendicitis initiates in the lower epigastrium or umbilical area. Epigastralgia in the present case might be related to appendicitis. However, epigastralgia is not an uncommon symptom in patients with severe OHSS with massive ascites. Furthermore, a right lower quadrant pain, a typical symptom of appendicitis, was not manifested in this case. Febrile morbidity is often observed in patients with severe OHSS without infection (Abramov et al., 1998). An elevated white blood cell count is also found both in patients with severe OHSS (Fabregues et al., 1998
) and in those with appendicitis.
The possibility is raised that OHSS might affect the course of concurrent appendicitis. An increased rate of infectious disease was reported in patients with OHSS, possibly due to immunodeficiency as a consequence of hypoglobulinaemia, a frequent occurrence in patients with severe OHSS (Abramov et al., 1998). Severe stress associated with symptoms of OHSS, a hospital stay, multiple monitoring and therapies might also impair immunoprotective status (Agarwal and Marshall, 2001;
Cohen et al., 2001
). In a recent report of perforated duodenal ulcer with OHSS, severe stress was suggested to be a causative factor (Uhler et al., 2001
). Following this logic, it may be that appendicitis with OHSS could be more aggressive and likely to rupture than without OHSS. Once bacteria are seeded into the peritoneal cavity associated with OHSS, they may grow rapidly to form abdominal abscesses, because ascitic fluid of OHSS serves as excellent culture medium for bacteria with its rich source of nutrients including albumin (Laroche and Harding, 1998
). It seems that OHSS, if complicated by intraperitoneal inflammatory disease, may worsen its potentially life-threatening conditions.
As a very rare complication of IVFembryo transfer, a case of acute appendicitis was reported (Roest et al., 1996). In this case, an appendix punctuated with the needle for oocyte retrieval was the suspected cause of appendicitis. Transvaginal procedures are also suggested to be potential inducers of pelvic inflammatory diseases. In this regard, our case is unique because transvaginal procedures were not performed.
In the present case, a right tubal pregnancy co-existed. Although a few cases of tubal pregnancy complicated by appendicitis have been reported (Pelosi et al., 1979; Barnett et al., 1999
), causal relationship between these two conditions remains unknown. The present case was noted with positive serum antibodies for Chlamydia trachomatis and stenosis of the right tube on HSG, these being possible risk factors for tubal pregnancies. As the right tube is anatomically close to the appendix, it is tempting to speculate that local inflammatory reactions associated with appendicitis might affect tubal functions, resulting in the development of tubal pregnancy.
The lesson from this case is that severe OHSS, apart from itself being life-threatening, could further compromise the conditions when intraperitoneal pathologies concurrently take place. Careful observations of its clinical courses and prompt optimum procedures including a surgical approach, when appropriate, are mandated.
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Notes |
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References |
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Agarwal, S.K. and Marshall, G.D. Jr (2001) Stress effects on immunity and its application to clinical immunology. Clin. Exp. Allergy, 31, 2531.[ISI][Medline]
Barnett, A., Chipchase, J. and Hewitt, J. (1999) Simultaneous rupturing heterotopic pregnancy and acute appendicitis in an in-vitro fertilization twin pregnancy. Hum. Reprod, 14, 850851.
Cohen, S., Miller, G.E. and Rabin, B.S. (2001) Psychological stress and antibody response to immunization: a critical review of the human literature. Psychosom. Med., 63, 718.
Fabregues, F., Balasch, J., Manau, D., Jimenez, W., Arroyo, V., Creus, M., Rivera, F. and Vanrell, J.A. (1998) Haematocrit, leukocyte and platelet counts and the severity of the ovarian hyperstimulation syndrome. Hum. Reprod, 13, 24062410.[Abstract]
Golan, A., Ron-El, R., Herman, A., Soffer, Y., Weinraub, Z. and Caspi, E. (1989) Ovarian hyperstimulation syndrome: an update review. Obstet. Gynecol. Surv., 44, 430440.[Medline]
Laroche, M. and Harding, G. (1998) Primary and secondary peritonitis: an update. Eur. J. Clin. Microbiol. Infect. Dis., 17, 542550.[ISI][Medline]
Pelosi, M.A., Apuzzio, J. and Iffy, L. (1979) Ectopic pregnancy as an etiologic agent in appendicitis. Obstet. Gynecol., 53, 4S6S.[Medline]
Roest, J., Mous, H.V., Zeilmaker, G.H. and Verhoeff, A. (1996) The incidence of major clinical complications in a Dutch transport IVF programme. Hum. Reprod Update., 2, 345353.
Uhler, M.L., Budinger, G.R., Gabram, S.G. and Zinaman, M.J. (2001) Perforated duodenal ulcer associated with ovarian hyperstimulation syndrome: case report. Hum. Reprod, 16, 174176.
Submitted on September 17, 2001; accepted on December 11, 2001.