CASE REPORT
Tubo-Ovarian Abscess Caused by
Candida Albicans in an Obese Patient
Valerie To, MDCM, Joshua Gurberg, MDCM, Srinivasan Krishnamurthy, MD, FRCSEd, FRCOG
Department of Obstetrics and Gynaecology, McGill University Health Centre, Montreal QC
Abstract
Background: Tubo-ovarian abscess (TOA) arises in most
cases from pelvic infection.. Appropriate treatment includes
use of antimicrobials and, especially in patients with
increased BMI, drainage of the contents..
Case: A 44-year-old morbidly obese woman (BMI 72) had a
persistent TOA despite receiving antibiotic treatment for four
months.. She had no history of diabetes, and denied being
sexually active.. Imaging demonstrated a pelvic abscess of 14..9
8..9 11..1 cm.. Successful percutaneous drainage was
performed yielding purulent material which grew Candida
albicans. The patient recovered after drainage of the abscess and
the addition of fluconazole to her antimicrobials. She had no
apparent risk factor for acquiring such an opportunistic infection,
other than her morbid obesity..
Conclusion: Because morbid obesity may confer a relative
immunodeficiency, morbidly obese patients may develop
unusual infections such as opportunistic fungal abscesses..
Rsum
Contexte : Les abcs ovario-tubaires (AOT) sont, dans la plupart
des cas, attribuables une infection pelvienne.. Parmi les
moyens de prise en charge adquats, on trouve le recours des
agents antimicrobiens et, particulirement chez les patientes qui
prsentent un IMC accru, le drainage des abcs en question..
Cas : Une femme obse morbide de 44 ans (IMC 72) prsentait un AOT
persistant malgr ladministration dune antibiothrapie pendant
quatre mois.. Elle ne prsentait pas dantcdents de diabte et
affirmait ne pas tre sexuellement active. Limagerie a rvl la
prsence dun abcs pelvien de 14,9 cm sur 8,9 cm sur 11,1 cm..
Un drainage percutan a t men avec succs; la prsence de
Candida albicans a t identifie dans le matriel purulent drain.
La patiente a rcupr la suite du drainage de labcs et de lajout
de fluconazole ses agents antimicrobiens.
part son obsit morbide, elle ne prsentait aucun facteur de
risque apparent de contracter une telle infection opportuniste..
Key Words: Female, pelvic infection, opportunistic
infection, Candida albicans, drainage, obesity, morbid
Competing Interests: None declared..
Received on June 3, 2014
Accepted on August 5, 2014
426 l MAY JOGC MAI
2015
Conclusion : Puisque lobsit morbide pourrait confrer une
immunodficience relative, les patientes obses morbides
pourraient contracter des infections inhabituelles, telles que
des abcs fongiques opportunistes..
J Obstet Gynaecol Can 2015;37(5):426429
INTRODUCTION
A
pproximately 800000 women develop pelvic
inflammatory disease annually in the United
States, corresponding to approximately an incidence of
0.05%, which is similar to the Canadian incidence. 13 Tubo-
ovarian abscess is reported to complicate 10% to 15% of
cases of PID, especially if the initial episode was
inadequately treated.4 Appropriate management is crucial,
because there are potentially severe short-term consequences
(such as abscess rupture and ensuing peritonitis and sepsis)
and long term consequences (such as infertility, ectopic
pregnancy, and chronic abdominal/pelvic pain). Risk factors
for TOA development include having had a previous episode
of PID, having multiple sexual partners, having an
intrauterine device, and immunosuppression.4 PID is thought
to arise from vaginal or cervical pathogens ascending into the
sterile endometrial cavity, fallopian tubes, and peritoneal
cavity.5 A TOA can also result from other causes, such as
diverticulitis, appendicitis, inflammatory
bowel disease, and gynaecologic or obstetric surgery.4
The infection is usually polymicrobial; microorganisms
involved can include
N. gonorrhoea, C. trachomatis, Bacteroides
species, Peptococcus, Peptostreptococcus, and E.
coli. 6 Nearly all causative pathogens are bacteria, and can
include rare microorganisms such as
Edwardsiella tarda and Pasteurella Multocida.7,8
TOA caused by a fungus has been described in only three
case reports to date; in all three cases the causative organism
was Candida glabrata, and the patients either had an
IUD or were immunocomprised.9-11 We report here a case of
TOA caused by Candida albicans, in a non-diabetic 44-
year-old woman with no apparent risk factors except morbid
obesity.
 Tubo-Ovarian Abscess Caused by Candida Albicans in an Obese Patient

THE CASE CT scan showing large gas-containing fluid collection

extending into the uterus and anterior abdominal wall
A 44-year-old woman, gravida 1 para 1, presented to her
community hospital with bilateral lower abdominal pain,
fever, and chills. Her past gynaecological history was
characterized by regular heavy menstrual flow and
dysmenorrhea, normal Papanicolaou smears, no history of
sexually transmitted infections, and no notable intrauterine
device use. Her past medical history included venous
thromboembolic events (a deep vein thrombosis and a
pulmonary embolism), urolithiasis, recurrent urinary tract
infections, chronic obstructive pulmonary disease, gout,
asthma, and morbid obesity (BMI 72). She was not diabetic.
Her surgical history included cholecystectomy, a Caesarean
section at term, and surgery for renal calculi. Her current
medications were warfarin, allopurinol, ferrous sulfate, and
fluticasone and salbutamol inhalers.
After the patient was found on CT scan to have a tubo-ovarian was 37.4C. Her hemoglobin concentration was 88 g/L,
abscess measuring 12712cm, she began intravenous and white blood cell concentration was 12.2giga/L. A CT
antibiotic treatment with clindamycin, gentamicin, and scan of her abdomen and pelvis revealed a 15 9 11cm
ampicillin. Two weeks later, she was transferred to a tertiary care
gas-containing fluid collection extending into the
hospital because her condition was not improving. A repeat CT
uterus and anterior abdominal wall, consistent with an
scan showed a 161314cm multiloculated pelvic abscess.
abscess, as shown in the Figure.
Her white blood cell concentration was 17giga/L. She received
intravenous Tazocin and oral doxycycline. After a few days of Treatment was switched to intravenous Tazocin (4.5 g at
defervescence, and after consultation with an infectious disease 8-hour intervals). She subsequently developed
specialist, this treatment was switched to oral metronidazole C.difficile colitis and was given oral vancomycin.
(500mg 3 times daily) and oral levofloxacin (750mg daily). Concurrently, she developed a cutaneous fistula in her
Her blood and urine cultures were negative, as well as a lower abdomen, confirmed by CT scan, and this
gonorrhea and Chlamydia PCR. An interventional radiologist drained purulent fluid which was not cultured. Despite
attempted percutaneous drainage of the abscess, but was this treatment, the patient continued to have fever,
unsuccessful. One week later, the abscess size had decreased to persistent left lower quadrant rebound tenderness, and
859cm on repeat CT. The patient felt better, and her level leukocytosis. Urine and blood cultures showed no growth
of pain had decreased significantly. She was discharged of pathogens throughout each of her hospitalizations. A
from hospital two weeks after admission (four weeks since her vaginal culture, however, was positive for Candida
first presentation) to take oral antibiotics for three weeks. albicans, but because the patient had no vaginal
symptoms, no antifungal treatment was given. Three days
At three weeks after discharge from hospital, the patient
after readmission to hospital, an interventional radiologist
presented back to her community hospital with
was able to perform ultrasound-guided drainage of the
recurrent lower abdominal pain, increasing over four
abscess despite the patients body habitus, and inserted a
days, with accompanying fever (up to 40C) and chills.
pig-tail catheter for continuous drainage:
She began treatment with meropenem and was
200mL of purulent, blood tinged fluid were
transferred again to our tertiary care hospital.
drained. She had been on antibiotics at that point for
On initial assessment, she had rebound tenderness in the approximately three months.
left lower quadrant of the abdomen, and her temperature
Microscopy of the abscess fluid showed numerous hyphae,
and culture resulted in growth of Candida albicans
and
ABBREVIATIONS mixed enteric organisms. Treatment with oral fluconazole
PID pelvic inflammatory disease (400mg daily) was added, and the patient showed rapid
TOA tubo-ovarian abscess clinical improvement. A repeat ultrasound examination nine
days after abscess drainage showed interval resolution. The
patients level of pain improved, her white blood cell count
normalized, and she remained continuously afebrile.
MAY JOGC MAI 2015 l
427
Case Report
The patient was transferred to her community hospital
two weeks after admission on intravenous Tazocin, oral
fluconazole, and oral vancomycin. She
continued to receive Tazocin and
fluconazole for a total of four weeks, until a repeat
CT scan showed complete resolution of the abscess.
She then stopped her antibiotic therapy and was finally
able to return home.
DISCUSSION
In patients hospitalized with severe PID or who have PID
that is not responding to antibiotic therapy, tubo-ovarian
abscess should be ruled out by means of imaging by
ultrasonography or computed tomography. Once the
diagnosis of TOA is made, management options include
treatment with intravenous antibiotics alone, antibiotic
therapy with imaging-assisted drainage of the abscess, or
antibiotic therapy combined with surgery. Antibiotic
regimens include a broad spectrum beta-lactamase agent
(usually a third-generation cephalosporin) with oral
doxycycline, or clindamycin plus gentamycin. These
regimens have been shown to have
comparable efficacy and response rates
(defined as decreased pain, decreased white
cell concentration, and loss of fever) of 63% to 75%. 6,12
However, a study by McNeeley et al. found that a triple
therapy regimen (using ampicillin, clindamycin, and
gentamycin) was significantly more effective
(87.5% response) than cefotetan plus doxycycline (34%
response) or clindamycin plus gentamicin (47%
response).13 Treatment failure may well be related to the
size of the abscess, as shown in a study by Reed et al., in
which 60% of women with an abscess diameter of 10 cm
or more required surgical intervention compared with 30%
of those measuring 7 to 9cm and 15% of those measuring
4 to 6cm.12
Patients with a TOA who fail to respond to antibiotic
treatment alone within 48 to 72 hours should be
considered for abscess drainage or surgery.14 Many
patients treated successfully with antibiotics may still
require surgery for recurrence in the long term. 6
Alternatively, if the patient is not responding to antibiotic
therapy or if the abscess is large, imaging-guided drainage
can be considered and has been shown in several studies to
be well-tolerated and efficacious.15,16 It can be guided
by CT scanning or by ultrasound, via the transabdominal,
transvaginal, transrectal, and transgluteal routes. Surgical
treatment is reserved for ruptured, severe, or refractory
cases of TOA, and includes laparoscopy or possibly
laparotomy for drainage of an abscess, adhesiolysis,
salpingo-oophorectomy, and/or hysterectomy.4
The patient in our case did not wish to preserve her
fertility, but to assist in counselling women who do,
several case series have reported on pregnancy outcomes
after the different modalities used in treatment of an
unruptured TOA. In a review by Rosen et al., only 4% to
15% of women treated with antibiotics alone subsequently
became pregnant, a rate similar to those who required a
laparotomy and antibiotics, but pregnancy rates reached
62% to 53% following laparoscopic drainage and
antibiotic therapy.17 These authors advocated for
emergency laparoscopy and medical management in all
women presenting with a TOA who wish to conceive in
the future. It is hypothesized that this management
decreases the exposure of the adnexa to purulent material,
thereby minimizing scarring and fibrosis.17 A
retrospective study reported pregnancy rates of
approximately 50% after transvaginal ultrasound-guided
drainage of TOA.18
We had hoped initially that a prolonged course of antibiotics
alone would be sufficient treatment for our
patient, because her high BMI and comorbidities made her
a very poor candidate for surgery; percutaneous drainage of
the abscess was deemed to be almost impossible because of
the thickness of her abdominal wall. However, weeks of
antibiotic therapy did not result in resolution, and she
improved only with the combination of ultrasound-guided
drainage (to decompress the abscess and allow
identification of the causative organism) and appropriate
antimicrobial treatment (with the addition of antifungals to
her therapy). Curiously, yeast is an opportunistic
microorganism and is not known to cause severe infection
and form abscesses unless the patient is
9,19
immunocompromised or has an IUD, as in two other case
reports.10,11 It is possible that the prolonged antibiotic
therapy before transfer to our hospital could have suppressed
the detection of bacteria in culture media.
The patient did not have any of the known risks for
immune suppression; she was not diabetic and was
presumed to be HIV-negative because she had not been
sexually active for many years (she declined testing at that
time). Other conditions known to be associated with
immune suppression include use of immunosuppressive
drugs, renal or hepatic insufficiency, certain
autoimmune diseases, malignancy and asplenia.20 It
is possible however that her morbid obesity
contributed to a relative immunodeficiency
state, resulting in an opportunistic fungal infection
ascending from the vagina. Obesity is a state of low-grade
chronic inflammation, with altered circulating
levels of nutrients and hormones.21
Epidemiological data have shown that obese individuals
are more prone than individuals of normal weight to
infections, including postoperative and nosocomial
428 l MAY JOGC MAI
2015
 Tubo-Ovarian Abscess Caused by Candida Albicans in an Obese Patient

5.Lareau SM, Beigi RH. Pelvic inflammatory

disease and tubo-ovarian abscess. Infect Dis Clin
North Am 2008;22(4):693708, vii.
infections.22 Physiologically, this can be
6.Landers DV, Sweet RL. Tubo-ovarian abscess:
correlated with an altered immune response contemporary approach to management. Rev Infect
to infection, such as impaired lymphocyte Dis 1983;5(5):87684.
proliferation.23 However, more studies are
required to better understand why obese
people are more prone to infections and if and
how they respond differently to treatment
(e.g., requiring higher doses of antibiotics).

CONCLUSION

An unruptured tubo-ovarian abscess should

be drained, especially if it is large or not
responding well to antibiotic therapy, or if
future fertility is a concern. Drainage can
be performed either percutaneously with
imaging guidance or by surgery. Both
approaches can be challenging in an obese
patient. Draining the abscess allows
antibiotics to better penetrate it and allows
antibiotic therapy to be tailored
appropriately to the organisms cultured.
Causative agents may include yeast,
necessitating the use of antifungal agents.
Obese individuals may have impaired
immunity compared with lean individuals,
and they may have a different response to
antibiotic therapy.

ACKNOWLEDGEMENTS

The woman whose story is told in this case

report has provided written consent for its
publication.

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