Septic shock due to a ruptured ovarian abscess caused by hematogenous Staphylococcus aureus infection in a sexually inactive woman with atopic dermatitis: a case report

BACKGROUND: Tubo-ovarian abscess is a severe form of pelvic inflammatory disease that is typically caused by ascending polymicrobial infections in sexually active women. However, it is extremely rare in sexually inactive women, and its pathogenesis in such cases remains poorly understood. Atopic dermatitis is associated with impaired skin barrier function and increased susceptibility to Staphylococcus aureus bacteremia. Here, we present a rare case of septic shock due to a ruptured ovarian abscess caused by S. aureus in a sexually inactive woman with atopic dermatitis. CASE PRESENTATION: A 44-year-old Japanese woman with no history of sexual intercourse presented with a prolonged fever lasting 4 weeks. Six weeks before admission, she developed pruritic blisters between the right index and middle fingers due to atopic dermatitis, which subsequently ruptured. Seventeen days before referral, she had watery diarrhea and was diagnosed with enteritis at a clinic. Persistent symptoms raised suspicion for viral hepatitis based on elevated C-reactive protein levels and mild liver dysfunction. Subsequently, the patient developed recurrent high-grade fever and lower abdominal pain. Imaging revealed a large pelvic abscess with ascites, and she was transferred to our hospital. On arrival, she was in septic shock, with a blood pressure of 80/40 mmHg and a pulse rate of 125 bpm. A ruptured left ovarian abscess arising from an infected mature cystic teratoma was diagnosed, and emergency laparoscopic surgery was performed. The procedure revealed severe intraperitoneal inflammation with purulent ascites. S. aureus was isolated from both blood cultures and abscess contents. Postoperatively, the patient underwent intensive care management for septic shock and acute kidney injury, gradually recovering with appropriate antibiotic therapy. She was discharged without complications and remained recurrence-free at the 1-year follow-up. CONCLUSIONS: No gastrointestinal or gynecological source of infection was identified despite extensive evaluation, raising the possibility of a hematogenous route of infection. The patient's atopic dermatitis may have contributed to increased susceptibility to S. aureus bacteremia through skin blistering, potentially resulting in bacterial seeding of the ovary. This case underscores the diagnostic challenges associated with atypical ovarian abscesses and highlights the importance of including them in the differential diagnosis of atypical, prolonged fever and abdominal symptoms, even in sexually inactive women, particularly those with atopic dermatitis.