1 Sharma P, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2017-221213 SUMMARY We report a case of a tubo-ovarian abscess infected with Salmonella enterica serotype typhi. A 19-year-old Nepalese woman presented to a hospital in Kathmandu with lower abdominal pain, constipation, fever and a non-healing, suppurative surgical wound from an emergency caesarian section performed 2 months previously at 37 weeks of pregnancy. She also had an exploratory laparotomy for an appendix perforation with peritonitis at 25 weeks of gestation. Her wound infection did not respond to cloxacillin and she had an exploratory laparotomy, and a tubo-ovarian abscess was found from which S. typhi was isolated. She had a bilateral salpingo-oophorectomy and responded to 14 days of chloramphenicol. A tubo-ovarian abscess is a rare complication of enteric fever. BACKGROUND Salmonella enterica serovar typhi (S. typhi) is a leading cause of illness in Nepal. 1 A tubo-ovarian abscess caused by S. typhi is a rare complication with only two patients reported in the literature. 2 3 Here we describe a case of tubo-ovarian abscess caused by S. typhi in Nepal. CASE PRESENTATION A 19-year-old woman presented in January 2017 to Patan Hospital in Kathmandu, Nepal, with abdominal pain localised around the site of a recent incision for a caesarian section. She had a prior history of an exploratory laparotomy for perforated appendicitis and peritonitis at 25 weeks of preg- nancy. At operation, 100 mL of pus was aspirated from the bilateral paracolic gutters. At 37 weeks of pregnancy, an emergency caesarean section was performed because of meconium-stained liquor. The baby was born healthy. She was discharged on the fourth day postcaesarean. Suture removal was performed a week later when cloxacillin was prescribed for 7 days because of serous discharge from the wound. A wound culture showed no bacterial growth. She was then well until 2 months later when she presented with abdominal pain. On examination, her temperature was 100 o F, pulse 98 bpm and blood pressure 90/60 mm Hg. Her surgical incision site was red, indurated, with fluctu- ating tenderness. Ten millilitres of pus was aspirated but had no bacterial growth after 48 hours. Ultraso- nography revealed cystic collection posterior to the uterus. Cloxacillin was started at 500 mg four times daily. Further wound debridement with culdocen- tesis was performed on day 20 of admission and 150 mL of pus was drained. S. typhi was cultured from this pus but, because she showed no signs of fever, the cloxacillin was continued for 2 weeks and she was discharged. She returned to hospital 6 days later having become unwell with fever, pain in the right lower quadrant, nausea, vomiting and constipation. She appeared toxic, with a temperature of 101.2 o F, with a 5 cm gap in the abdominal wound, associated with minimal discharge and tenderness. Per-vaginal examination revealed a bulky tender uterus with decreased mobility. INVESTIGATIONS An ultrasonography showed a 10×10 cm 2 mass in the Pouch of Douglas (figure 1). An exploratory laparotomy was performed which revealed dense adhesions in the rectus sheath, subcutaneous tissue, muscle, omentum and uterus. The left ovary was adherent to the Pouch of Douglas and rectum posteriorly with additional inflammation of the right tube and ovary. Approxi- mately 40 mL of pus was drained from a left ovarian abscess and bilateral salpingo-oophorectomy was carried out (figure 2). S. typhi was cultured from the pus (figure 3). By disc sensitivity testing, the isolate was susceptible to chloramphenicol, amoxicillin, trimethoprim-sul- famethoxazole, ceftriaxone and azithromycin but resistant to ciprofloxacin and gatifloxacin. TREATMENT The patient had already been on antibiotics for a long period of time. Keeping in mind the uprising resistance to ceftriaxone, chloramphenicol at 500 mg four times a day was started. OUTCOME AND FOLLOW-UP The fever subsided within 48 hours and the chloramphenicol was continued for 14 days (figure 4). She was reviewed at 1-month follow-up when she was improving and her child was healthy. DISCUSSION A tubo-ovarian abscess is an inflammatory mass that presents as a late complication of pelvic inflamma- tory disease, infected intrauterine devices, acute appendicitis, diverticulitis or any abdominal surgery. Predisposing factors include diabetes mellitus, immunodeficiency and pregnancy. The route of transmission is commonly through an ascending infection from the cervix or haematogenous/ CASE REPORT Tubo-ovarian abscess infected by Salmonella typhi Paban Sharma, 1 Abhusani Bhuju, 2 Ruhee Tuladhar, 1 Christopher M Parry, 3 Buddha Basnyat 2 Unusual presentation of more common disease/injury To cite: Sharma P, Bhuju A, Tuladhar R, et al. BMJ Case Rep Published Online First: [please include Day Month Year]. doi:10.1136/bcr-2017- 221213 1 Department of Obstetrics and Gynecology, Patan Hospital, Kathmandu, Nepal 2 Oxford University Clinical Research Unit, Patan Hospital, Kathmandu, Nepal 3 Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK Correspondence to Professor Buddha Basnyat, buddha.basnyat@ndm.ox.ac.uk Accepted 30 July 2017