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 Conclusion: Puisque lobsit morbide pourrait confrer une

immunodficience relative, les patientes obses morbides
Background: Tubo-ovarian abscess (TOA) arises in most cases pourraient contracter des infections inhabituelles, telles que des
from pelvic infection. Appropriate treatment includes use of abcs fongiques opportunistes.
antimicrobials and, especially in patients with increased BMI,
drainage of the contents.
J Obstet Gynaecol Can 2015;37(5):426429
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 INTRODUCTION

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 44ans (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 14,9cm sur 8,9cm diverticulitis, appendicitis, inflammatory bowel disease,
sur 11,1cm. 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 obsitmorbide, 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
A
pproximately 800 000 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
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.

426 l MAY JOGC MAI 2015


THE CASE
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
abscess measuring 12712cm, she began intravenous
antibiotic treatment with clindamycin, gentamicin, and
ampicillin. Two weeks later, she was transferred to a tertiary
care hospital because her condition was not improving. A
repeat CT scan showed a 161314cm multiloculated
pelvic abscess. Her white blood cell concentration was
17giga/L. She received intravenous Tazocin and oral
doxycycline. After a few days of defervescence, and after
consultation with an infectious disease specialist, this
treatment was switched to oral metronidazole (500mg 3
times daily) and oral levofloxacin (750mg daily). Her blood
and urine cultures were negative, as well as a gonorrhea and
Chlamydia PCR. An interventional radiologist attempted
percutaneous drainage of the abscess, but was unsuccessful.
One week later, the abscess size had decreased to
859cm on repeat CT. The patient felt better, and her
level of pain had decreased significantly. She was discharged
from hospital two weeks after admission (four weeks since
her first presentation) to take oral antibiotics for three weeks.
At three weeks after discharge from hospital, the patient
presented back to her community hospital with recurrent
lower abdominal pain, increasing over four days, with
accompanying fever (up to 40C) and chills. She began
treatment with meropenem and was transferred again to
our tertiary care hospital.
On initial assessment, she had rebound tenderness in the
left lower quadrant of the abdomen, and her temperature
ABBREVIATIONS
PID pelvic inflammatory disease
TOA tubo-ovarian abscess
Tubo-Ovarian Abscess Caused by Candida Albicans in an Obese Patient
CT scan showing large gas-containing fluid collection
extending into the uterus and anterior abdominal wall
was 37.4C. Her hemoglobin concentration was 88g/L,
and white blood cell concentration was 12.2giga/L. A CT
scan of her abdomen and pelvis revealed a 15911cm
gas-containing fluid collection extending into the uterus
and anterior abdominal wall, consistent with an abscess, as
shown in the Figure.
Treatment was switched to intravenous Tazocin (4.5g at
8-hour intervals). She subsequently developed C.difficile
colitis and was given oral vancomycin. Concurrently, she
developed a cutaneous fistula in her lower abdomen,
confirmed by CT scan, and this drained purulent fluid
which was not cultured. Despite this treatment, the patient
continued to have fever, persistent left lower quadrant
rebound tenderness, and leukocytosis. Urine and blood
cultures showed no growth of pathogens throughout each
of her hospitalizations. A vaginal culture, however, was
positive for Candida albicans, but because the patient had
no vaginal symptoms, no antifungal treatment was given.
Three days after readmission to hospital, an interventional
radiologist was able to perform ultrasound-guided
drainage of the abscess despite the patients body habitus,
and inserted a pig-tail catheter for continuous drainage:
200mL of purulent, blood tinged fluid were drained. She
had been on antibiotics at that point for approximately
three months.
Microscopy of the abscess fluid showed numerous hyphae,
and culture resulted in growth of Candida albicans and
mixed enteric organisms. Treatment with oral fluconazole
(400mg daily) was added, and the patient showed rapid
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 10cm 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
428 l MAY JOGC MAI 2015
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 immunocompromised9,19 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
 Tubo-Ovarian Abscess Caused by Candida Albicans in an Obese Patient
infections.22 Physiologically, this can be correlated with an
altered immune response to infection, such as impaired
lymphocyte 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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