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Year : 2018  |  Volume : 14  |  Issue : 5  |  Page : 1154-1156

Superinfection of mature ovarian cystic teratoma in a child: An unusual presentation

1 Department of Pediatric Surgery, Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences, Faridkot, Punjab, India
2 Department of Microbiology, Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences, Faridkot, Punjab, India
3 Department of Pathology, Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences, Faridkot, Punjab, India

Date of Web Publication7-Sep-2018

Correspondence Address:
Ashish Chhabra
Department of Pediatric Surgery, Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences, Faridkot - 151 203, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0973-1482.187238

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 > Abstract 

Mature cystic teratoma is the most common type of ovarian germ cell tumor. The presentation ranges from its asymptomatic nature to various complications such as torsion, rupture, and malignant change. The present case summarizes the rarest complication in the form of superinfection in a young girl without preexisting risk factors.

Keywords: Escherichia coli, mature cystic teratoma, ovary, superinfection

How to cite this article:
Chhabra A, Galhotra S, Nibhoria S. Superinfection of mature ovarian cystic teratoma in a child: An unusual presentation. J Can Res Ther 2018;14:1154-6

How to cite this URL:
Chhabra A, Galhotra S, Nibhoria S. Superinfection of mature ovarian cystic teratoma in a child: An unusual presentation. J Can Res Ther [serial online] 2018 [cited 2021 Oct 25];14:1154-6. Available from: https://www.cancerjournal.net/text.asp?2018/14/5/1154/187238

 > Introduction Top

Mature cystic teratomas are the most common benign ovarian tumors, accounting for 10–20% of all ovarian tumors and almost half of the ovarian malignancies among children.[1] They may remain asymptomatic or might become complicated by torsion, rupture, and malignant degeneration.[2] The secondary infection in a mature cystic teratoma is an extremely rare occurrence and often misdiagnosed.[3] We present an unusual case of  Escherichia More Details coli superinfection in mature dermoid cyst of the ovary in a young girl.

 > Case Report Top

An 8-year-old girl was admitted with a 1-month history of fever and abdominal pain together with a mass in her lower abdomen for 20 days. She was also having poor urinary stream for 10 days. The child was febrile with a temperature of 40.2°C. Weight and height percentiles were more than 50th percentile as per the World Health Organization growth charts. Examination of the abdomen revealed a large, well-defined midline abdominopelvic mass and it was soft to firm in consistency, slightly tender, and mobile in nature. External genitalia examination was unremarkable.

Ultrasound of the abdomen revealed a cystic mass measuring 10.2 cm × 7.6 cm along with echogenic contents. Laboratory studies revealed total leukocyte count of 16.5 × 103/dl. Rest of the routine blood work-up, serum lactate dehydrogenase, serum alpha-fetoprotein, and serum beta human chorionic gonadotrophic values were within the normal range. Abdominal magnetic resonance imaging (MRI) revealed a 12.0 cm × 12.0 cm × 6.7 cm sized predominantly cystic abdominopelvic lesion likely originating from the left ovary. Mild free fluid was seen in the pouch of douglas in addition.

The patient was started on intravenous cefoperazone-sulbactam, amikacin, and antipyretics, and subsequently, the patient was subjected to exploratory laparotomy. A 12.0 cm × 10.5 cm × 8.5 cm sized left ovarian cystic mass with pale surface was noted without any local invasion. There was minimal serous-free fluid in the pelvis. Left  Fallopian tube More Details, right-sided adnexal structures, uterus, and rest of the abdominal viscera were normal in appearance. Left oophorectomy was performed as per the standard surgical protocols. On cut section of the mass, approximately 350 ml of thick pus was noticed along with a tuft of hairs, teeth, and cartilaginous material [Figure 1]. Microbiological examination reported growth of E. coli and as per the sensitivity report, the patient was continued on the same antibiotics. The child had a resolution of her symptoms and was discharged in the satisfactory condition. Histopathology of the resected left ovarian specimen was suggestive of mature cystic teratoma [Figure 2]. She is now being followed up as an outpatient and is doing well.
Figure 1: Infected mature ovarian cystic teratoma showing thick pus, tuft of hairs, teeth, and cartilaginous material as its contents

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Figure 2: Photomicrograph (H and E, ×100) depicting the elements of mature cystic teratoma

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 > Discussion Top

Mature cystic teratomas, often referred to as dermoid cysts, are the most common germ cell tumors of the ovary. They display a varying admixture of elements of one or more of the three germ cell layers: ectoderm, mesoderm, and endodermal.[4] Unlike other germ cells of the ovary, it has a wider age distribution and may be encountered at any age.[1]

These tumors are usually asymptomatic until they reach considerable size or become complicated. The complications reported are - torsion, hemorrhage, infection, or spontaneous rupture of the cyst either into the peritoneal cavity or into the adjacent hollow viscera.[4] The secondary infection is a rare phenomenon, and only a few cases were found on data search. Gong et al. studied clinical aspects of 695 cases of mature dermoid ovarian cysts, and superinfection was found to be the rarest complication.[5] In a series of 501 cases of mature ovarian cystic teratomas operated over 34 years, total complication rate was 10.7% with torsion being the most common (4.9%). None of the patient was reported to have secondary infection as a complication in the study.[1]

The coliform bacteria are the leading culprits for the superinfection in these tumors; the other rare organisms being Actinomyces,  Salmonella More Details,  Brucella More Details, and Schistosoma.[2],[3],[6] This complication has been seen mostly among the sexually active females and in those patients undergoing uterovaginal interventions.[7] The other routes which have been identified are - hematogenous and directly from the gastrointestinal system infected with Salmonella species. These patients usually have background symptomology suggestive of bacteremia and gastroenteritis, respectively.[3],[8] Coliform bacteria, for example, E. coli are present as nonpathogenic resident flora in the vagina and also at external genitalia of the females.[9] Moreover, thus, we can assume E. coli bacteria to have transmitted through the ascending route in the left ovary. Interestingly, this patient did not have any of the risk factors numerated previously.

Most of the patients with superadded infection present with abdominal pain/distension and fever as their primary symptoms.[1],[2] This patient was admitted with the similar complaints, and in addition, she also developed urinary complaints in the form of poor urinary stream and dysuria. These urinary symptoms can be associated with the external mass effect of the large infected left ovarian tumor over the urinary bladder.

The literature as described suggests that infection in a mature teratoma is a relatively uncommon event. Diagnosis dilemma remains, however, it should be considered in a female patient presenting with an abdominopelvic mass along with the abdominal pain and fever. Imaging modalities in the form of ultrasonography followed by computed tomography/MRI abdomen and tumor markers' evaluation are needed to confirm the diagnosis. Prompt surgical intervention together with appropriate antibiotic therapy is the optimal clinical management in the setting of infected ovarian teratomas to prevent further complications such as spontaneous perforation into the peritoneal cavity and/or invasion into the neighboring hollow viscera.

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Conflicts of interest

There are no conflicts of interest.

 > References Top

Ayhan A, Bukulmez O, Genc C, Karamursel BS, Ayhan A. Mature cystic teratomas of the ovary: Case series from one institution over 34 years. Eur J Obstet Gynecol Reprod Biol 2000;88:153-7.  Back to cited text no. 1
Salehpour S, Akbari Sene A. Super infection of an ovarian dermoid cyst with Actinomyces in an infertile woman. Int J Fertil Steril 2013;7:134-7.  Back to cited text no. 2
Gorisek NM, Oreskovic S, But I. Salmonella ovarian abscess in young girl presented as acute abdomen – Case report. Coll Antropol 2011;35:223-5.  Back to cited text no. 3
von-Walter AR, Nelken RS. Benign cystic ovarian teratoma with a fistula into the small and large bowel. Obstet Gynecol 2012;119 (2 Pt 2):434-6.  Back to cited text no. 4
Gong XM, Leng JH, Lang JH, Huang RL, Liu ZF, Sun DW, et al. Clinical aspects of mature ovarian teratoma: Result of 695 cases. Zhongguo Yi Xue Ke Xue Yuan Xue Bao 2004;26:692-5.  Back to cited text no. 5
Uwaydah M, Khalil A, Shamsuddine N, Matar F, Araj GF. Brucella-infected ovarian dermoid cyst causing initial treatment failure in a patient with acute brucellosis. Infection 1998;26:131-2.  Back to cited text no. 6
Manning S, Saridogan E. Tubo-ovarian abscess: An unusual route of acquisition. J Obstet Gynaecol 2009;29:355-6.  Back to cited text no. 7
Tohya T, Yoshimura T, Onoda C. Unilateral ovarian abscess caused by Salmonella. Infect Dis Obstet Gynecol 2003;11:217-9.  Back to cited text no. 8
Lamont RF, Sobel JD, Akins RA, Hassan SS, Chaiworapongsa T, Kusanovic JP, et al. The vaginal microbiome: New information about genital tract flora using molecular based techniques. BJOG 2011;118:533-49.  Back to cited text no. 9


  [Figure 1], [Figure 2]


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