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E2292. The Infected Endometrioma: A Review of its Pathophysiology, Risk Factors and Multimodality Imaging Features
Authors
  1. Matheus Gomes; Universidade Federal de São Paulo (Unifesp)
  2. Rafaelle Vargas; Fleury Medicina e Saúde
  3. Lucas Torres; Fleury Medicina e Saúde
  4. Ulysses Torres; Fleury Medicina e Saúde
  5. Leandro de Mattos; Alta Excelência Diagnóstica/DASA; Universidade Federal de São Paulo (Unifesp)
  6. Ana Paula Moura; Fleury Medicina e Saúde; Santa Casa de Misericórdia de São Paulo
  7. Giuseppe D'Ippolito; Fleury Medicina e Saúde; Universidade Federal de São Paulo (Unifesp)
Background
The radiological recognition of secondary infection of an endometrioma can be challenging and have clinical and surgical consequences. This panel displays cases of infected endometriomas and deep endometriosis associated with pelvic inflammatory disease (PID), and reinforces the pathophysiology behind this association.

Educational Goals / Teaching Points
1) Although endometriosis per se is a risk factor for tubo-ovarian abscess, endometriomas can rarely infect. Clinical presentation is variable and may be even oligosymptomatic. 2) Imaging (namely US and MRI) appearance has also a wide spectrum of features, and suspicion of infection is often challenging.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
The propensity of endometriomas to become infected has been attributed to locally reduced resistance to infection as well as to endometriotic blood products acting as an effective culture medium (1). The probable routes by which the endometrioma is infected include (2): - Direct infection during puncture; - Ascending route via the vagina or cervix; - Direct spread from the colon wall; - Hematogenous or lymphatic spread. MRI findings include (3-5): - Complex multilocular adnexal cyst - Uni or bilateral - Enhancing wall - Fluid in the cul-de-sac - Gas within the cyst - Considerable signal variability on T1-WI and T2-WI - Restricted diffusion - Fistula to bowel or bladder

Conclusion
Spontaneous infection of an endometrioma is rare, and is due to local and systemic immunological changes, greater permeability of its walls and hematic stasis content. Procedures such as drainage and puncture may facilitate superinfection. Awareness of such risk factors and wide-ranging imaging features is paramount for radiologists, as imaging prediction of infected endometriomas has clinical and surgical consequences.