[Downloaded free from http://www.jscisociety.com on Sunday, December 16, 2018, IP: 125.166.135.

104]

Case Report

A huge dermoid cyst with thrombocytosis

and preoperative intraperitoneal rupture:
An unusual presentation
Ramya Shankar,
Sujata Narendra Datti,
Jayanta Kumar,
Rangahanumaiah Manjushree
Department of Obstetrics and
Gynecology, MVJ Medical College and
Research Hospital, Karnataka, India
Address for correspondence:
Dr. Ramya Shankar,
No 34, 20th Main, 18th cross, Vijayanagar,
Bangalore, Karnataka - 560 040, India.
E-mail: drramyashankar@yahoo.co.in
Abstract
Benign cystic ovarian teratoma is the most common ovarian neoplasm accounting
for 10-25% of ovarian tumors.They affect women of all age and particularly women of
reproductive age group.They may present with a variety of symptoms ranging from being
asymptomatic to pain abdomen, dysmenorrhea, pelvic pain, nausea, vomiting, fever,
anorexia, loss of weight and shortness of breath. The complications associated with
benign cystic teratoma are torsion (16%), malignant degeneration (2%), rupture (1-2%),
and infection (1%). Its spontaneous or iatrogenic intraperitoneal rupture is associated
with chemical peritonitis. A dermoid cyst has been associated with thrombocytosis in
30% of the cases.
Hereby we present a case of huge ovarian dermoid cyst associated with thrombocytosis
and spontaneous preoperative rupture with chemical peritonitis.
Key words: Chemical peritonitis, dermoid cyst, thrombocytosis

INTRODUCTION CASE REPORT

Dermoid cysts constitutes about 10-25% of all benign
ovarian neoplasms and are the most common germ cell
tumors in women of reproductive age.[1,2] Spontaneous
rupture, although rare occurs in <1% of cases which
requires immediate intervention. Further, rupture leads
to intraperitoneal spillage of its contents resulting in
chemical peritonitis with protracted recovery phase.[3]
Though thrombocytosis has been reported in 30% of
the cases of dermoid cysts in a study[4] there has been
no case report showing this association. Hence, we
are presenting a rare case of huge dermoid cyst with
thrombocytosis and preoperative intraperitoneal
rupture.
Access this article online
Quick Response Code
Website:
www.jscisociety.com
A 25years old nulliparous lady with a married life of
7 years presented with abdominal pain of six months
duration more since one month, abdominal distension
noticed since one month, oligomenorrhoea since one year
(menses once in two to three months for one day with
scanty flow). Had significant weight loss (25 kilograms
over last 6 months), anorexia, breathlessness and easy
fatigability.
On examination, patient was afebrile, comfortable in
propped up position, had moderate pallor, preoperative
weight of 55 kilograms (weight along with huge ovarian
mass) and BMI of 26 kg/meter.[2] On palpation mass arising
from pelvis corresponded to 36weeks gravid uterus
size and clinically measured 34 × 28 cms. It had variable
consistency and restricted mobility in both vertical and
horizontal plane. On per vaginal examination the mass
was felt through all the fornices with minimal tenderness.
Rectal examination revealed that the rectal mucosa and
parametrium was free of nodularity or indurations.

DOI: Investigations
10.4103/0974-5009.120063 Haemoglobin-7.4g/dl, PCV-24.4%, WBC-8000/cu mm,
platelet count-600,000/µL, peripheral smear- dimorphic
180 Journal of the Scientific Society, Vol 40 / Issue 3 / September-December 2013
[Downloaded free from http://www.jscisociety.com on Sunday, December 16, 2018, IP: 125.166.135.104]

Shankar, et al.: A rare case of huge dermoid cyst with thrombocytosis and preoperative intraperitoneal rupture

anemia with thrombocytosis, urine routine and culture- Management

normal, RFT and LFT, blood sugars were normal. Tumor
markers CA 125: 158.70U/ml, LDH - 137.79U/L.
Abdominopelvic Ultrasound revealed a uterine size of
7.3 × 3.8 × 4.4 cm, with endometrial thickness of 6 mm,
a well defined cystic lesion of 24 × 15 × 20 cm with
diffusely or partially echogenic mass with posterior
sound attenuation owing to sebaceous material and hair
seen within the cyst cavity (the tip of the iceberg sign).
There was no evidence of internal vascularity. The two
ovaries could not be seen separately. Impression: A large
ovarian dermoid cyst.
CT Scan showed a well circumscribed rounded soft tissue
density lesion in right adnexa measuring 28.4 × 12.5 × 14.9
cms. The lesion showed predominately cystic areas with
interspersed fat within, a 4 mm nodular calcific focus was
noted in the anterior wall. There was evidence of mass
effect in the form of displacement of uterus and urinary
bladder. Impression: Right sided dermoid cyst.
Pre operatively two pint packed cells were transfused
and anemia corrected. Simultaneously was evaluated
for thrombocytosis, bone marrow biopsy was advised
but patient refused. During the course of preoperative
preparation she developed acute breathlessness and
pain abdomen, spontaneous rupture was suspected
and was taken for emergency laparotomy. During
surgery a very thick peritoneal surface was noted
which looked inflammed. On opening the parietal
peritoneum, a thick yellowish fluid of about 1.5 litres
which had collected in the paracolic gutters and
subhepatic spaces was suctioned [Figure 1]. A left
ovarian mass of 30 × 20 cm (weighing 10 kilograms)
was noted [Figure 2] with thick yellowish fluid oozing
from the ruptured site. This huge ovarian mass was
excised and sent for frozen section which revealed
ulcerated dermoid cyst [Figure 3]. Uterus, right ovary
and appendix were normal. Omental biopsy and
peritoneal biopsy was taken. A thorough peritoneal
lavage was given and abdomen closed.

Figure 1: Pultaceous material draining out on opening parietal Figure 2: Huge ovarian dermoid exteriorised
peritoneum.

Figure 4: Histopathology of the specimen, (a) Sebaceous glands

Figure 3: Site of rupture of ovarian dermoid (b) Ectodermal tissue

Journal of the Scientific Society, Vol 40 / Issue 3 / September-December 2013 181

[Downloaded free from http://www.jscisociety.com on Sunday, December 16, 2018, IP: 125.166.135.104]
Shankar, et al.: A rare case of huge dermoid cyst with thrombocytosis and preoperative intraperitoneal rupture
Post operatively she developed fever and was treated
symptomatically. Post operatively platelet count was
repeated and was as high as 800,000/ µL probably due
to reactionary thrombocytosis. Further, monitoring
of platelet count 2 weeks later revealed a drop to
preoperative value. On 21st postoperative day, the patient
reported back to us with symptoms of vomiting and pain
abdomen, was diagnosed to have subacute intestinal
obstruction which was treated conservatively. She
recovered and went back after one week. On subsequent
follow up in outpatient department, platelet had dropped
to 420,000/µL suggesting that preoperative elevated
platelet count was due to reactionary thrombocytosis.
Histopathological examination
Mature cystic teratoma [Figure 4]
Omentum: Non specific inflammation
Peritoneum: Non specific inflammation
Tube: Inflammed and congested
DISCUSSION
Dermoid cyst or mature cystic teratomas is the most
common benign germ cell tumor and the most common
neoplasm of the ovary.[5] Mature teratoma of the ovary
comprises a cyst lined by an epidermis- like epithelium and
contains a variable admixture of elements of one or more of
the three cell lines; meso, endo and ecto-dermal derivatives
including sebaceous secretions, hair, teeth, bone or fat.[6]
Katie Williams et al, have reported a maximum of 15 × 15
cms sized dermoid cyst in their case report; however, the
weight of ovarian dermoid has not been mentioned in
any of the case reports.
The diagnosis of a mature cystic teratoma using CT
imaging is straight forward because this modality is
more sensitive for fat.[7] Fat is reported in 93% of cases
and teeth or other calcifications in 50%.[8]
Despite the benign nature of the neoplasm’s they have
generated considerable interest because of their unusual
presentation. Rupture or perforation of the cyst may
give rise to peritonitis however spontaneous rupture of
an ovarian dermoid cyst is very rare (<1%) due to the
thick capsule.[8] Peritonitis resulting from a chronically
leaking dermoid cyst is characterized by multiple small
white peritoneal implants, diffuse or focal omental
infiltration and inflammatory masses involving the
omentum and bowel and dense adhesions and variable
ascites that simulate carcinomatous or tuberculous
peritonitis.[9] In our case there was chemical peritonitis
induced by chronic leakage of sebaceous material
182 Journal of the Scientific Society, Vol 40 / Issue 3 / September-December 2013
leading to omental, peritoneal and intestinal infiltration
mimicking malignancy.
Thrombocytosis (platelet count > 400,000/µL) and raised CA
125 levels are more frequently associated with malignant
ovarian tumor than with benign ovarian tumor.­[10]
Thrombocytosis is present in 30% of dermoid cysts, 25%
of serous cystadenomas.[4] In our case thrombocytosis
(platelet count = 600,000/µL) and elevated CA-125 (158.70U/
ml)was associated with a huge ovarian mass which
was diagnosed to be a dermoid cyst radiologically and
confirmed histopathologically. As thrombocytosis is said to
be present in both benign and malignant ovarian tumors,
thrombocytosis per se should not alter the management
and should just be considered as a marker of tumor burden.
CONCLUSION
Since, benign ovarian tumors like dermoid cyst can
present with thrombocytosis, elevated CA-125 and
mimic malignant ovarian tumor intra-operatively
(like peritoneal, omental and intestinal implants with
adhesions), the role of frozen section has to be over
emphasised to decide upon conservative surgery
particularly in nulliparous women.
REFERENCES
1. Fibus TF. Intraperitoneal rupture of a benign cystic ovarian teratoma:
Findings at CT and MR imaging. AJR Am J Roentgenol 2000;174:261-2.
2. Lipson SA, Hricak H. MR imaging of the femal pelvis. Radiol Clin North
Am 1996;34:1157-82.
3. Yang HS, Song TH, Bang HC, Park JH, Lee CH, Roh JW, et al. Persistant
chemical peritonitis resulting from spontaneous rupture of an ovarian mature
cytic teratoma. Korean J Obstet Gynecol 2011;54:726-30.
4. Noh HT, Son SK. The clinical significance of Thrombocytosis in Patients
presenting with a Pelvic Mass Korean J Gynaecol Oncol Colposc 1998;9:489-95.
5. Hertzberg BS, Kliewer MA. Sonography of benign cystic teratoma of the
ovary: Pitfalls in diagnosis Amer J Roentgenol 1996;167:1127-33.
6. Outwater EK, Siegelman ES, Hunt JL. Ovaria teratomas: Tumor types and
imaging characteristics. Radio Graphics 2001;21:475-90.
7. Guerriero S, Mallarini G, Ajossa S, Risalvato A, Satta R, Mais V, et al. Transvaginal
ultrasound and computed tomography combined with clinical parameters and
CA-125 determinations in the differential diagnosis of persistent ovarian cysts
in premenopausal women. Ultrasound Obstet Gynecol 1997;9:339-43.
8. Buy JN, Ghossain MA, Moss AA, Bazzot M, Doucet M, Hugol D, et al.
Cysticcxteratoma of the ovary: CT detection. Radiology 1989;171:697-701.
9. Pantoja E, Noy MA, Axtmayer RW, Colon FE, Pelegrina I. Ovarian dermoids
and their complications: Comprehensive historical review. Obstet Gynecol
Surv 1975;30:1-20.
10. Hakverdi AU, Yayla M, Gocmen A, Gul T, Erden AC, Demiroglu S. The
clinical significance of preoperative serum CA-125 levels and thrombocytosis
in patients with pelvic masses. Jinekoloji ve Obstetrik Dergisi 1995;9:205-9.
How to cite this article: Shankar R, Datti SN, Kumar J, Manjushree R. A
huge dermoid cyst with thrombocytosis and preoperative intraperitoneal
rupture: An unusual presentation. J Sci Soc 2013;40:180-2.
Source of Support: Nil. Conflict of Interest: None declared.