Reviewer ’s report  
 
Title:  Tubo -ovarian Abscess with Sepsis in a Nonagenarian Woman: A Case Report and 
Literature Review  
 
Version: 3 Date: 31 Mar 2019 
 
Reviewer:  Ludwin  Artur  
 
Reviewer’s report:  
 
My opinion is the same as previously that this case report does not add too many for existing 
literature. It is well kn own that tubo -ovarian abscess, if is untreated may cause of sepsis in post -
menopausal women.  
 
In literature there are studies focused on abscesses in postmenopausal women and this case 
report should not be considered as ‚unusual' (Protopapas et al., 2004;  Hoffman et al. 1990), 
becasue even 18% of tubo -ovarian abscesses is present in post -menopausal women.  For instance 
Hoffman et al. report 9 cases with tubo -ovarian abscess with 2 cases with septic shock. 
Lipscomb et al. found 20 cases of tubo -ovarian absc esses in postmenopausal women. The lack of 
prompt surgical exploration leads to sepsis.  
 
I believe that this case, if is considered for publication should be presented with review of 
literature or in context to the existing literature.  
 
Because, the edito r and other reviewers found this case report as interesting for publication, I 
have a few additional major comments before potential publication.  
 
 
1. The authors added the CARE checklist and many items are described as N/A - it is very 
confusing statement, because most of these items should be described  
 
 
2. There are not clear data how much time the patient spent in the hospital from the admission t o 
surgery  
 
 
3. The abdominal physical examination is not described clearly (presence of lower abdominal 
tenderness). According to the picture tha patient was slim and tumor had to be palpable in initial 
physical examination. Why abdominal and transvaginal ultrasound did not perfomed. It is a basic 
diagnostic method for pelvic mass and the described case. Why the patient did not undergo 
gynecological examination if palpable pelvic mass was present? It is impossible that doctors 
didn't found the mass by abdom inal palpation (see picture).  
 
BMI should be described. The dementia is not sufficient explanation for delayed diagnosis of 
tubo-ovarian abscess in case if huge palpable pelvic mass is present in context to laboratory 
results.  
 
 
4. Title should be clear and transparent for readers that it is a case report.  
 
‚women' should be changed on ‚woman'.  
 
I suggest adding that it is a case report. The word ‚unusual' overestimate the importance of the 
case.  The title should be informative.  
 
 
 
For instance:  
 
Tubo -ovarian ab scess and sepsis in a nonagenarian woman: a case report  
 
If the authors add the extensive review of literature the title should also highlight that it is a case 
report and review of literature.  
 
 
5. Both introduction and discussion should be based on review of the available literature. I 
suggest adding review of literature in tabular form.  
 
 
6. Information about histology of the mass should be added  
 
 
7. Information from this case report organized into a timeline with relevant dates (table or figure) 
should be provided (inital physical examination, all tests, surgery), bacause delayed surgical 
treatment of tubo -ovarian abscess may lead to sepsis.  
 
 
8. Conclusions: I think that tubo -ovarian abscess is listed in differential diagnostics in all 
postmenopausal women,  especially if the huge large palpable pelvic mass is present as in this 
case (see imege and relation between abdominal wall and the cyst). The authors should focus on 
items, which delayed propter treatment  (fast track surgery) in this case.  
 
 
9. The lack of gynecological examination in the initial step of diagnostics  if huge palpable mass 
(picture) was present is the main problem in this case. It is quite unusual that gynecological 
examination was not performed and it should be highlighted and explained.  
 
 
 
References.  
 
1. Hoffman M1, Molpus K, Rob erts WS, Lyman GH, Cavanagh D. Tuboovarian abscess in 
postmenopausal women. J Reprod Med. 1990 May;35(5):525 -8. 
 
2. Hsiao SM, Hsieh FJ, Lien YR. Tuboovarian abscesses in postmenopausal women. Taiwan J 
Obstet Gynec ol. 2006 Sep;45(3):234 -8.  
 
3. Vasilev SA, Roy S, Essin DJ. Chia CC1, Huang SC.Ruptured tubo -ovarian abscess in a 
postmenopausal woman presenting with septic shock: a case report and literature review. Taiwan 
J Obstet Gynecol. 2006 Mar;45(1):89 -91. 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further 
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manus cript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an 
organisation that may in any way gain or lose financially from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds or has applied for patents relating to t he content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
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