- Email: [email protected]
Misdiagnosis of rodenticide poisoning as ectopic pregnancy: a case report
Letters to the Editor / European Journal of Obstetrics & Gynecology and Reproductive Biology 163 (2012) 117–122
120
(called threadworms in the UK) are accidental finding of ova on cervical smears, vulvovaginitis, salpingo-oophoritis, pelvic or ovarian mass, pelvic pain, etc. Cases have been reported where patients presented with post-coital bleeding and foul-smelling discharge and vermicularis eggs were demonstrated during microscopic examination of a smear taken from the posterior fornix of vagina [2]. Pinworm infestation may rarely present as post-menopausal bleeding, in association with carcinoma of the cervix, or even in a macerated embryo [1]. Enterobius vermicularis may also remain asymptomatic and can present merely as an ectopy when, on colposcopic examination, live worms of enterobius vermicularis were visualized high in the vagina [3]. The case reported here is unusual because the patient presented with an unusual complaint of passage of worms in the menstrual blood and there were no associated complaints of pruritus ani. The worms might have been in the uterine cavity, coming out with the menstrual blood, and were visible due to color contrast. This finding of enterobius vermicularis in menstrual blood supports the theory that the worm and its eggs gain access to the peritoneal cavity through an ascending pathway of vagina, uterus and fallopian tube. References [1] Al-Rufaie HK, Rix GH, Perez CMP, Al-Shawaf T. Pinworm and post-menopausal bleeding. J Clin Pathol 1998;51:401–2. [2] Chung DI, Kong HH, Yu HS, Kim J, Cho CR. Live female enterobius vermicularis in the posterior fornix of vagina of a Korean woman. Korean J Parasitol 1997;35:67–9. [3] Ayala Castellanos Mde L, Monry Rodriguez F, Gomez Lopez EM. Enterobiasis vaginal. Report of one case. Ginecol Obstet Mex 2009;77:491–3.
Savita Rani Singhal* Anshu Paul Pushpa Dahiya Department of Obstetrics and gynecology, Pandit Bhagwat Dayal Sharma Post graduate Institute of Medical Sciences, Haryana, India *Corresponding author at: 14/8FM, Medical Campus, Rohtak, Haryana 124001, India. Tel.: +91 1262 213643 E-mail addresses: [email protected] [email protected] (S.R. Singhal) 1 August 2011 3 March 2012 12 March 2012 doi:10.1016/j.ejogrb.2012.03.017
Misdiagnosis of rodenticide poisoning as ectopic pregnancy: a case report Dear Editor, We report a rare case of rodenticide poisoning misdiagnosed as ectopic pregnancy. An 18-year-old woman was referred to the Emergency Department due to vaginal bleeding and abdominal pain. She was unmarried but sexually active. She had irregular menstrual intervals of 30–60 days, and her last period was 45 days ago. She had had irregular vaginal bleeding for 10 days, and painless hematuria for 5 days. Four hours before admission she
started to experience abdominal pain and coffee-ground vomiting. A urine pregnancy test in the local hospital was positive, and severe dysfunction of coagulation was found. She was given four units of packed red cells and transferred to our hospital because of hypovolemic shock. Physical examination showed that there were large areas of subcutaneous ecchymosis and blood in her mouth, nose and vagina. Her abdomen appeared very distended with tenderness but without rebound tenderness. Bimanual pelvic examination was unsatisfactory because of her non-cooperation and abdominal distention. A full blood count revealed hemoglobin of 63 g/L and platelets of 159 109/L. Emergency ultrasound showed a huge volume of intraperitoneal fluid, and an unevenly echoic mass with a diameter of 5 cm located in the right side of the pelvic cavity, which suggested an ectopic pregnancy or blood clot. Ectopic pregnancy with massive hemorrhage was strongly suspected. Rupture of a corpus luteum was also considered, given that there could be false positive in the previous urine pregnancy test. Emergency laparotomy was performed immediately while the coagulation test and serum HCG test were ongoing. During surgery, surprisingly, we found normal uterus, ovaries and tubes, but only a large amount of blood in the intestines and approximately 400 ml of blood in the pelvis. Subsequently, laboratory tests revealed a markedly prolonged prothrombin time (PT) (72.2 s vs 11.5 s) and activated partial thromboplastin time (APTT) (177.0 s vs 30.4 s). The thrombin time (TT), fibrinogen, and liver function tests were within normal limits. Serum HCG was negative. Therefore, super-warfarin ingestion was strongly suspected at that time. Four units of packed red cells, 1200 ml fresh frozen plasma totally and vitamin K 150 mg daily were given during operation and in the following two days postoperatively. We contacted her teacher and were told that she had recently been very depressed. At first she denied, but finally admitted to ingesting rodenticides (0.005% brodifacoum) three weeks ago. There was a remarkable improvement in her clinical symptoms and the coagulation profile, and she was discharged 4 days later. When cases appear with severe hemoperitoneum, gynecologists usually pay much attention to ectopic pregnancy or rupture of corpus luteum, which both need emergency operation. However, we should not overlook the possibility of coagulation dysfunction caused by poison ingestion, especially the rodenticides due to their commercially easy availability and wide use. Super-warfarin, the common type of rodenticide, has an anticoagulant effect more than 100 times that of warfarin [1,2]. Bleeding manifestations range from microscopic hematuria to massive blood loss, and they may resemble those of ectopic pregnancy complicated by disseminated intravascular coagulation (DIC). This patient, however, had had hematuria for several days, which could not be explained by DIC. Moreover, the coagulation dysfunctions are absolutely different between these two diseases. When excessive blood loss is caused by ectopic pregnancy, the main changes are exhausted platelets and fibrinogen, while in the case of poisoning with anticoagulants the main changes are prolonged PT and APTT with normal fibrinogen and platelet count. Furthermore, comprehensive evaluation, particularly a history of drug and poison use, should be very helpful in diagnosis.
References [1] Leck JB, Park BK. A comparative study of the effect of warfarin and brodifacoum on the relationship between vitamin K1 metabolism and clotting factor activity in warfarin-susceptible and warfarin-resistant rats. Biochem Phamacol 1981;30:123–8. [2] Spahr JE, Maul JS, Rodgers GM. Superwarfarin poisoning: a report of two cases and review of the literature. Am J Hematol 2007;82(7):656–60.
Letters to the Editor / European Journal of Obstetrics & Gynecology and Reproductive Biology 163 (2012) 117–122
121
Lin Wu* Xiaohui Lu Rutie Yin Donghao Lu Department of Obstetrics and Gyncecology, West China Second University Hospital, Sichuan University, No. 20, Section 3, Renmin Road South, Chengdu, China *Corresponding author. Tel.: +86 28 85501346; mobile: +86 13880183060 E-mail address: [email protected] (L. Wu) 8 December 2011 doi:10.1016/j.ejogrb.2012.03.021
A rare confounder in a case of ovarian torsion Dear Editor, We report a 26-year-old woman who presented to the Emergency Department in late 2011, with severe right iliac fossa pain, nausea and vomiting after two weeks of mild generalised abdominal pain. There was no history of fever, urinary symptoms, vaginal bleeding or discharge, or change in bowel habit. Apart from a previously diagnosed right ovarian cyst, her past medical and surgical histories were unremarkable. The cyst had been noted incidentally on a routine ultrasound in 2006 and measured 6.49 cm in diameter. It was simple in nature, unilocular and anechoic. The patient had been having annual follow-up with ultrasound surveillance. Due to the cyst’s lack of increase in size and its asymptomatic nature, the patient opted against surgical intervention. Her obstetric history consisted of two successful spontaneous vaginal deliveries in 2005 and 2006. She was not on any medications, had no known allergies and was a non-smoker. On physical examination, there was localised tenderness and involuntary guarding in the right iliac fossa. Vaginal examination revealed mild right adnexal tenderness and cervical excitation tenderness. No blood or purulent fluid was noted in the cervical os. Laboratory investigations revealed a leucocytosis (13.4 109/ L; normal range 4.0–11.0 109/L), predominately neutrophils (10.28 109/L; normal range 2.0–8.0 109/L). Biochemistry was normal. b-Human chorionic gonadotropin (bHCG) was negative and urinalysis normal. Transabdominal ultrasound revealed a thin-walled simple anechoic cyst involving the inferior pole of the right ovary, measuring 6 cm in diameter, with a trace of adjacent free fluid. Colour Doppler flow was seen within the right ovary. The uterus and left ovary were normal. The appendix was not visualised. Differential diagnoses included appendicitis, ruptured right ovarian cyst, ectopic pregnancy, right ovarian torsion and pelvic inflammatory disease. Diagnostic laparoscopy was performed. A right ovarian torsion was identified, with the ovary tangled around a fibrous intraperitoneal band connecting the terminal ileum to the anterior abdominal wall at the level of the umbilicus (Fig. 1). The right ovary did not appear necrotic in
Fig. 1. Intraoperative view during diagnostic laparoscopy showing the fibrous intraperitoneal band entangled in the right ovarian torsion.
appearance. The fibrous intraperitoneal band was then excised. The right ovarian cyst was then punctured, drained and stripped from the ovary, preserving the ovary. Post-operative recovery was unremarkable and the patient was discharged the following day. Histopathological examination of the band was consistent with an obliterated vitello-intestinal duct, persisting as a fibrous intraperitoneal band. The cyst was consistent with an ovarian cystadenoma. The vitello-intestinal duct conveys nutrients from the yolk sac to the foetus during the first eight weeks of gestation, after which it normally disappears. Persistence of the vitellointestinal duct results in various types of anomaly [1]. Most commonly seen is a Meckel’s diverticulum, while others include a patent vitello-intestinal duct, fibrous intraperitoneal band, umbilical sinus or vitello-intestinal duct cyst [2]. The commonest complication of the fibrous intraperitoneal band is usually an intestinal obstruction [3]. Unilateral ovarian torsions occur most commonly in relation to previous pelvic surgery, ovarian cysts or neoplasms, or an elongated utero-ovarian ligament [4,5]. An extensive literature search of Ovid MEDLINE1 and PubMed1 did not reveal any prior publications of vitello-intestinal remnants causing ovarian torsion. In conclusion, a persistent vitello-intestinal duct anomaly causing right ovarian torsion is a rare occurrence. We believe this report constitutes the only such case in the English-language literature. The possibility of this rare diagnosis should be entertained when treating patients with ovarian torsion. It is also recommended that large ovarian cysts should be followed more carefully and if persistent, managed surgically in a controlled fashion to avoid such complications as haemorrhage or torsion. References [1] Moore TC. Omphalomesenteric duct malformations. Seminars in Pediatric Surgery 1996;May:116–23. [2] Mahato NK. Obliterated, fibrous omphalo-mesenteric duct in an adult without Meckel’s diverticulum or vitelline cyst. Romanian Journal of Morphology and Embryology 2010;51:195–7. [3] Snyder CL. Current management of umbilical abnormalities and related anomalies. Seminars in Pediatric Surgery 2007;16:41–9. [4] Houry D, Abbott JT. Ovarian torsion: a fifteen-year review. Annals of Emergency Medicine 2001;38:156–9. [5] Varras M, Tsikini A, Polyzos D, et al. Uterine adnexal torsion: pathologic and gray-scale ultrasonographic findings. Clinical and Experimental Obstetrics and Gynecology 2004;31:34–8.
120
(called threadworms in the UK) are accidental finding of ova on cervical smears, vulvovaginitis, salpingo-oophoritis, pelvic or ovarian mass, pelvic pain, etc. Cases have been reported where patients presented with post-coital bleeding and foul-smelling discharge and vermicularis eggs were demonstrated during microscopic examination of a smear taken from the posterior fornix of vagina [2]. Pinworm infestation may rarely present as post-menopausal bleeding, in association with carcinoma of the cervix, or even in a macerated embryo [1]. Enterobius vermicularis may also remain asymptomatic and can present merely as an ectopy when, on colposcopic examination, live worms of enterobius vermicularis were visualized high in the vagina [3]. The case reported here is unusual because the patient presented with an unusual complaint of passage of worms in the menstrual blood and there were no associated complaints of pruritus ani. The worms might have been in the uterine cavity, coming out with the menstrual blood, and were visible due to color contrast. This finding of enterobius vermicularis in menstrual blood supports the theory that the worm and its eggs gain access to the peritoneal cavity through an ascending pathway of vagina, uterus and fallopian tube. References [1] Al-Rufaie HK, Rix GH, Perez CMP, Al-Shawaf T. Pinworm and post-menopausal bleeding. J Clin Pathol 1998;51:401–2. [2] Chung DI, Kong HH, Yu HS, Kim J, Cho CR. Live female enterobius vermicularis in the posterior fornix of vagina of a Korean woman. Korean J Parasitol 1997;35:67–9. [3] Ayala Castellanos Mde L, Monry Rodriguez F, Gomez Lopez EM. Enterobiasis vaginal. Report of one case. Ginecol Obstet Mex 2009;77:491–3.
Savita Rani Singhal* Anshu Paul Pushpa Dahiya Department of Obstetrics and gynecology, Pandit Bhagwat Dayal Sharma Post graduate Institute of Medical Sciences, Haryana, India *Corresponding author at: 14/8FM, Medical Campus, Rohtak, Haryana 124001, India. Tel.: +91 1262 213643 E-mail addresses: [email protected] [email protected] (S.R. Singhal) 1 August 2011 3 March 2012 12 March 2012 doi:10.1016/j.ejogrb.2012.03.017
Misdiagnosis of rodenticide poisoning as ectopic pregnancy: a case report Dear Editor, We report a rare case of rodenticide poisoning misdiagnosed as ectopic pregnancy. An 18-year-old woman was referred to the Emergency Department due to vaginal bleeding and abdominal pain. She was unmarried but sexually active. She had irregular menstrual intervals of 30–60 days, and her last period was 45 days ago. She had had irregular vaginal bleeding for 10 days, and painless hematuria for 5 days. Four hours before admission she
started to experience abdominal pain and coffee-ground vomiting. A urine pregnancy test in the local hospital was positive, and severe dysfunction of coagulation was found. She was given four units of packed red cells and transferred to our hospital because of hypovolemic shock. Physical examination showed that there were large areas of subcutaneous ecchymosis and blood in her mouth, nose and vagina. Her abdomen appeared very distended with tenderness but without rebound tenderness. Bimanual pelvic examination was unsatisfactory because of her non-cooperation and abdominal distention. A full blood count revealed hemoglobin of 63 g/L and platelets of 159 109/L. Emergency ultrasound showed a huge volume of intraperitoneal fluid, and an unevenly echoic mass with a diameter of 5 cm located in the right side of the pelvic cavity, which suggested an ectopic pregnancy or blood clot. Ectopic pregnancy with massive hemorrhage was strongly suspected. Rupture of a corpus luteum was also considered, given that there could be false positive in the previous urine pregnancy test. Emergency laparotomy was performed immediately while the coagulation test and serum HCG test were ongoing. During surgery, surprisingly, we found normal uterus, ovaries and tubes, but only a large amount of blood in the intestines and approximately 400 ml of blood in the pelvis. Subsequently, laboratory tests revealed a markedly prolonged prothrombin time (PT) (72.2 s vs 11.5 s) and activated partial thromboplastin time (APTT) (177.0 s vs 30.4 s). The thrombin time (TT), fibrinogen, and liver function tests were within normal limits. Serum HCG was negative. Therefore, super-warfarin ingestion was strongly suspected at that time. Four units of packed red cells, 1200 ml fresh frozen plasma totally and vitamin K 150 mg daily were given during operation and in the following two days postoperatively. We contacted her teacher and were told that she had recently been very depressed. At first she denied, but finally admitted to ingesting rodenticides (0.005% brodifacoum) three weeks ago. There was a remarkable improvement in her clinical symptoms and the coagulation profile, and she was discharged 4 days later. When cases appear with severe hemoperitoneum, gynecologists usually pay much attention to ectopic pregnancy or rupture of corpus luteum, which both need emergency operation. However, we should not overlook the possibility of coagulation dysfunction caused by poison ingestion, especially the rodenticides due to their commercially easy availability and wide use. Super-warfarin, the common type of rodenticide, has an anticoagulant effect more than 100 times that of warfarin [1,2]. Bleeding manifestations range from microscopic hematuria to massive blood loss, and they may resemble those of ectopic pregnancy complicated by disseminated intravascular coagulation (DIC). This patient, however, had had hematuria for several days, which could not be explained by DIC. Moreover, the coagulation dysfunctions are absolutely different between these two diseases. When excessive blood loss is caused by ectopic pregnancy, the main changes are exhausted platelets and fibrinogen, while in the case of poisoning with anticoagulants the main changes are prolonged PT and APTT with normal fibrinogen and platelet count. Furthermore, comprehensive evaluation, particularly a history of drug and poison use, should be very helpful in diagnosis.
References [1] Leck JB, Park BK. A comparative study of the effect of warfarin and brodifacoum on the relationship between vitamin K1 metabolism and clotting factor activity in warfarin-susceptible and warfarin-resistant rats. Biochem Phamacol 1981;30:123–8. [2] Spahr JE, Maul JS, Rodgers GM. Superwarfarin poisoning: a report of two cases and review of the literature. Am J Hematol 2007;82(7):656–60.
Letters to the Editor / European Journal of Obstetrics & Gynecology and Reproductive Biology 163 (2012) 117–122
121
Lin Wu* Xiaohui Lu Rutie Yin Donghao Lu Department of Obstetrics and Gyncecology, West China Second University Hospital, Sichuan University, No. 20, Section 3, Renmin Road South, Chengdu, China *Corresponding author. Tel.: +86 28 85501346; mobile: +86 13880183060 E-mail address: [email protected] (L. Wu) 8 December 2011 doi:10.1016/j.ejogrb.2012.03.021
A rare confounder in a case of ovarian torsion Dear Editor, We report a 26-year-old woman who presented to the Emergency Department in late 2011, with severe right iliac fossa pain, nausea and vomiting after two weeks of mild generalised abdominal pain. There was no history of fever, urinary symptoms, vaginal bleeding or discharge, or change in bowel habit. Apart from a previously diagnosed right ovarian cyst, her past medical and surgical histories were unremarkable. The cyst had been noted incidentally on a routine ultrasound in 2006 and measured 6.49 cm in diameter. It was simple in nature, unilocular and anechoic. The patient had been having annual follow-up with ultrasound surveillance. Due to the cyst’s lack of increase in size and its asymptomatic nature, the patient opted against surgical intervention. Her obstetric history consisted of two successful spontaneous vaginal deliveries in 2005 and 2006. She was not on any medications, had no known allergies and was a non-smoker. On physical examination, there was localised tenderness and involuntary guarding in the right iliac fossa. Vaginal examination revealed mild right adnexal tenderness and cervical excitation tenderness. No blood or purulent fluid was noted in the cervical os. Laboratory investigations revealed a leucocytosis (13.4 109/ L; normal range 4.0–11.0 109/L), predominately neutrophils (10.28 109/L; normal range 2.0–8.0 109/L). Biochemistry was normal. b-Human chorionic gonadotropin (bHCG) was negative and urinalysis normal. Transabdominal ultrasound revealed a thin-walled simple anechoic cyst involving the inferior pole of the right ovary, measuring 6 cm in diameter, with a trace of adjacent free fluid. Colour Doppler flow was seen within the right ovary. The uterus and left ovary were normal. The appendix was not visualised. Differential diagnoses included appendicitis, ruptured right ovarian cyst, ectopic pregnancy, right ovarian torsion and pelvic inflammatory disease. Diagnostic laparoscopy was performed. A right ovarian torsion was identified, with the ovary tangled around a fibrous intraperitoneal band connecting the terminal ileum to the anterior abdominal wall at the level of the umbilicus (Fig. 1). The right ovary did not appear necrotic in
Fig. 1. Intraoperative view during diagnostic laparoscopy showing the fibrous intraperitoneal band entangled in the right ovarian torsion.
appearance. The fibrous intraperitoneal band was then excised. The right ovarian cyst was then punctured, drained and stripped from the ovary, preserving the ovary. Post-operative recovery was unremarkable and the patient was discharged the following day. Histopathological examination of the band was consistent with an obliterated vitello-intestinal duct, persisting as a fibrous intraperitoneal band. The cyst was consistent with an ovarian cystadenoma. The vitello-intestinal duct conveys nutrients from the yolk sac to the foetus during the first eight weeks of gestation, after which it normally disappears. Persistence of the vitellointestinal duct results in various types of anomaly [1]. Most commonly seen is a Meckel’s diverticulum, while others include a patent vitello-intestinal duct, fibrous intraperitoneal band, umbilical sinus or vitello-intestinal duct cyst [2]. The commonest complication of the fibrous intraperitoneal band is usually an intestinal obstruction [3]. Unilateral ovarian torsions occur most commonly in relation to previous pelvic surgery, ovarian cysts or neoplasms, or an elongated utero-ovarian ligament [4,5]. An extensive literature search of Ovid MEDLINE1 and PubMed1 did not reveal any prior publications of vitello-intestinal remnants causing ovarian torsion. In conclusion, a persistent vitello-intestinal duct anomaly causing right ovarian torsion is a rare occurrence. We believe this report constitutes the only such case in the English-language literature. The possibility of this rare diagnosis should be entertained when treating patients with ovarian torsion. It is also recommended that large ovarian cysts should be followed more carefully and if persistent, managed surgically in a controlled fashion to avoid such complications as haemorrhage or torsion. References [1] Moore TC. Omphalomesenteric duct malformations. Seminars in Pediatric Surgery 1996;May:116–23. [2] Mahato NK. Obliterated, fibrous omphalo-mesenteric duct in an adult without Meckel’s diverticulum or vitelline cyst. Romanian Journal of Morphology and Embryology 2010;51:195–7. [3] Snyder CL. Current management of umbilical abnormalities and related anomalies. Seminars in Pediatric Surgery 2007;16:41–9. [4] Houry D, Abbott JT. Ovarian torsion: a fifteen-year review. Annals of Emergency Medicine 2001;38:156–9. [5] Varras M, Tsikini A, Polyzos D, et al. Uterine adnexal torsion: pathologic and gray-scale ultrasonographic findings. Clinical and Experimental Obstetrics and Gynecology 2004;31:34–8.