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Torsion of normal ovary in the first two years of life
CASE
REPORTS
Torsion of Normal Ovary in the First Two Years of Life CAPT. JAY L. GROSFELD, MC, USAR, Fort Jackson,
Torsion
of the ovarian
and benign
pedicle
and malignant
well established
entity
complicating
tumors
[I$].
of the ovary
cysts is a
Although
quite rare, normal ovary. Torsion of normal adnexal structures in children most often occurs in the premenarche age group (seven to fourteen years) [S]. It is exceptionally rare in the first two years of life, only three cases being recorded in the literature [Q-B]. (Table I.) torsion may also occur in a previously
An
additional
ovary
instance
in a twenty-two with acut,e abdominal presentation.
of torsion
month findings
of a normal
old female infant seems worthy of
Case Report The patient (1~. S.), a twenty-two month old white female infant, was admitted to the U. S. Army Hospital, Fort Jackson, South Carolina, because of a three day history of anorexia, nausea, vomiting, and abdominal pain. There was no constipation or diarrhea. Low grade fever and resistance to weight bezring on the right leg had been noted. History revealed no allergies or serious illnesses and a normal growth and development pattern. Review of systems and family history were noncontributory. Physical examination revealed an irritable and acutely ill infant. Temperature was 101.6”~., pulse rate 140 per minute, blood pressure 95/50 mm. Hg, and respiratory rate 28 per minute. The abdomen was flat, semirigid, and tender in the right lower quadrant. Muscle guarding and rebound tenderness were elicited, and no masses were palpable. Psoas sign was positive. Bowel sounds were absent. Rectal examination revealed tenderness of the right wall. The remainder of the physical examination was unremarkable. Laboratory data were as follows: hemoglobin 11.2 gm. per cent, hematocrit 34 per cent, white blood cell count 18,200 per mm3., with 62 per cent polymorphonuclear leukocytes, 11 per cent band neutrophils, and 27 per cent lymphocytes on differential count. Urinalysis was negative for sugar, acetone, and
From the Department of Surgery, U. S. Army Hospital, Fort Jackson, South Carolina 29207. Present Address: Department of Pediatric Surgery. The Children’s Hospital, Columbus, Ohio 43205.
726
South
Carolina
albumin. Microscopic examination gave normal results. The chest roentgenogram was clear. Erect and recumbent abdominal roentgenograms showed small and large bowel distention consistent with adynamic ileus. No masses or calcification was observed. After a preoperative diagnosis of perforated appendicitis was made, operation was performed through a transverse incision in the right lower quadrant. Bloody fluid was noted on entrance into the peritoneal cavity. The appendix was normal. A mass was palpable in the pelvis and proved to be a gangrenous right ovary and tube twisted three times on its pedicle. Right salpingo-oophorectomy and incidental appendectomy were performed. The postoperative course was uneventful. The operative specimen consisted of a gangrenous ovarian mass measuring 4.5 by 2.5 by 2.5 cm. (Fig. 1.) On section the mass was hemorrhagic. Microscopic examination revealed edematous stroma with extravasated red blood cells actually obliterating the tissue architecture. Occasional follicles were seen. Many areas of frank infarction and necrosis were noted. The pathologic diagnosis was infarcted ovary with hemorrhagic necrosis.
Comments It is apparent from the present study and previously reported cases that torsion of a previously normal ovary is often misdiagnosed as acute appendicitis. Lower abdominal pain, usually of longer than fortyeight hours’ duration, anorexia, nausea, and vomiting are the common presenting symptoms. Excessive mobility of the adnexa in children appears to be the most likely cause [S]. Recurrent episodes of pain noted in older premenarchal children with ovarian torsion do not occur in infants and therefore cannot be used to differentiate between ovarian torsion and acute appendicitis in infants. Leukocytosis, fever, and tachycardia are common symptoms to both appendicitis and torsion. A palpable mass is common in premenarchal children, being found in approximately 66 per cent of instances. Only one of four patients in the first two years presented with a mass. Delay in diagnosis of the acute abdomen in early life is unfortunately the rule rather than the exception. It is doubtful that diagnosis in infants can be made early enough to allow salvage of the adnexal structures The American
Journal of Surgery
Torsion
TABLE
I
Summary
Author Gould [4] Rost [5] Seiber [6] Grosfeld (present
of Reported
Cases of Torsion
of Normal
Age (mo. 1
Side of Torsion
Palpable Abdominal Mass
24 5.5 4
Right Right Right
No Yes No
22
Right
No
instance)
of Normal
Ovary in Infant
Ovary in the First Two Years of Life
Preoperative Diagnosis Acute appendicitis Acute appendicitis Appendicitis with perforation Appendicitis with perforation
Operation Performed Salpingo-oophorectomy Salpingo-oophorectomy Salpingo-oophorectomy Salpingo-oophorectomy
rare. A fourth instance in this age group is reported. The presenting symptoms and difficulties in diaguosis are discussed. Torsion of a normal ovary should be considered in the differential diagnosis of acute abdominal pain in female infants in the first two years of life.
References
Fig. 1. Gangrenous ovarian mass measuring 4.5 by 2.5 by 2.5 cm. Microscopic examination revealed infarcted ovary with hemorrhagic necrosis. after torsion. Salpingo-oophorectomy operation of choke.
brxcomes
the
Summary The occurrence of torsion of a previously normal ovary in the first two years of life is exceptionally
Vol.117,May 1969
1. BOLES, E. T., JR., HARDACRE, J. Al.,and NE\VTON, W. A., JR. Ovarian tumors and cysts in infants and children. :lrch. Surg., X3: 580, 1!$61. 2. MAKSHAIA, J. K. Ovarian enlargements in the first year of life: review of 45 cases. Ann. Sury., 161: 372: 1965. 3. ScHuLTz, L. It., NEWTON, W. A., JR., and CI.ATWOHTHY, H. W. Torsion of previously normal tube and ovary in children. New England J. Ned., 268: 343, 1963. 4. GOULD, A. H. Torsion of ovarian pedicle in a two year old child. Rocky Mountain M. J., 44: 38.5, 1947. 5. ROST, W. L. Twisted ovarian pedicle. Arch. Perlid., 40: 787, 1923. 6. SEIBER, W. K. Torsion of normal uterine adnera in infancy and childhood. Pediatrics, 14: 663, 1954.
727
REPORTS
Torsion of Normal Ovary in the First Two Years of Life CAPT. JAY L. GROSFELD, MC, USAR, Fort Jackson,
Torsion
of the ovarian
and benign
pedicle
and malignant
well established
entity
complicating
tumors
[I$].
of the ovary
cysts is a
Although
quite rare, normal ovary. Torsion of normal adnexal structures in children most often occurs in the premenarche age group (seven to fourteen years) [S]. It is exceptionally rare in the first two years of life, only three cases being recorded in the literature [Q-B]. (Table I.) torsion may also occur in a previously
An
additional
ovary
instance
in a twenty-two with acut,e abdominal presentation.
of torsion
month findings
of a normal
old female infant seems worthy of
Case Report The patient (1~. S.), a twenty-two month old white female infant, was admitted to the U. S. Army Hospital, Fort Jackson, South Carolina, because of a three day history of anorexia, nausea, vomiting, and abdominal pain. There was no constipation or diarrhea. Low grade fever and resistance to weight bezring on the right leg had been noted. History revealed no allergies or serious illnesses and a normal growth and development pattern. Review of systems and family history were noncontributory. Physical examination revealed an irritable and acutely ill infant. Temperature was 101.6”~., pulse rate 140 per minute, blood pressure 95/50 mm. Hg, and respiratory rate 28 per minute. The abdomen was flat, semirigid, and tender in the right lower quadrant. Muscle guarding and rebound tenderness were elicited, and no masses were palpable. Psoas sign was positive. Bowel sounds were absent. Rectal examination revealed tenderness of the right wall. The remainder of the physical examination was unremarkable. Laboratory data were as follows: hemoglobin 11.2 gm. per cent, hematocrit 34 per cent, white blood cell count 18,200 per mm3., with 62 per cent polymorphonuclear leukocytes, 11 per cent band neutrophils, and 27 per cent lymphocytes on differential count. Urinalysis was negative for sugar, acetone, and
From the Department of Surgery, U. S. Army Hospital, Fort Jackson, South Carolina 29207. Present Address: Department of Pediatric Surgery. The Children’s Hospital, Columbus, Ohio 43205.
726
South
Carolina
albumin. Microscopic examination gave normal results. The chest roentgenogram was clear. Erect and recumbent abdominal roentgenograms showed small and large bowel distention consistent with adynamic ileus. No masses or calcification was observed. After a preoperative diagnosis of perforated appendicitis was made, operation was performed through a transverse incision in the right lower quadrant. Bloody fluid was noted on entrance into the peritoneal cavity. The appendix was normal. A mass was palpable in the pelvis and proved to be a gangrenous right ovary and tube twisted three times on its pedicle. Right salpingo-oophorectomy and incidental appendectomy were performed. The postoperative course was uneventful. The operative specimen consisted of a gangrenous ovarian mass measuring 4.5 by 2.5 by 2.5 cm. (Fig. 1.) On section the mass was hemorrhagic. Microscopic examination revealed edematous stroma with extravasated red blood cells actually obliterating the tissue architecture. Occasional follicles were seen. Many areas of frank infarction and necrosis were noted. The pathologic diagnosis was infarcted ovary with hemorrhagic necrosis.
Comments It is apparent from the present study and previously reported cases that torsion of a previously normal ovary is often misdiagnosed as acute appendicitis. Lower abdominal pain, usually of longer than fortyeight hours’ duration, anorexia, nausea, and vomiting are the common presenting symptoms. Excessive mobility of the adnexa in children appears to be the most likely cause [S]. Recurrent episodes of pain noted in older premenarchal children with ovarian torsion do not occur in infants and therefore cannot be used to differentiate between ovarian torsion and acute appendicitis in infants. Leukocytosis, fever, and tachycardia are common symptoms to both appendicitis and torsion. A palpable mass is common in premenarchal children, being found in approximately 66 per cent of instances. Only one of four patients in the first two years presented with a mass. Delay in diagnosis of the acute abdomen in early life is unfortunately the rule rather than the exception. It is doubtful that diagnosis in infants can be made early enough to allow salvage of the adnexal structures The American
Journal of Surgery
Torsion
TABLE
I
Summary
Author Gould [4] Rost [5] Seiber [6] Grosfeld (present
of Reported
Cases of Torsion
of Normal
Age (mo. 1
Side of Torsion
Palpable Abdominal Mass
24 5.5 4
Right Right Right
No Yes No
22
Right
No
instance)
of Normal
Ovary in Infant
Ovary in the First Two Years of Life
Preoperative Diagnosis Acute appendicitis Acute appendicitis Appendicitis with perforation Appendicitis with perforation
Operation Performed Salpingo-oophorectomy Salpingo-oophorectomy Salpingo-oophorectomy Salpingo-oophorectomy
rare. A fourth instance in this age group is reported. The presenting symptoms and difficulties in diaguosis are discussed. Torsion of a normal ovary should be considered in the differential diagnosis of acute abdominal pain in female infants in the first two years of life.
References
Fig. 1. Gangrenous ovarian mass measuring 4.5 by 2.5 by 2.5 cm. Microscopic examination revealed infarcted ovary with hemorrhagic necrosis. after torsion. Salpingo-oophorectomy operation of choke.
brxcomes
the
Summary The occurrence of torsion of a previously normal ovary in the first two years of life is exceptionally
Vol.117,May 1969
1. BOLES, E. T., JR., HARDACRE, J. Al.,and NE\VTON, W. A., JR. Ovarian tumors and cysts in infants and children. :lrch. Surg., X3: 580, 1!$61. 2. MAKSHAIA, J. K. Ovarian enlargements in the first year of life: review of 45 cases. Ann. Sury., 161: 372: 1965. 3. ScHuLTz, L. It., NEWTON, W. A., JR., and CI.ATWOHTHY, H. W. Torsion of previously normal tube and ovary in children. New England J. Ned., 268: 343, 1963. 4. GOULD, A. H. Torsion of ovarian pedicle in a two year old child. Rocky Mountain M. J., 44: 38.5, 1947. 5. ROST, W. L. Twisted ovarian pedicle. Arch. Perlid., 40: 787, 1923. 6. SEIBER, W. K. Torsion of normal uterine adnera in infancy and childhood. Pediatrics, 14: 663, 1954.
727