Ovarian dermoid torsion with concomitant acute appendicitis: A case report

Abstract

Acute appendicitis and adnexal torsion are leading causes of acute surgical abdomen in female patients. However, the simultaneous occurrence of these 2 conditions is extremely rare. Here, we present an extraordinary case of a woman radiologically diagnosed with ovarian dermoid torsion coexisting with acute appendicitis. The patient was managed operatively by surgeons from the respective fields in a single setting, thereby meeting the patient's standard of care. This case provides valuable insight into the possible coexistence of acute adnexal pathology with acute bowel pathology and vice versa, emphasizing that radiologists should avoid satisfaction of search after a single possible explanation of the condition.

Introduction

Adnexal torsion is a leading cause of acute abdomen in females, accounting for up to 3% of women presenting with acute abdominal pain in an emergency department [1]. This condition can occur across a wide range of age groups, most often involving females of reproductive age. Torsion typically occurs against the background of an underlying ovarian cyst or mass [2].

Acute appendicitis is the most frequently encountered surgical cause of abdominal pain, affecting all age groups, with a lifetime incidence of approximately 7% [3,4]. The association of acute appendicitis with gynecological pathology is estimated to be about 4.6% [5,6]. However, the concomitant association of acute adnexal torsion with acute appendicitis is extremely rare. Notable associations in the literature include cases described by Youssef et al. (2022), Hoey et al. (2005), Gavrilenko et al. (1986), Kokoszka et al. (1978), and Nikolaev et al. [2,[7], [8], [9], [10]]. Some of these cases were clinically diagnosed, while others were identified through imaging. Here, we present a case of an adult female with acute ovarian dermoid torsion and concomitant acute appendicitis.

Case presentation

A 39-year-old female presented with acute abdominal pain for a few hours, associated with mild nausea. On examination, she had a distended abdomen with tenderness over the right iliac fossa. Basic lab investigations revealed leukocytosis with elevated neutrophils.

A contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis (Figs. 1A and B, Video 1) revealed an enlarged appendix with thickened and enhancing walls and associated periappendiceal soft tissue strandings, consistent with acute appendicitis. A large, well-defined cystic lesion was observed on the right side of the abdominal cavity, showing a nonenhancing mural nodule and coarse calcifications. A fat-fluid level was noted within the lesion. No obvious enhancing solid components were noted. These features were consistent with a dermoid cyst. The pedicle of this dermoid had a whorled appearance (Fig. 1B), and the right ovary was not separately visualized. A small simple cyst was noted in the left ovary, and mild free fluid was observed in the pelvis.

Fig. 1.

(A) Abdomen and pelvic contrast-enhanced CT scan, coronal view, showing a large right ovarian dermoid cyst with Rokitansky nodule, fat, and calcific components. The uterus is tilted towards the torsed ovary (orange arrow). Note the enlarged and enhancing appendix (blue arrow) in the right iliac fossa with surrounding soft tissue strandings. (B) Abdomen and pelvic contrast-enhanced CT scan, coronal view, showing similar findings. Note the twisted pedicle giving a whorled appearance (blue arrow) just medial to the inflamed appendix.

With these clinical and imaging findings, a final diagnosis of acute appendicitis with torsion of the right ovarian dermoid was made. The patient underwent right salpingo-oophorectomy and appendectomy in a single setting by the respective departments. The imaging findings were confirmed by operative findings, revealing a large gangrenous right ovary twisted twice over its pedicle (Figs. 2A and B). The ipsilateral fallopian tube was also edematous. The cut section of the cyst revealed fatty components, a tooth, and cartilaginous structures. The appendix was inflamed and enlarged, measuring 7 cm in length and 12 mm in diameter (Fig. 3). Both specimens were sent for histopathological examinations, confirming the radiological and surgical findings.

Fig. 2.

(A) Intraoperative findings of a large twisted ovarian cyst. Note the twisted pedicle (blue arrow). (B) Surgically excised specimen of the ovarian cyst along with its pedicle and fallopian tube.

Fig. 3.

Surgically excised specimen of the inflamed appendix.

Discussion

The ovary is a mobile structure, suspended by the infundibulopelvic (suspensory) ligament and the utero-ovarian ligament. It has a dual blood supply from the ovarian vessels (within the suspensory ligament) and uterine vessels (within the utero-ovarian ligament). Torsion occurs when there is a twist along any of these ligaments, resulting in obstruction of lymphatic, venous, and arterial supply. Ovarian torsion usually occurs with underlying ovarian pathology, commonly ovarian cysts or masses [2]. Ovarian dermoid cysts account for a substantial number of such cases [11].

Dermoid cysts are the most common ovarian tumors, accounting for approximately 15% of all ovarian neoplasms [12]. They are usually asymptomatic unless complicated and detected incidentally. The most frequently encountered complication associated with dermoid cysts is torsion, which occurs in approximately 15% of all dermoid cases [11]. Typical imaging findings in ovarian dermoid cases include a cystic lesion with mural nodule (Rokitansky nodule), calcific components, fat components with fat-fluid level, tufts of hair, and sometimes the floating ball appearance [13]. Associated ovarian torsion has characteristic imaging findings, including enlarged round ovaries with peripherally placed follicles, shifting of the ovaries towards midline, deviation of the uterus towards the torsed ovary, twisted pedicle or whirlpool between the uterus and ovary (pathognomonic), associated peritoneal free fluid, and underlying ovarian pathology [14,15]. Our case had typical imaging features of dermoid cysts consistent with most of the above-mentioned findings. The uterus appeared pulled up towards the torsed ovary with remarkable twisting of the pedicle, giving a whirlpool appearance and mild pelvic ascites.

CT findings indicating appendicitis include increased appendiceal diameter (outer to outer diameter greater than 8-9 mm) with increased wall thickness (>3 mm), periappendiceal soft tissue strandings, and periappendiceal fluid [16,17]. Other associated features include appendicolith, focal nonenhancing segment of the wall with gas locules suggesting gangrenous changes, signs of perforation with focal discontinuity in the wall, and associated abscess formation [16].

Conclusion

This case highlights the rare coincidence of acute ovarian dermoid torsion with acute appendicitis. The take-home message from our case is to avoid the satisfaction of search after finding an acute adnexal pathology and be vigilant for other associated or coexisting pathologies. In a female with an acute abdomen, such as appendicitis, we should thoroughly investigate for any possible adnexal pathology before giving a final diagnosis.

Patient consent

Written informed consent was obtained from the patients for publication of this case report and any accompanying images.

Appendix. Supplementary materials

Video 1: Video clip of abdomen and pelvic contrast-enhanced CT scan, coronal view, showing the large right ovarian dermoid cyst with twisting of the pedicle, giving a whorled appearance. Note the enlarged and inflamed appendix in the right iliac fossa with surrounding fat strandings and mild pelvic ascites.