Rane V*, Samant PY**, Kamat S***, Daigavane MM****.
(* First year resident, ** Professor Additional, *** Second year resident, **** Assistant Professor. Department of Obstetrics and Gynecology, Seth G S Medical College & KEM Hospital, Mumbai, India.)
A 36 year old woman was diagnosed with autoimmune disorder with multi system involvement. She presented with a large vulvar abscess extending to the groin, and perineum and also had inguinal lymph adenitis. Abscess was drained and dressings were followed by secondary suturing. The large abscess healed. Here we discuss autoimmune disease and extreme presentation of inflammatory pathology with reference to other autoimmune conditions with similar predilection.
Vulvar abscess is a common gynecological problem. These abscesses most commonly originate as simple infection in the vulvar skin or subcutaneous tissue superficial to the fascia. Spread of the infection located in the vulvar area may occur easily due to the loose areolar tissue in the subcutaneous layers into adjoining fascial planes of the groin and anterior abdominal wall. The response to treatment in immunocompetent patients differs from those in patients with autoimmune disorders and immunodeficient cases. Such cases may require special investigations. We report a case of large vulvar abscess in a patient of rheumatoid arthritis.
A 36 years old multiparous woman presented with sudden onset of severe pain in vulvar region, rapidly growing swelling over the left labium majus over a few days and fever with chills for a day. She did not report any significant injury, vaginal discharge preceding the occurrence of swelling. There was no history of similar lesions in the past anywhere else on the body. She also reported having joint pains and swelling of her wrists, knees and ankles for 3 years. She was taking ayurvedic medications for the same on and off. Her menstrual history was unremarkable. Her last menses were 4 days before presentation. She did not have diabetes mellitus. Her both deliveries were by cesarean section.
On physical examination, she was pale but afebrile. Pulse and blood pressure were normal. Local examination showed 10 x 4 cm tender and tense left labial swelling with erythema extending to perineal and perianal region and left inguinal lymphadenopathy. There was no vaginal extension. Bimanual examination was difficult. The affected joints were swollen, but there was minimal deformity of one wrist. Her hemoglobin was 5.9 gm%, and ESR was 45 at the end of 1 hour. Blood sugar, liver and renal function tests were within normal range. She was seronegative for syphilis, hepatitis B, hepatitis C and HIV. Her TSH was 9.48 mIU/ ml. Her anti TPO was < 0.8 U/ ml (normal up to 60 U/ ml). She was advised by endocrinologists to repeat TSH after 3 months and follow up. Local ultrasound showed ill-defined heteroechoic lesion in her perineal region, suggestive of early local abscess. Multiple enlarged inguinal lymph nodes on the left side were also seen.
Figure 1. Left labial swelling.
In view of anemia, three packed cell transfusions were given. Tetanus toxoid was administered. Incision and drainage of the abscess under saddle block was done after administering prophylactic amoxicillin-clavulanic acid and metronidazole. Extremely foul smelling pus was drained which was sent for culture and antibiotic sensitivity.
Rheumatology opinion was taken for multiple joint pain and swelling. RA levels were > 64 IU/ml. Hydroxylchloroquin 300 mg once a day and calcium supplements were started as per advice of the rheumatologist. In addition to prophylactic antibiotics, injection amikacin was started as per pus culture, which grew E. coli. It was given for 10 days. Anti-inflammatory drugs were given. Daily dressing of the wound was done with povidone iodine. Secondary suturing was done 2 weeks after abscess drainage when the wound looked healthy. A week after suturing, minimal discharge was seen from the suture line. Repeat wound swab culture was suggestive of insignificant polymicrobial growth. Suture removal was done after a week. Wound had healed well and looked healthy. At 6 weeks follow up, she had vaginitis unrelated to surgery and on examination, minimal edema of the labium around the scar was noted. Vaginitis was duly treated.
Figure 2. Healed wound.
Vulvar abscesses are not uncommon. Causes of vulvar abscess can range from skin and hair follicle infection to vulvar carcinoma. Bartholin’s gland cysts can progress to an abscess. Hidradenitis suppurativa of vulva may progress to an abscess. Bartholin’s gland cysts can progress to an abscess. Hematoma following an episiotomy may develop infection to form an abscess. Vulvar cancer can be mistaken for a vulvar abscess with acute onset of redness, swelling and severe pain. If cancer is suspected, biopsy should be done. Many vulvar abscesses have mixed polymicrobial infection, which include staphylococcus aureus, streptococci, E. coli, methicillin resistant staphylococcus aureus.[2,3] In our case, pus grew E. coli. Immunocompetent hosts clear the infections more readily and recover with no sequelae. Immunocompromised hosts fail to mount an immune response, which results in infectious process getting exacerbated. Lesions that initially look innocuous may progress to possibly fatal necrotizing fasciitis. If the patient shows predilection for recurrent abscesses, underlying immune mediated pathology should be investigated. Elevated IgE levels may indicate atopy and very high levels may be suggestive of hyper IgE syndrome. White cell phenotyping, Interferon pathway analysis and other specialized investigations may be required for diagnosis of underlying immunological conditions. In rare cases even after surgical drainage, infection may progress to necrotising fasciitis; a condition with high mortality. Our patient had symptomatic rheumatoid arthritis; but was not on any medication for a long time. She also had a raised TSH level and severe anemia without menorrhagia or any other predisposing factor; probably of autoimmune origin. Rheumatoid arthritis is known to have a host of cutaneous manifestations like vasculitis, granulomatous dermatosis and neutrophilic dermatosis. These are caused by activation of complement cascade by immune complexes. Neutrophils and lymphocytes are recruited and vasculitis of subcutaneous small vessels may cause recurrent ulcers. Suppurative hidradenitis may be one of the cutaneous manifestations in PASH (Pyoderma gangrenosum, acne and suppurative hydradenitis) syndrome in rheumatoid arthritis.
It is important to bear in mind possibility of underlying immunological condition in cases with atypical presentation of abscesses. Timely treatment of the immunological condition can help in reducing morbidity.
- Nayak AU, Sundari N., Nandini G. Wolf in lamb's skin: Vulval carcinoma mimicking bartholin gland abscess. Indian J Sex Transm Dis. 2009; 30(1): 46–47.
- Bhide A, Nama V, Patel S, Kalu E. Microbiology of cysts/ abscesses of Bartholin's gland: review of empirical antibiotic therapy against microbial culture. J Obstet Gynaecol 2010; 30(7): 701-3.
- Thurman AR, Satterfield TM, Soper DE. Methicillin-resistant Staphylococcus aureus as a common cause of vulvar abscesses. Obstet Gynecol 2008;112(3):538-44
- Stephenson H, Dotters DJ, Katz V, Droegemueller W. Necrotizing fasciitis of the vulva. Am J Obstet Gynecol 1992;166(5):1324-7.
- Johnston SL. Clinical Immunology Review Series: An approach to the patient with recurrent superficial abscesses. Clin Exp Immunol 2008; 152(3): 397–405.
- Kdous M, Hachicha R, Iraqui Y, Jacob D, Piquet PM, Truc JB. Necrotizing fasciitis of the perineum secondary to a surgical treatment of Bartholin's gland abscess. Gynecol Obstet Fertil 2005;33(11):887.
- Marzano A.V. Cutaneous manifestations in rheumatoid arthritis. Clinical Dermatology 2013;1(2): 53-59.
Rane V, Samant PY, Kamat S, Daigavane MM. Vulvar Abscess in Autoimmune Disorder - A Clinical Challenge. JPGO 2017. Volume 4 No. 4. Available from: http://www.jpgo.org/2017/04/vulvar-abscess-in-autoimmune-disorder.html