P3.Q329: Twists and Turns: Ovarian Torsion Unveiled in an Infant

Introduction: Ovarian torsion is rare in infants with an incidence of 4.9 per 100,000 children, and up to 4% of pediatric emergency department (ED) visits. The presentation can be nonspecific and there are far more commonly encountered diagnoses in infants in the ED, which makes it a dangerous pathology that can go easily unrecognized in this age group. It should be considered in the differential in any female infant with acute abdominal pain with feeding intolerance and vomiting and mandates early surgical management. As Osteopathic physicians embracing a holistic approach, we must remain vigilant for uncommon presentations or deviations from the typical, ensuring comprehensive care. Here we describe a unique case that is important to publish to expand the literature on cases of ovarian torsion in infants.

Case Description: A 2-month-old female with no significant birth or past medical history presented to the ED with 2 weeks of intermittent abdominal pain and 1 week of intermittent projectile, non-bilious vomiting. She had decreased appetite, feeding intolerance, with subsequent decrease in wet diapers. She had no fevers, cough, congestion, diarrhea or constipation. No known sick contacts or recent travel. Exam revealed a well nourished, well hydrated, afebrile and normotensive infant with no cardiorespiratory abnormalities. Abdominal exam was remarkable for pain and inconsolability on palpation of the right abdomen even with minimal pressure, and intermittent pulling of her knees to her chest. She had normal bowel sounds and no palpable masses. Laboratory results were significant for mild hyponatremia, without leukocytosis or anemia. Viral polymerase chain reaction was positive for COVID-19. An ultrasound pylorus showed normal pylorus length and wall thickness. An enlarged right ovary with numerous enlarged follicles was incidentally seen in the right upper quadrant below the right hepatic edge. High resistivity flow was demonstrated in the right ovary parenchyma. There was a suggestion of a twisted right fallopian tube/pedicle, indicative of the whirlpool sign. The left ovary was normal sized.

Discussion: The diagnostic possibilities initially included infectious etiology, infantile colic, constipation, pyloric stenosis, appendicitis, and bowel obstruction.
Once ultrasound pylorus resulted, our patient was surprisingly diagnosed with acute ovarian torsion. She underwent emergent diagnostic laparoscopy, reduction of right ovarian torsion, and ovarian cystotomy. She was monitored in the pediatric intensive care unit and recovered uneventfully.

Conclusion: Ovarian torsion is a rare but serious medical emergency in females, occurring mostly in adolescents and young women, although it may affect all ages. It is a vital differential diagnosis that should be considered in any female with acute abdominal pain and vomiting, as it is a surgical emergency and mandates early surgical management. Early recognition and timely diagnostic imaging with surgical intervention are essential to prevent the complications of ovarian torsion and reduce adverse effects on future fertility.