Abstract
Pyosalpinx, the accumulation of pus within the fallopian tube, rarely causes acute appendicitis. We report a 38-year-old woman who presented with a 10-day history of right lower quadrant pain and low-grade fever and was diagnosed radiologically with a perforated appendix. At laparoscopy, intraperitoneal pus, an appendix perforated at its tip, and a perforated right fallopian tube near the utero-tubal junction were found. Laparoscopic appendectomy with right salpingectomy was performed. Histopathology confirmed acute appendicitis and acute salpingitis; cultures showed no growth and GeneXpert was negative. She recovered uneventfully over six months of follow-up. To our knowledge, this is the first documented perforated appendix caused by ascending infection from a perforated pyosalpinx managed laparoscopically. The case highlights the importance of considering gynaecological pathology in atypical appendicitis and the value of a laparoscopic, interdisciplinary approach.
Introduction
Acute appendicitis is a common surgical emergency, usually caused by intrinsic obstruction of the appendiceal lumen by a faecolith or lymphoid hyperplasia [1, 2]. Extrinsic, infective causes are exceedingly rare. Pyosalpinx—the accumulation of purulent fluid within the fallopian tube—usually complicates pelvic inflammatory disease and is associated with sexually transmitted or enteric organisms [3, 4]. Its complications include infertility, ectopic pregnancy, and peritonitis following rupture [5, 6]. Because the right fallopian tube lies close to the appendix and caecum, tubal infection can occasionally mimic or precipitate appendicitis. We report a woman with acute appendicitis and appendiceal perforation caused by ascending infection from a ruptured pyosalpinx, managed entirely laparoscopically. To our knowledge, no previous report describes a perforated appendix resulting directly from a perforated pyosalpinx treated in this way.
Case report
A 38-year-old woman, a known diabetic with three previous lower-segment caesarean sections, presented with a 10-day history of intermittent right lower quadrant pain, nausea, vomiting, and anorexia, low-grade fever, and intermittent burning micturition. She reported heavy menstrual bleeding during this illness; her cycles were otherwise regular. There was a family history of hypertension and diabetes mellitus.
On examination she was febrile (37.8°C) and tachycardic, with right iliac fossa tenderness, rebound tenderness, and a positive Rovsing’s sign. Haemoglobin was 10.8 g/dl with leucocytosis and C-reactive protein 134 mg/l; β-hCG was normal and the modified Alvarado score was 9. Ultrasound showed a heterogeneous right iliac fossa mass (6.9 × 4.8 cm). Contrast-enhanced computed tomography (CT) demonstrated an indistinct appendiceal base with fat stranding and an irregular hypodense collection (4.0 × 2.8 cm) inseparable from the caecum, right ovary, and uterus, suggesting appendiceal perforation with phlegmon (Fig. 1).
Contrast-enhanced CT showing an indistinct appendiceal base with adjacent fat stranding and phlegmon formation involving the caecum.
At laparoscopy there was intraperitoneal pus (Fig. 2), an acutely inflamed appendix perforated at its tip with adhesions to the abdominal wall (Fig. 3), and a perforated right fallopian tube near the utero-tubal junction (Fig. 4). After intraoperative gynaecology consultation and family consent, laparoscopic appendectomy with right salpingectomy was performed; the right ovary was conserved and the left adnexa and pouch of Douglas were normal.
Intraperitoneal frank pus in the pelvic cavity.
Acutely inflamed appendix perforated at its tip.
Perforation of the right fallopian tube near the utero-tubal junction.
Gram stain of the pus showed pus cells without organisms, and aerobic and anaerobic cultures showed no growth; GeneXpert (MTB/RIF) was negative. Histopathology confirmed acute appendicitis and acute salpingitis, with no malignancy. She received intravenous piperacillin–tazobactam and was discharged in stable condition on the second postoperative day. Over six months of outpatient follow-up (at one week, one month, and two further visits ten weeks apart) she recovered uneventfully without complications.
Discussion
Acute appendicitis usually results from intraluminal or, less often, intramural obstruction; extramural and infective causes account for ~1% of cases and are rarely reported [7–10]. In our patient, a ruptured, suppurative right fallopian tube lying against the caecum and appendix produced an ascending infection that precipitated appendicitis and, ultimately, extramural compression and perforation. Only three comparable cases of pyosalpinx-associated appendicitis have been reported (Table 1) [8–10]; ours appears to be the first caused by a perforated pyosalpinx and managed entirely laparoscopically.
Reported cases of pyosalpinx-associated appendicitis compared with the present case
| Report | Pathology | Treatment | Outcome |
|---|---|---|---|
| Geryk, 1992 [9] | Right pyosalpinx, gangrene, reactionary appendicitis | Open appendectomy and right salpingectomy | Uneventful |
| Habek, 2002 [8] | Right pyosalpinx; inflamed appendix | Open appendectomy and salpingectomy; IV antibiotics | Uneventful |
| Agbor, 2016 [10] | Right pyosalpinx compressing the appendix | Open appendectomy and right salpingectomy; drainage | Uneventful |
| Present case | Perforated right pyosalpinx and perforated appendix | Laparoscopic appendectomy and right salpingectomy | Uneventful |
Pyosalpinx is usually attributed to enteric bacteria, Chlamydia trachomatis, or Neisseria gonorrhoeae, often following sexually transmitted or intra-abdominal infection or instrumentation [6, 10]. In our patient both cultures were sterile and GeneXpert was negative for tuberculosis; culture-negative suppuration may reflect prior antimicrobial exposure or fastidious organisms. Diabetes mellitus probably predisposed her to a more aggressive suppurative course, as impaired host immunity favours complicated appendicitis.
When the right tube is involved, pyosalpinx may closely mimic appendicitis [11, 12]. Ultrasound is the first-line investigation but is often inconclusive in complex pelvic infection, and computed tomography—though preferred for anatomical detail—could not clearly separate the involved organs in our case [11, 12]. Laparoscopy therefore offered both diagnostic clarity and definitive treatment, with better visualization, less postoperative pain, and faster recovery [11]; salpingectomy is appropriate when the tube is destroyed [10]. Early interdisciplinary involvement of gynaecology is recommended when appendiceal and tubal pathology coexist [13, 14].
This report is limited by its single-case nature and by causation being inferred from operative and pathological findings rather than proven. Nonetheless, the findings and clinical course support the proposed mechanism. Clinicians should consider gynaecological pathology in women with atypical appendicitis, and imaging and operative protocols should assess the abdominal and gynaecological systems together, with early interdisciplinary collaboration.
Author contributions
N.A.K. conceived the report, performed the surgery, supervised the work, and critically revised the manuscript; R.R. contributed to patient management, intraoperative assistance, data acquisition, and revision; M.M. collected the data, drafted the manuscript, and is the corresponding author; A.S.A., S.A.A., and U.Y. contributed to the literature review, drafting, and editing. All authors read and approved the final manuscript and agree to be accountable for all aspects of the work.
Conflicts of interest
None declared.
Funding
None declared.
Data availability
The data supporting this report are available from the corresponding author on reasonable request.
Consent
Written informed consent for publication of this report and the accompanying images was obtained from the patient. Ethical approval was not required for a single de-identified case report in accordance with institutional policy.
