Abdominal abscesses with Streptococcus milleri group after laparoscopic chromopertubation

Abstract

Sir, Laparoscopic chromopertubation is a basic and safe lement in infertility evaluation (1). Complications of this procedure are uncommon. Vaginal bleeding, mild pelvic pain and vasovagal response have been described. Severe complications such as pulmonary edema, anaphylactic shock and methemoglobinemia are rare (2-4). We wish to call attention to a patient with multiple abdominal abscesses after laparoscopic chromopertubation. A 22-year-old nulligravida underwent laparoscopic chromopertubation as part of an evaluation for primary infertility. Her medical history revealed polycystic ovarian syndrome and morbid obesity. The chromopertubation was uncomplicated and tubal patency was established. Two days after the procedure the patient experienced abdominal pain and fever. A week after chromopertubation she was presented at the Emergency Department with clinical signs of peritonitis. Laboratory data showed leukocytes of 26.3 × 109/L and C-reactive protein of 341 mg/L. Computed tomogram of the abdomen showed an abscess measuring 20 × 10 × 5 cm in the lower abdomen. Laparotomy with drainage of the abscess was performed. Postoperatively she was admitted to the Intensive Care Unit (ICU) with septic shock. The patient was initially treated with cefuroxime (1.5 g three times a day) and metronidazole (500 mg three times a day) and after 2 days piperacillin/tazobactam (4 g/0.5 g three times a day). Cultures of drained material grew Streptococcus milleri group. Pre-procedure cultures revealed no potentially pathogenic flora. The patient deteriorated with respiratory failure. She was transferred to our ICU. A second laparotomy revealed diffuse peritonitis with multiple abscesses which were drained. Despite adequate antibiotic therapy the patient continued to have fever. CT scan revealed another right paracolic abscess that was percutaneously drained. After 22 days the patient was discharged to the surgical ward. Post-procedural infection after chromopertubation is rare. We did not find previous reports. In the case presented here, the reason for the intra-abdominal abscesses most likely was the introduction of Streptococcus milleri in the abdomen via the transcervical injection of methylene blue since Streptococcus milleri is a commensal of the urogenital tract. Introduction via the laparoscopic route is less likely. The Streptococcus milleri group is a heterogeneous complex of streptococci and consists of the species Streptococcus intermedius, Streptococcus constellatus and Streptococcus anginosus. These organisms are not only commensals of the oral cavity, genitourinary tract and gastrointestinal tract, but also notorious causes of pyogenic, invasive infections. Patients with underlying medical conditions, such as cirrhosis, diabetes mellitus and malignancies are predisposed to invasive infections with Streptococcus milleri. Most infections with Streptococcus milleri group organisms respond well to combined surgical and antibiotic treatment but may require multiple procedures and the course can be protracted (5). Although this complication seems to be rare, awareness is of utmost importance because immediate surgical or percutaneous intervention and antibiotic treatment can mitigate the course of the disease and can even be life saving. Patient instruction might have prevented delay in this case.