CASE REPORT

BARTHOLINS ABCESS CAUSED BY ESCHERICHIA COLLI

Endang tri wahyuni, Muhammad Dali Amiruddin, Alwi Mappiasse Departement of Dermatovenereology Medical Faculty of Hasanuddin University / Wahidin Sudirohusodo Hospital Makassar

ABSTRACT
Bartholin's abscess involves an accumulation of pus that forms a lump (swelling) in one of the mucous-producing Bartholin's glands. A Bartholin's abscess forms when a duct from the gland gets blocked. This swelling is hot to the touch, sensitive, and painful. Many different types of bacteria can cause the infection. Reported a case of Bartholins abcess in a woman 47 years old. Poor personal hygiene are predispotition factor in this patient. Bacteria culture showed Escherichia coli as the etiology. Treatment using oral antibiotic, vertical incision and drainage gave satisfactory result. Keyword : bartholins abcess, Escherichia coli, incision and drainage

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Bartholin Abcess Caused By Escherichia Colli

INTRODUCTION
Bartolins glands was first introduced by a Dutch anatomist in the year 1677.1This gland is the largest vestibular glands which resembles Cowper glands (bulbourethral glands) in males.1,2,3 Bartholini gland is the vulvovaginal bilateral, located in the labium minor about at the four and eight o'clock positions posterolateral aspect of vestibulum.2,4,5 Approximately normal sizeof a pea. Each gland mucus release into the duct length is approximately 2.5 cm and the orifice located on the lateral hymenal ductus in the indentation between the hymen and the labium minor.Its function is to maintain surface moisture vagina vestibular mucosa.1,3 In the normal gland was not palpable unless there is illness or infection.2 Abscesses are accumulation of pus which causes swelling in one of the bartholins glands that produce mucous.5 Abscess of Bartolins glands have formed when the channel closure, cause intense swelling that occurs is pain, tenderness and warm in palpable.7 Increasing the secretion of the glands and can cause infection. Bartholins gland abscess is almost three times more common than cystic duct Bartolini. Bartholins gland abscesses are common in women in the reproductive periode. Gland infection is not always caused by an infection transmitted through sexual.6 Bartolins abscesses can be caused by organisms pyococcal, gonococcus andChlamydia trachomatis. In one study only about 21 of 109 cases caused by staphylococci, while 50 cases are caused by Escherichia coli and 46 cases caused by Streptococcus faecalis.8 Treatment is recommended Bartholins abscess incision drainage.6,9 Antizbiotics can be given to fight infection, but not all cases require antibiotics if the abscess can be issued .6 The prognosis of this disease is good,it is seen from the response to treatment with a satisfactory improvement

and only 10% in the incidence of recurrent abscesses.10 This is a case reportof bartholins abcess in a woman, 47 years old, caused by E.coli, and the treatment is incision and drainage.

CASE REPORT
A woman 47 years old, have married, came to dermatovenereology clinic Wahidin Sudirohusodo hospital (RSWS) Makassar, complaint with nodule in the labium majora since 4 days ago. Nodule gradually more bigger than before, it more pain after activities. The patient have take oral antibiotic (amoxycillin) by herself and analgetic, but the complain not reduce. History of sexual contact one week earlier denied and there was not a history of fluor albus. General condition and nutritional status were good. Vital sign were normal. Physical examination at right labia minora were erythematous nodule with pain and fluctuation. There was no vaginal secret. (Picture 1) According to anamnese and phisical examination the diagnose was bartholinitis.

Picture 1.Bartholins glandabscess showed erythematous nodule with fluctuation.

Laboratory examination in normal values (table 1), after incision and drainage, the pus was aspirated and examined. The laboratory examination were gram staining, culture, VDRL. The treatment are doxicyclin 100 mg twice a day and natrium diclofenak 2 x 50 mg.

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Tabel 1. Laboratorium examinattion results Routine Blood : Hb Lekosit : 12,7 (12-14) : 6,5 x 103/mm3

Picture of operative procedure

Erythrocyte : 4, 31 x 106/mm3 ESR GDP CT/BT VDRL : 35/66 (kurang 20) : 111 (kurang 140) : 830 / 300 : Non reactive Picture post incision and drainage
Picture 2 and 3. Vertical incision and drainage the bartholins abscess

Urine sedimentation : Leucocyte Erythrocyte Epithel Ca oxalat : 7 (0-5/LPB) : 3 (0-3/LPB) : + +++ penuh : +
Picture 4. Scar post incision, seen no more erythematous nodule and painless

Gram staining : positive There are negative gram bacillus Culture Aerob : Escherichia coli Anaerob : There is no growth Result of sensitivity test Drugs Kons Disk Ket S S R S S S S S R S S S S R

DISCUSSION
Bartholins glands (greater vestibular glands) are homologues of the Cowpers glands (bulbourethral glands) in males. At puberty, these glands begin to function, providing moisture for the vestibule.1 Bartholini cyst is a obstruction of one of bartholin duct caused by genital infection, inflamation or mucous. The symptoms are painless nodule in vulva. In infection it become very pain bartholins abcess.2 Bartholins abcess is accumulation of secret cause sweeling in one of the gland which produce mucous.5 Bartholins abcess appear when the duct is closed, swelling can causes very pain, sensitive, and hot in palpable.7 This is according to case with complains are nodule erytematous in genital area very pain, mainly if patient had activity. Bartholins abcess often found in reproductive women at 2% aged 20-40 years old.11But a case bartholins abcess in one month baby had been reported. 12

1. Astreonam 30 g 2. Cefazolin 20 g 3. Amoxycillin 8 g 4. Ceftazidin 26 g 5. Cefuroxim 20 g 6. Ceptriazon 30 g 7. Doxyciclin 18 ug 8. Streptomycin 10g 9. Chloramphenicol 8 g 10. Tetracycline 24 g 11. Sulfamethoxasole 18 g 12. Sulfaperason 25 g 13. Neomicin 18 g 14. Norfloxacin 12 g

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Bartholin Abcess Caused By Escherichia Colli

This is according to case with patient is a woman 40 years old who has married. Bartholins abcess more big until 8 cm in diameter after four or five days.13 The incidens of infection bartholin gland associated by sexual transmitted disease. Although Neisseria gonorrhoeae is a predominant caused, but the other anaerob isolate also can caused bartholins abcess. It reported by Brook that there were 67 different pathogens isolated from vagina in case bartholins abcess. 14 Patient in this case with achieve compain of sweeling in vulva area with small nodule and gradually more biger after four days.Gram staining examination is negative and cultur examination there were aerob isolate Escherichia coli. Escherichia coli is a family of Enterobacteriaceae. Enterobacteriaceaeis a main normal flora in human intestinal, but it become pathogen if found in other body. Enterobacteriaceaecan cause infection in extra intestinal, specially in tractus urinarius.15The patient in this case , there was infection of E.coliin bartholin gland maybe caused by poor hygiene and cause migration pathogen. The treatment in this case were doxicyclin 2 x 100 mg and natrium diclofenac 2 x 50 mg before there is result of sensitivity test. And after the sensitivity test the treatment is still gave doxicyclin 100 mgtwice a day on 7 days. Doxicyclin is a second generation of tetracyclin with inhibits protein synthese with binding ribosom 30S subunit and 50S, and can use for gram negative and positive. In addition to antibiotics, the management of the patient's incision and drainage, this was done because the size of the tumor mass is large enough, aim for the drainage of secretions as much as possible. After incision of action, complaint of patient reduced , and outpatient care to evaluate and monitor the patient's condition. On the third day, drain off the set when urinating, afteran evaluation ofthe drainwas not there, the incisionwas

still open, noedemaandpuswas found, treatmentwas continued. Bartholins gland cyst treatment depends on the symptoms caused. For the case of Bartholins gland cysts are asymptomatic may not require treatment, but Bartholins gland cysts and abscesses are symptomatic should be taken incision drainage. Barring a spontaneous rupture, abscess Bartholin rarely heal themselves.16 Although incision and drainage is a procedure that is relatively quick and easy, and proven to quickly cure the patient but this technique has a tendency to cause recurrent cysts or abscesses.17 Prognosis is quite good with Bartholins abscess recurrence rate of less than 20%. In case of recurrence up to several times it can be done bartholins cyst excision in the absence of active infection. Scarring, and complications of chronic pain after surgery can occur when previously been carried out several measures for the drainage of secretions / abscess so the possibility of adhesions that would complicate the act of excision.6 Education given to these patients was to maintain the good hygiene of body and sex.

REFERENCES
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Omelo F, Simmons BL, Hacker Y. Management of Bartholins duct cyst and gland abscess. Am Fam Physician, 2003; 68: 135-40. Eckert LO, Lentz GM. Infections of the lower genital tract : vulva, vagina, cervix, toxic shock syndrome, HIV infections. In Katz VL, Lentz GM, eds. Comprehensive Gynecology. Philadelphia : Mosby Elsevier, 2007. 641-7. Bunker CB, Neill SM. The genital, Perianal, and Umbilical regions. In Burns T, Breathnach S, Cox N, Griffiths C. Editors. Rooks textbook of dermatology th 8 ed. Wiley-Blackwell, 2010; 71.5271.79. Tanaka K, Mikamo H, Ninomiya M, et al. Microbiology of Bartholins gland abscess in Japan. J Clin Microbiol, 2005; 43(8): 4258-61. Tilton P. Diseases of the vulva. In Havens CSS, Nancy D., editor. Manual of Outpatient Gynecology. 4th ed. California: Lippincott Williams & Wilkins; 2002. p. 1625 Holmes KK, Stamm WE. Lower genital tract infection syndromes in women. In: Holmes KK, Mardh P-A, Sparling PF, Lemon SM, Stamm WE, Piot P, et al., editors. Sexually transmitted diseases. rd 3 ed. New York: McGraw-Hill Health Professions Division; 1999. p. 761-81. Pernoll ML. Disorder of the vulva and vagina. Benson & Pernoll's handbook of th obstetrics & gynecology. 10 ed. New York: McGraw-Hill Medical Publishing Division; 2001. p. 571-9. Kady SE, Zahrani AA, Jednak R, Sherbiny SE. Bartholins gland abcess in a neonate: a case report. CUAJ, 2007; 1(2): 117-9. Brook I. Aerobic and anaerobic microbiology of Bartholins abscess. Surg GynecolObstet 1989; 169: 32-4. Chart H. Klebsielle, enterobacter, proteus & other enterobacteriae. In: Wood DG, Slack RBC, Pentherer JF, editors. Medical microbiology. London:Churhill livingston 2002.p.275-81. Hill DA, Lense JJ. Office management of Bartholin gland cysts and abscesses. Am Fam Physician 1998; 57:1611-6,1619-20.

17. Stenchever MA. Comprehensive gynecology. 4th ed. 2001:482-6,645-6. St. Louis: Mosby,

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