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H ind a w i P ublishing Co r p o r ation Case R epo r ts in Emergency M edicine V olume 2012, A r ticle ID 679121, 3 pages doi:10.1155/2012/679121 Ca s e R e po r t O v a r ian T orsion in a 5 Y e ar O ld: A Case R e p o r t and R e v i ew M atthew F R yan and B ob b y K. Desai D e pa rt m e nt o f E m er g e ncy M edi c ine, C o ll e g e o f M edi c ine, U niv er si t y o f Flo r ida, P O B o x 100186, Gaines v ille, FL 32610 0186, USA Co r r esponden c e should be add r essed t o B ob b y K. Desai, bdesai@ufl.edu R e c e i v ed 5 M a r c h 2012; A cc ep t ed 22 A p r il 2012 A cademic Edi t ors: V P apa do p oulos and M. Sand Cop y r i g ht 2012 M. F R y an and B K. Desai. This is an o p en a cc ess a r ti c le dis t r ibu t ed under the Cr eat i v e C ommons A t t r ibution Li c ense, w hi c h p e r mits un r es t r ic t ed use, dis t r ibution, and r ep r o duction in a n y medium, p ro v ided the o r i g inal w o r k is p r o perly ci t ed. Ova r ian t orsion r ep r esents a tr ue sur g ical e mergenc y P r o mpt dia g nosis is essential t o o va r ian sa l vage, and hi g h c linical suspicion is impo r tant in this r e ga r d. C onfounding the dia g nosis in gene r al a r e mo r e c o mmonly e n c oun t e r ed ab do minal c omplaints in the Emergency Depa r t ment (ED) su c h as c o nstipation, dia r r hea, and u r ina r y t r act infections and mo r e c o mmon sur g ical e mergencies su c h as appendicitis. P r o mpt dia g nosis can b e fu r ther c o mplica t ed in l o w r isk p o pulations su c h as y oung c hild r en. H e r ein, w e desc r ibe the case o f a 5 y ea r old g irl w ith a seemin g ly beni g n p r esentation o f ab d ominal pain w ho was dia g nosed in the ED and t r ea t ed for acu t e o va r ian t orsion af t e r t w o p r ior c linic v isits. A b r ief discussion of e va l uation, t r ea t ment, and management of o va r ian t orsion fo l l o ws. 1. I n t r o d uc t i o n Ova r ian t o rsi o n can b e an ab do minal catas t r op he f o r w o men, es p ecia l ly if o va r ian sa l vage is not possible. P a thop h ysiological r amifications include o va r ian loss, in t r a abominal infe c tion, sepsis, and e v e n d eath. The ps y c holog ical impa c ts can also be p r ofound [ 1 2 ]. Early dia g nosis and hi g h c linical suspicion a r e k e ys t o p r ompt identification and d efinit i v e s ur g ical t r ea t ment of this dia g nostic dilemma. W e r epo r t on a case o f o va r ian t o rsion in a f i v e y ea r old g irl w ho initia l l y p r esen t ed t o her p edia t r ician w ith nons p ecific ab do minal pain. The r e w e r e s e v e r al fa c t ors that c o nfounded the dia g nosis: firstl y was the fa c t that the patient had b een seen and e xamined t w i c e p r ior t o p r esenting t o the Emergency Depa r t ment (ED). Se c ondl y the mista k e n belief of the r a r i t y of o va r ian t orsion w ithin this patient p o pulation; f i v e y ea r old g irls a r e w e l l w ithin the bimodal dis t r ibution for o va r ian t orsion. A nd lastl y the patien t s seemin g ly beni g n p r esentation. 2. Case R e p o r t A p r e v iously healt h y f i v e y ea r old g irl p r esen t ed t o the ED w ith a o ne d a y his t o r y o f f e v er and r i g ht l o we r q uad r ant pain. She had been e valua t ed b y her p edia t r ician the p r e v ious

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d a y and was dia g nosed w ith acu t e g as t r oen t e r itis af t e r a beni g n p h ysical e xam and ne g at i v e u r inalysis. H o w e v e r her s y mp t o ms p r o g r essed and her pa r ents b r ou g ht her t o an af t e r hours urgent ca r e facili t y w he r e a se c ond u r inalysis was p erfo r med and was a g ain ne g at i v e. The patient was a g ain dis c harged w ith a dia g nosis of g as t r oen t e r itis. The n e xt mo r ning the patien t s pain had be c o me mo r e s e v e r e and she was sent t o the ED b y her p edia t r ician for fu r ther e valuation. U pon p r esentation t o the E D the patient appea r ed i l l and un c omfo r table. She c o mplained o f c onstant pain not r eli e v ed w ith a c etamin o phen or ibup r o fen. H e r r e v iew o f s y mp t o ms was posit i v e for f e v e r one episode o f v omitin g and ab d ominal pain. She was bo r n fu l l t e r m and has a his t o r y o f asthma managed w ith inhaled c o r t i c os t e r o ids and albu t e r ol. She has t w o siblin g s w ho we r e healt h y and she had no i l l c onta c ts. On p h ysical e xam, the patien t s v ital si g ns w e r e w ithin n o r mal pa r am e t e rs f o r h e r age. H e r o r al t e m p e r atu r e was 36.5 C, hea r t r a t e o f 90, blood p r essu r e of 110/70, and r espi r a t o r y r a t e o f 18, and o xygen satu r ation was 100% on r oom ai r The patien t s ab do men was sli g htly dis t e nded and t e nder in the r i g ht l o w er quad r ant, p e l v ic, and s up r apubic a r eas. She had some i n v olunta r y gua r ding but no r ebound t e nde r ness, hepa t osplenome g al y o r c os to v e r t eb r al an g le t e nde r ness. P ain was elici t ed s p ecifica l ly at the r i g ht inguinal

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2 C ase R epo r ts in Emergency M edicine E xplo r a t o r y lapa r os c o p y demons t r a t ed large r i g ht o va r ian cyst (5.5 cm 3.9 cm 3.7 cm) w ith the r i g ht adn e xa t w is t ed 360 The t o rsion was c o r r e c t ed and a r i g ht o va r ian cyst d r ained. The patient was dis c harged o n pos t o p e r at i v e d a y 2 w ithout fu r ther c omplications. F o l l o w up ul t r asound p e r fo r med th r ee months la t er sh o w ed d e v el o ping fo l licles in both adn e xa w ith good a r t e r ial and v enous blood fl o w F igu r e 1: Co mpu t ed t o mo gr ap h y of the p e l v is w ith IV c on t r ast demons t r a t es a c ompl e x locula t ed f l uid c ollection w ithin r i g ht adn e xa. F igu r e 2: Doppler ul t r asound of a large r i g ht o va r ian cyst (estima t ed o va r ian v o l ume o f 41 c m 3 ) d emons t r ating a r t e r ial fl o w but scant v e nous outfl o w li g ament. Classic si g ns for ap p endicitis, including R o vsin g s and P s o as si g ns, we r e absent. The r e mainder of the e xam was no r mal including hea r t t ones, l ung sounds, capi l la r y r efi l l, and skin turgo r H e r cathe t e r i z ed u r ine sample sh o w ed no p r o t ein, k e t o nes, ni t r i t es, or l e u k oc y t e es t e r ase; the mic r os c o pic U A sh o w ed 30 50 r ed blood c e l ls w ith no w hi t e c e l ls o r bac t e r ia. The patien t s w hi t e blood c ount was el e va t ed at 14.6 thou/mm 3 w hile hemo g lobin, hema t oc r it, and pla t elets we r e w ithin no r mal l e v els. A basic c hemis t r y panel was no r mal. C o mpu t ed t o mo gr ap h y (C T ) scan of the ab do men and p e l v is w ith in t r av e nous c o n t r ast demons t r a t ed no r mal solid or g ans and no r mal b o w el g as pat t e r n. A noninflammed ap p e ndix was v isuali z ed. A c ompl e x locula t ed f l uid c o l le ct ion w ithin the r i g ht adn e xa and associa t ed pe l v ic f r ee fluid we r e seen ( Figu r e 1 ). A fo l l o w up ab do minal ul t r asound w ith D o pple r pe r fo r med t o fu r ther in t e r r o g a t e the r i g ht l o w er quad r ant, r e v ealed a si g nificantly enlarged r i g ht o va r y w ith p r ese r v ed a r t e r ial fl o w but scant v e nous outfl o w ( Figu r e 2 ). The left o va r y was n o r mal. 3. Discussion Ova r ian t orsion is a r a r e p r oblem w ithin the p edia t r ic p o p ulation, y e t it r ep r esents a tr ue g yne c olo g ical and sur g ical emergency [ 1 2 ]. Ova r ian t orsion a cc ounts for app r o xi ma t ely 2.7% of a l l cases of acu t e abdominal pain in c hild r e n [ 3 4 ]. A dnexal t orsion is of t e n di cult t o dia g noe g i v e n the p r esen c e of nons p ecific s y mp t o ms and mo r e c ommonly en c oun t e r ed dia g noses. The p r esenta t ion of adnexal t orsion can mimic ap p e ndicitis, u r ina r y t r a c t infe c tion, r enal c olic, g as t r oen t e r itis, or other c onditions of acu t e ab d ominal and p e l v ic pain [ 5 ]. T o rsion o c curs mo r e f r equently in a d oles c ents and y oung w o m e n [ 6 ]. F o r p r e mena r c hal patients, adn e xal t orsion o c curs mostly in neona t es [ 7 ]. H e r e, fetal and ne w bo r n o va r ian cysts d e v el o p d ue t o the hi g h l e v els of ci r culating ma t e r nal ho r mones. The cysts t y pica l ly r eso l v e af t er bi r th w ith w ithd r a wal o f ma t e r nal ho r mones. I n t w o independent sono gr aphic studies, Orsini and c o w o r k ers [ 8 ], and Sala r di et al. [ 9 ] r epo r t ed the t y pical o va r y t o b e solid and homo geneous in e c hogenici t y in p r e mena r c hal g irls less than six y ears o f age. The homogeneous e c hogenici t y is in t e r p r e t ed t o r ep r esent o va r ian pa r e n c h y ma w ithout cysts. La t e r C ohen et al. [ 10 ] sh o w ed mic r ocysts ( < 9 mm in g r ea t est length) t o be c o mmon in g irls 2 12 y ears old but mac r oc y ts t o be less c o mmon, and no cyst was seen in a n y g irl aged 2 12 in their stu d y o f the si z e desc r ibed he r ein. T o rsion o c curs f r equently (60%) o n the r i g ht side p r e sumably b ecause the si g moid c olon le av es limi t ed

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2 C ase R epo r ts in Emergency M edicine E xplo r a t o r y lapa r os c o p y demons t r a t ed large r i g ht o va r ian cyst (5.5 cm 3.9 cm 3.7 cm) w ith the r i g ht adn e xa spa c e for adnexal m o v ement [ 4 11 12 ]. The p r e do minan c e o f r i g ht sided ab d ominal pain c onfounds dia g nosis, and 38% of c hild r en w ith identified adn e xal masses in o ne stu d y we r e initia l l y dia g nosed in the emergency d epa r t ment w ith ap p e ndicitis [ 5 ]. T o rsion is o f t en associa t ed w ith p r e e xisting o va r ian pa tholo g y [ 6 13 ] y et large cysts (as was the case in our patient) a r e thou g ht t o be less li k ely t o undergo t orsion se c o nda r ily t o their si z e and mass [ 14 ]. The large si z e of our patien t s r i g ht o va r y po t entia l ly limi t ed the t o rsion, w hi c h facilita t ed o va r ian sa l vage as the a r t e r ial supply was not y e t c omp r omised. N o r mal p r epu b e r tal o va r ian v olume is app r o xima t ely 1 2 cm 3 [ 15 ]. Our patient had an estima t ed r i g ht o va r ian v o l ume o f 40 c m 3 The dia g nosis of o va r ian t orsion was s uppo r t ed b y ul t r a sound (app r o xima t ely 87% a c cu r a t e for o va r ian patholo g y [ 16 ]). W hile CT m a y be useful in dia g nosing o va r ian t o rsi o n [ 17 18 ], its utili t y he r e was in dis c e r ning ab do minal v e rsus g yne c olo g ical patholo g y for e xample, CT r uled o ut ap p e ndicitis but did not r ule in, satisfa c t o r ily o va r ian t orsion se c o nda r y t o an o va r ian cyst.

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C ase R epo r ts in Emergency M edicine 3 4. Conc l usion [14] B W W a r ne r J C. K uhn, L. L. Ba r r J L. Gr osfeld, R. A. A mou r y and M. W L. Gaude r e r C onse r vat i v e management Pr ompt dia g nosis and e mergent s ur g ical in t e r v e ntion a r e k e ys t o o va r y sa l vage, especia l l y c onside r ing the sensit i v e natu r e of o va r ian loss in the p r epubes c e nt patient. A misdiag nosis can h av e di r e c onsequen c es including o va r ian loss. Our patient was able t o undergo o va r ian sa l vage as blood fl o w was r es t o r ed af t er c o r r ection. M a n y s urgeons r e c ommended a g ainst d e t orsing the o va r y and p r efer o o pho r e c t o m y for c o n c e r ns of embolization [ 18 19 ], y e t no s t r ong e v iden c e e xists t o suppo r t this c laim [ 2 20 22 ]. A s demons t r a t ed in this pape r o va r ian t o rsion can o c cur at a n y age. The r efo r e a hi g h ind e x of suspicion c oupled w ith r adio gr aphic e v iden c e and c linical p r esentation w i l l facilita t e p r ompt dia g n osis and o va r ian sa l vage w ith si g nificantly r edu c ed patient c o mo r b idi t y Publication of this article was funded in part by the University of Florida Open Access Publishing Fund. R efe r e n c es [1] L. L. B r ee c h and P J A. H illa r d, A dn e xal t orsion in pedia t r ic and adoles c ent g irls C u r r e nt O pinion in O bst e tr i c s and G yne c o lo g y v ol. 17, n o 5, p p 483 489, 2005. [2] D A ziz, V D a v is, L. Allen, and J C. Lange r Ova r ian t o rsion in c hild r en: is o op ho r ec t o m y ne c essa r J o u r nal o f P edia tr ic S u r g e r y v ol. 39, n o 5, p p 750 753, 2004. [3] B A. H o e y S. P St a w i c ki, W S. H o R. K. V ee r amasuneni, H. K o v i c h, and M. D Gr ossman, Ova r ian t orsion associa t ed w ith appendicitis in a 5 y ea r old g irl: a case r epo r t and r e v iew of the li t e r atu r e J o u r nal o f P edia tr ic S urg e r y v ol. 40, n o 9, p p E17 E20, 2005. [4] L. T H ibba r d, A dn e xal t orsion A m e r ican J o u r nal o f O bst e t r i c s and G y ne c o lo g y v ol. 152, n o 4, p p 456 461, 1985. [5] A. J P ome r anz and S. Sabnis, M isdia g noses of o va r ian masses in c hild r en and a d oles c ents P edia tr ic E m e rg e ncy Ca r e v ol. 20, n o 3, p p 172 174, 2004. [6] P A. A rgenta, T J Y ea g l e y G. Ott, and S. J Sondheime r T o r sion of the u t e r ine adn e xa: patholo g ic c o r r elations and cu r r ent management t r ends J o u r nal o f R e pr oduc t ive M edi c in e v ol. 45, n o 10, p p 831 836, 2000. [7] P B agolan, C. Giorlandin o A. N ahom et al., The manage ment of fetal o va r ian cysts J o u r nal o f P edia tr ic S urg e r y v ol. 37, n o 1, p p 25 30, 2002. [8] L. F Orsini, S. Sala r di, and G. Pi l u, P e l v ic o rgans in p r eme nar c heal g irls: r eal time ul t r asono gr ap h y Radi o lo g y v ol. 153, n o 1, p p 113 116, 1984. [9] S. Sala r di, L. F Orsini, and E. C a c cia r i, P e l v ic ul t r asonog r a p h y in p r e m e na rc heal g i r ls: r ela t i o n t o pu b e r t y and s ex ho r mone c on c e n t r a t ions A r chives o f D i s ea s e in Childhood v ol. 60, n o 2, p p 120 125, 1985. [10] H. L. C ohen, P E isenber g F M andel, and J O H alle r Ova r ian cysts a r e c ommon in p r e mena r c hal g irls: a sono gr aphic stu d y o f 101 c hild r en 2 12 y ears old A m e r ican J o u r nal o f R o e nt g e n o lo g y v ol. 159, n o 1, p p 89 91, 1992. [11] F Alb a y r am and U M. H am p e r Ova r ian and adn e xal t o rsion: spec tr um of sono gr aphic findin g s w ith patholo g ic c o r r elation J o u r nal o f Ul t r a s o und in M edi c ine v ol. 20, n o 10, p p 1083 1089, 2001. [12] D H. N i c hols and D J J ulina, T o rsion o f the adn e xa Clinical O bs t et r i c s and G y ne c o lo g y v ol. 28, n o 2, p p 375 380, 1985. [13] A. C elik, O E r g u ¨ n, H. Aldemir et al., t e r m r esults of c o nse r vat i v e management of adn e xal t orsion in c hild r en J o u r nal o f P edia tr ic S urg e r y v ol. 40, n o 4, p p 704 708, 2005.

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C ase R epo r ts in Emergency M edicine 3 4. Conc l usion [14] B W W a r ne r J C. K uhn, L. L. Ba r r J L. Gr osfeld, R. A. A mou r y and M. W L. Gaude r e r C onse r vat i v e management of large o va r ian cysts in c hild r en: the va l ue o f se r ial p e l v ic ul t r asonog r ap h y S u r g e r y v ol. 112, n o 4, p p 749 755, 1992. [15] L. Ga r el, J Dubais, A. G r i g non, D Filia t r ault, and G. V an Vliet, o f the pedia t r ic female pe l v is: a c linical perspect i v e Radio g r aphi c s v ol. 21, n o 6, p p 1393 1407, 2001. [16] S. B V ij a y a r a g h a van, Sono gr aphic whirlpool si g n in o va r ian t o rsion J o u r nal o f Ul t r a s o und in M edi c ine v ol. 23, n o 12, p p 1643 1649, 2004. [17] A. M. Gittl e man, A. P P r i c e, L. G o ne r and D S. K atz, Ova r ian t o rsion: CT findin g s in a c hild J o u r nal o f P edia tr ic S u r g e r y v ol. 39, n o 8, p p 1270 1272, 2004. [18] E. R. K o k oska, M. S. K elle r and T R. W ebe r A cu t e o va r ian t o rsion in c hild r en A m e r ican J o u r nal o f S urg e r y v ol. 180, n o 6, p p 462 465, 2000. [19] J M o r d ehai, A. J M a r es, Y B a r ki, R. Final y and I. M eizne r T orsion of u t e r ine adn e xa in neona t es and c hild r en: a r epo r t of 20 cases J o u r nal o f P edia tr ic S urg e r y v ol. 26, n o 10, p p 1195 1199, 1991. [20] J F A nders and E. C. P o w e l l, U rgency of e valuation and o ut c o me of acu t e o va r ian t o rsion in p edia t r ic patients A r c h i ves o f P edia tr i c s and A d o le s c e nt M edi c ine v ol. 159, n o 6, p p 532 535, 2005. [21] S. E. Dol g in, M. L ublin, and E. Shlas ko M aximizing o va r ian sa l vage w hen t r eating idi o pathic adn e xal t orsion J o u r nal o f P edia tr ic S urg e r y v ol. 35, n o 4, p p 624 626, 2000. [22] M. A b e s and H. Sa r ihan, O op ho r o p e xy in c hild r en w ith o var ian t orsion E u ro pean J o u r nal o f P edia tr ic S urg e r y v ol. 14, n o 3, p p 168 171, 2004.