Hot Seat #150: 13 year-old with abscess

Posted on: April 17, 2020, by :

HPI: 13 yo F with no pertinent PMH presents as a transfer from OSH with vulvar abscess, which developed 5 days prior.  She denies fevers, vomiting, and is tolerating PO. Per provider at the outside institution who requested transfer, the abscess is large and will likely require surgical drainage. When the provider at the OSH did the GU exam earlier, there was abnormal vaginal discharge and STI testing was sent.

Following her arrival, the referring hospital calls to inform you the patient tested positive for Trichomonas vaginalis. All other STI testing was negative. Urinalysis and urine pregnancy testing were negative.

You call the lab to confirm the test result and it is accurate. She is currently NPO in the ED and awaiting surgery for operative drainage.

Exam:

Vitals all normal

General:  Alert, appropriate for age, cooperative.   

Skin: Warm, dry. 

GU: 7x4cm tender area of induration over R vulva, +fluctuance located along R labia majora. Minimal erythema without streaking or warmth.     

Gastrointestinal:  Soft, non-tender, non-distended.  Normal bowel sounds.  No organomegaly.    

Psychiatric: Cooperative. Appropriate mood and affect.   

You privately tell the patient the test results. She denies any sexual activity.  She also denies sexual abuse, inappropriate touching, and reports she has never dated. She states that she is safe at home and safe at school. You ask her if it is okay that you disclose to her mom, who is waiting with her for surgery, because you are concerned for her young age and positive STI testing. She does not give or deny permission to discuss with parent.

You decide to talk to her mom just as the OR is calling for her. Treatment for trichomonas is metronidazole 2g PO; you are concerned she might vomit if she takes it now or vomit during intubation.

You speak with the surgical team and they state they will give it to her post-operatively. The ED sent the medication up with the patient. You later review her chart and it appears that Anesthesia gave her IV metronidazole 500 mg and patient was not discharged with any other medication. You call the family’s phone number in the chart to follow up, but only get her voicemail.

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6 thoughts on “Hot Seat #150: 13 year-old with abscess


  1. Small point, but a personal pet peeve of mine. The opening line states this child was transferred for a “vaginal abscess.” As medical providers, when we communicate to other providers, we should be as specific as possible. It sounds like this child had a “vulvar” abscess, not a “vaginal” abscess as likely reported by the OSH.


  2. From a general surgery perspective, I would recommend waiting for PO metronidazole until the postoperative period. The acute issue bothering this patient is the abscess. If the OR is available without any significant delay, I do not believe the Trichomonas treatment needs to be given emergently. The procedure length is not long (< 20 mins) and we could give this to her in the PACU without issue, as she will be given clears and advanced to regular diet immediately postoperatively, once she is adequately awake.

    I believe that it would be a higher risk of aspiration or delay to the case compared to the benefit of starting Trichomonas treatment earlier, e.g. one hour. She has likely had this discharge (either acutely or subacutely) for days.


  3. …there’s something afoot here. The pediatrician definitely needs to be involved in the this case. While I anticipate the patient may have a f/u with Peds Surg to evaluate the wound, I would make sure the patient has a follow up appointment with the Pediatrician to address both abx regimen and high risk sexual behavior.


  4. From an anesthesia perspective PO medication pre-op would not necessarily delay going to the OR or increase risk of aspiration. However, this depends on the patient’s clinical symptoms (signs of n/v), the volume of the medication administered, and comes down to a risk vs benefit decision. We frequently give pre-medication (both pills and liquid) in pre-op with small sips of water/apple juice (ie midazolam for anxiolysis, methadone and gabapentin in our spinal fusion protocol). Other places give pre-op tylenol, NSAIDS, oxycodone to decrease perioperative pain medication requirement, have patients take home medication morning of surgery, and administer PO aspiration prophylaxis (bicitra).


  5. I would not disclose to her mother, without her permission, that she has Trich. While other states may have different laws, in DC a minor has rights to consent to her own treatment for STIs. I would encourage the pt to include her mother in the conversation, and I think involving social work is appropriate, but I don’t think it’s appropriate for the clinician to disclose this information to her mother without her permission. If there were concerns for assault, the case may be different. Regarding treatment, could the patient get IV metronidazole prior to going to the OR? I would be sure to inform her that you’re treating for Trich, and involve the PCP and possibly SW in follow-up.

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