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Conclusion Signs and symptoms of Mullerian duct anomalies including a non-functional rudimentary endometrial cavity could be very subtle. Any patient who presented with an intrauterine abscess and no significant risk factors for PID should be assessed regarding congenital uterine malformations. MRI scan has superiority in diagnosis of uterine malformations over grey scale ultrasound with increased sensitivity and specificity. It is important to bear in mind that it is rare but still possible to diagnose a pelvic abscess in low risk p atients who are not sexually active with negative vaginal swap tests with subtle clinical symptoms. In addition, other rare causes of TOAs should be considered such as abscess formation on base of an endometrioma cyst, HIV infection or TOA secondary to appendicitis or underlying gastrointestinal malignancy. References 1. Munro K, Gharaibeh A, Nagabushanam S, Martin C : Diagnosis and management of tubo-ovarian abscesses. The Obstetrician and Gynaecologist 2018: 20:11-9 2. British Association of Sexual Health and HIV, UK National Guideline for the Management of Pelvic Inflammatory Disease 2011. Figure 1 Figure 2 Figure 5 Figure 6 Figure 3 Figure 1: Endometrial abscess and hydro salpinx, CT image Figure 2: Bilateral hydronephrosis and pelvic-para aortic lymphadenopathy, CT image Figure 3: Splenomegaly, CT image Figure 4:Post operative MRI scan showing existing TOA abscess, normal intrauterine cavity Figure 5: Intraoperative image of enlarged uterus filled with pus. Figure 6: Intraoperative view showing drainage of intrauterine abscess by needle aspiration. Intrauterine abscess presenting with severe systemic reactive changes with subtle clinical symptoms ; A Case Presentation and review of literature N Dover, MRCOG, Clinical Fellow in Obstetrics and Gynaecology, Musgrove Park Hospital, Department of Gynaecology B Attilia, MRCOG MBBS BSc, Consultant Obstetrician and Gynaecologist , Musgrove Park Hospital, Department of Gynaecology H Haerizadeh, MD MRCOG, Consultant Obstetrician and Gynaecologist , Musgrove Park Hospital, Department of Gynaecology Introduction Pelvic abscess is a severe complication of untreated pelvic inflammatory disease (PID) usually located in tubes and ovaries. PIDis a disease of reproductive age and 60% of patients are nulliparous. The most common cause of PID is ascending/upper genital tract infection. A number of risk factors associated with PID and pelvic abscess including non-use of barrier contraception, intrauterine contraceptive devices, previous episode(s) of PID, earlier age at first intercourse, multiple sexual partners, diabetes and an immunocompromised state. The tubo-ovarian abscess formation is around 15-35% (1)in PID cases. Interestingly, TOAs have been reported in women who are not sexually active. The common signs and symptoms of PID includes adnexal tenderness, cervical excitation, pyrexia, abnormal cervical and vaginal discharge, elevated WBC, ESR, CRP levels, positive Neisseria gonorrhoeae and Chlamydia trachomatis tests and an adnexal mass on abdominal/bimanual examination. The absence of pyrexia or raised WBC does not exclude pelvic abscess. However, if the abscess structure develops in a relatively large cavity such as in a functional non-communicating endometrial cavity, the symptoms of chronic infection could be subtle but subsequent systemic reactive changes would be significant. In rare cases, such as pelvic abscess formation secondary to ovarian endometrioma or hematometra in congenital uterine malformations; blood in those particular structures may cause a good culture medium for pathogens. As for diagnosis, ultrasound should be the first-line imaging tool. Computed tomography (CT) is useful when there is a suspicion of gastrointestinal pathology or urinary tract involvement such as hydroureter/hydronephrosis. Magnetic resonance imaging (MRI) has higher sensitivity and specificity than ultrasound and has an advantage over CT of being a non-irradiating imaging tool but comes with cost and not always being readily accessible. The management is antibiotic therapy in clinically stable and systemically well patients. Clinically unwell patients who are unresponsive to antibiotics within 24 hours, severe systemic inflammatory reactions, acute abdomen due to rupture of abscess structure warrants the surgical management of abscess and drainage of pus. Case Presentation Nulliparous, 21-year-old woman presented with chronic fatigue and unintentional significant weight loss over a 6-month period. Blood tests significantly increased CRP levels, iron deficiency anaemia, increased ALP and low albumin levels, abnormal autoimmune liver function tests and prolon clotting parameters. Patient referred to gynaecology by medics with a CT showing a possible endometrial abscess, hydro salpinx (figure 1), bilateral hydron 2), splenomegaly (figure 3) and pelvic-para aortic lymphadenopathy (figure 2) .The patient revealed not being sexually active for the la not using any contraceptive methods. Examination showed no signs of acute PID but subtle pyrexia. Intravenous antibiotics were started, and emergency laparoscopy showed an enlarged boggy uterus. Pus was drained laparoscopically using a Vress needle inserted into the uterine cavity. aetiology could be an abscess secondary to an undiagnosed congenital uterine malformation such as a communicating uterine horn. The patient was booked for an outpatient MRI scan for confirmation of diagnosis and follow-up for future management. The outpatient MRI result showed a remaining cystic structure in left adnexa possible tubo-ovarian abscess and uterus reported to be in normal size and shape as seen as separate from the cystic structure. Overall, MRI was inconclusive for differentiating an intrauterine abscess secondary to hematometra in a communicating uterine horn froma remaining left adnexal tubo-ovarian abscess. In due course, patient completed her 14 days of oral PID antibiotic protocol as per local guidance and her inflammatory markers improved within 3/52 after operation as CRP came down as low as 2 mg/dL and iron-deficiency anaemia corrected with oral iron supplementation and haemoglobin level increased up to 140 g/dL. N.gonorrhoeae and Chlamydia swabs and HIV test came back as negative. Figure 4
