Teen's severe abdominal pain came at her from two directions | Medical Mystery

A 16-year-old girl with no previous health issues came to the emergency room after several days of severe abdominal pain. The pain began 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. She also had nausea and vomiting. Though her menstrual periods usually came every month, she told us her last period started 6 weeks earlier, and she hadn’t had another. In the ER, the triage nurse found she had a high fever of 103 °F. The first doctor on the scene tried to examine her, and found her right lower abdomen was extremely tender.

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

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

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

Kidney conditions including kidney stones, urinary tract infections, and kidney infections (pyelonephritis) can also cause severe lower abdominal pain but were eliminated as suspects when the patient’s urinalysis and kidney function blood tests came back normal.

Gastrointestinal infections involving the stomach or intestines are frequent offenders. Symptoms of gastroenteritis include nausea, vomiting, diarrhea, and abdominal pain. Most cases of gastroenteritis improve over a few days of resting and hydrating. Our patient’s pain was only 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 sexual intercourse, leaving a sexually transmitted infection like PID off the list of potential diagnoses. .

The most revealing clues were in the abdominal MRI. It showed a tubo-ovarian abscess involving the right ovary, as well as an enlarged and inflamed appendix. This kind of abscess usually is a complication of pelvic inflammatory disease, so it wasn’t at all what we were expecting.

Here is how we connected the details: bacteria from the infected appendix leaked out and infiltrated the nearby right ovary causing a TOA.

Mystery solved, she 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 started improving enough so that she could continue with oral antibiotics to treat both infections.

Medical providers usually try to fit patients’ symptoms under one diagnosis — and that’s appropriate, since it’s usually what happens. But this teenage patient provided a valuable reminder that medical detectives also need to remain alert to the possibility of simultaneous conditions so that both can be promptly addressed

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