AAGL Stump the Professors: 1 win and 1 loss

November 14, 2013

Panelists Leila V. Adamyan, MD, Alan H. DeCherney, MD, and Linda M. Nicoll, MD, went 1 for 2 during the “Stump the Professors” session at the 42nd AAGL Global Congress on Minimally Invasive Gynecology in Washington, DC.

 

Panelists Leila V. Adamyan, MD, Alan H. DeCherney, MD, and Linda M. Nicoll, MD, went 1 for 2 during the “Stump the Professors” session at the 42nd AAGL Global Congress on Minimally Invasive Gynecology in Washington, DC.

Jessica Shepherd, MD, MBA, chaired the session, which featured two clinical cases designed to challenge the diagnostic ability of the learned professors.  Case 1 was presented by Erika Mowers, MD, of the University of Michigan. Case 2 was presented by Olubunmi Olude, MD, of Eastern Virginia Medical School.

The 20-year-old nulligravida in Case 1 presented to the Emergency Department (ED) on the third day of a course of Bactrim with a fever of 103.5°F, pain on urination, and pelvic pain. She reported a history of night sweats but neither sexually transmitted disease nor abnormal Pap smears.  For the past 2 years, while in a monogamous relationship, she had been taking oral contraceptives. Pelvic exam revealed a left-sided adnexal mass with tenderness. The patient’s pregnancy test was negative.

The panelists suggested a differential of unilateral salpingitis or pelvic inflammatory disease (PID) but noted that those diagnoses were so common that they could not have been included in a Stump the Professors session.  Subsequent testing with ultrasound was revealed to have shown a mass in the left adnexa but the left ovary was not visualized. The woman’s fallopian tubes and ovaries were normal on laparoscopy. Cystoscopy showed pus within the bladder and a drain was placed for drainage. The patient remained febrile with continued drainage despite multiple changes in antibiotics.

The final diagnosis-which stumped the professors-was retropubic abscess caused by an urachal anomaly, a condition more common in men than in women.

The patient in Case 2 was a 30-year-old G5P5005 who presented to the ED with severe and worsening abdominal pain and fever. Eight days before, she had undergone an Essure procedure and her pain began 2 days after insertion. Physical examination revealed a distended abdomen and an umbilical hernia. The patient was 8 weeks postpartum and had not had a menstrual period since the vaginal delivery.

The panel’s working diagnosis was PID or possibly perforation from Essure. Subsequent computed tomography of the abdomen and pelvis was revealed to have shown a large amount of fluid. The patient was started on broad-spectrum antibiotics and subsequently underwent laparoscopy, which revealed large amounts of pus but no evidence of tubal perforation.

Although the panel members did not pin down the exact bacterium causing the infection, they had suggested calling for the appropriate tests, so Dr. Shepherd declared them unstumped.

 

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