Case Presentation: A 39-year-old female with past medical history of multiple sclerosis and tobacco use presented to the emergency room with three days severe progressive abdominal pain and intermittent fever. She was found to be in septic shock, requiring vasopressor support. Laboratory analysis was notable for bandemia, acute kidney injury and lactic acidosis. Four days prior she had been evaluated for abnormal uterine bleeding and vaginal odor where a retained tampon had been discovered. A wet prep, a previously scheduled endometrial biopsy (EMB) and cervical biopsy were performed. She reported that pelvic cramping began shortly after the procedure. The following day she started on metronidazole due to clue cells noted on her wet prep. On admission, she was placed on broad spectrum antibiotics with clindamycin due to concern about early Toxic-Shock like physiology. Her CT-scan showed nonspecific colonic inflammation and a complex hypoechoic ovarian cyst. Blood and vaginal cultures subsequently reveal group A strep (GAS). She improved hemodynamically but developed worsening leukocytosis, thrombocytopenia and with persistent abdominal pain. MRI and PETs scan were performed which revealed findings consistent with tubo-ovarian abscess (TOA). Interventional radiology was consulted and performed percutaneous drainage. She improved and was discharged home on an extended antibiotic course.
Discussion: Invasive GAS with septic shock is a rare but severe pathological process with mortality rates of 40%-60%. Toxic-shock syndrome (TSS) is found in approximately 6% of patients.1 Rapid deterioration is common so early aggressive treatment with source control is paramount. Early in the course, patients may not meet full criteria for TSS so it is important to initiate antibiotic therapy with coverage immediately for GAS/Staphylococcus, as well as, the addition of clindamycin to reduce production toxin production.1 Vaginal seeding, causing severe GAS infections and TOAs are known but rare complications following office based gynecological procedures including EMBs .2,3 The vaginal track is not normally colonized by GAS except in the setting of vulvovaginitis where the rates are reported up to 4.9%.4 Retained tampons are typically associated with Staphylococci rather than GAS however in this case may have been a nidus for her colonization, vaginitis and subsequent invasive GAS. Historically surgical treatment of TOA has been reserved for select patients including those with ruptured or large TOAs and antibiotic failure, however recent studies show improved patient outcomes in patients with early minimally invasive drainage.5, 6
Conclusions: Patients and providers should be aware of rare but serious complications from officed-based gynecological procedures including invasive GAS infections such as TSS and TOAs. Patients should be instructed to return for care immediately in the setting of new fevers or severe abdominal pain following these procedures. Hospitalists should have high clinical suspicion for GAS/TSS in these patients and initiate early aggressive treatment including drainage of any suspected TOAs with specialist assistance as TOAs may represent inadequate source control.