History and Symptoms
This young adult female (22 years old) had no significant complaints and was referred for a routine ultrasound scan of the abdomen to rule out any pathology. She complained of minor thyroid issues, and an ultrasonography suggested presence of Hashimoto thyroiditis.
She had a past history of surgery during childhood for a mass in the abdomen. We have deliberately hidden the details of the surgery and histopathologic report for the diagnosis.
Her parents both had no major surgery or illness. There was no history of diabetes, hypertension, or renal, hepatic, or gastroenterologic complaints in either parent. The patient was the only child and was delivered at full term. Her birth weight was also normal. The child was normal at birth with no reason to suspect any abdominal pathology.
Examination revealed a normal liver, spleen, and pelvis. In fact, she had no tenderness anywhere in the abdomen or pelvis. Repeated visits to the surgeon or family physician did not suggest any abdominal pathology. The visits to the doctor were part of the follow-up for the surgery she had earlier. The endocrinologist examined her and decided that other than a case of early Hashimoto thyroiditis, she was perfectly normal. This was confirmed by both hormonal assay and thyroid sonography.
The patient had a history of normal and regular menses and a routine abdominal ultrasound study was advised due to her past history of an abdominal mass for which surgery was performed.
Transabdominal ultrasound imaging of the liver, spleen, and both kidneys revealed normal viscera. However, this is what we found on sonography of the pelvis:
This organ was clearly normal in size (measuring 7.5 x 2.6 x 3.4 cm). The endometrium measured 5 mm in thickness. The patient did not have a history of coitus. The ovaries clearly revealed abnormalities on both sides.
What's your diagnosis?
Both ovaries show small but well defined, echogenic masses within them. These masses are well defined in outline and measure about 2 to 2.5 cm each. The mass in the left ovary is slightly larger at about 2.5 cm.
What else do you see? The masses in both ovaries are hyperechoic with mild posterior attenuation of the ultrasound beam. This point is important as it may be the only differentiating feature of these masses from 2 other similar types of masses of the ovaries - the hemorrhagic cyst and the endometrioma. In both these latter masses, there is significant posterior acoustic enhancement of the beam as opposed to the posterior acoustic attenuation seen here.
The right ovary is seen in transverse section (to the left) in this ultrasound image. The uterus is seen to the right of the image.
Ultrasound image of the uterus in sagittal plane
Transverse section ultrasound image showing echogenic masses in both ovaries.
Here are some more ultrasound images of the pelvis of this patient:
This image shows another view of the echogenic mass (arrow) in the right ovary. Note the lack of any posterior acoustic enhancement beyond the mass. Note also the nearby bowel loops producing similar appearances.
Image of both ovaries
The left ovary shows fine fimbriated strands within the ovarian cyst. These suggest presence of hair within the cystic lesion in left ovary.
Another image of both ovaries showing the lesions.
The image of left ovary above shows a view at a slightly different angle showing less of the echogenic mass and an adjacent part of the left ovarian cyst just above the echogenic mass.
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