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P40.03: Torsion of paraovarian cyst in pregnancy ‐ case report

Background: Hyperandrogenism is a common cause of irregular menses associated with hirsutism in adolescent females. We present a rare case of a fifteen years old girl with severe virilism and behavioral changes associated with testosterone secreting mature ovarian teratoma. Case report: The patient, a 15 years nulligravida, presented to our clinic with complaints of hirsutism, acne, voice changes, menometrorrhagia, clitoromegaly, behavioral changes and abdominal mass. Her physical exam was significant for facial and bodily hirsutism, acne and clitoromegaly. A large abdominal mass was palpated extending to the epigastrium and was smooth and mobile. There were no signs for ascites. Laboratory work up revealed testosterone level at 213 ng/dl (normal is < 90 ng/dl) and normal DHEA-S levels. Ultrasound scan was performed and was significant for a large complex cyst measuring 20 × 18.2 × 11.6 cm originating from the left adnexa. Low levels echos and echogenic mass with shadowing were suggestive of a dermoid cyst. However, irregular semisolid mass at interior side of the cyst was noted. This mass was positive for color Doppler with resistive index of 0.62. The patient underwent exploratory laparotomy, left salpingo-oophorectomy and appendectomy. The cystic mass that weighed 2390 grams was diagnosed histologically as mature cystic teratoma containing well differentiated Leydig cells. Normal testosterone levels were found shortly after the surgery and the patient reported regular periods and improvement in agitation in her follow up visits. Discussion: Our case introduces two very unusual and interesting aspects associated with mature ovarian teratoma. First, we report on a rare etiology for hyperandrogenism. To our knowledge this is the first report on testosterone producing benign leydig cells from mature teratoma. Second, we report for the first time on presence of blood flow within a mature ovarian teratoma that is not related to thyroid tissue.