Endometriosis Unveiled: A Tale of Two Extremes, From Acute Sepsis to Silent Suspicion

Endometriosis may rarely present with atypical manifestations that closely mimic intra-abdominal malignancy or severe pelvic sepsis, resulting in significant diagnostic uncertainty. We present two contrasting cases of presumed severe endometriosis with uncommon clinical and radiological presentations. In the first case, a woman in her 30s presented with acute abdominal pain, progressive abdominal distension, and respiratory compromise associated with massive haemorrhagic ascites and markedly elevated cancer antigen 125 levels. Cross-sectional imaging demonstrated extensive deep infiltrative endometriosis with haemoperitoneum and multiple extra-pelvic endometriotic deposits. In the second case, a woman in her 30s presented with a complex adnexal mass, para-aortic lymphadenopathy and inflammatory features initially concerning for tubo-ovarian abscess or underlying malignancy. Following prolonged antibiotic therapy, complete radiological resolution of the adnexal lesion was observed, with subsequent imaging findings considered highly suggestive of an infected endometrioma. These cases emphasise the diverse spectrum of endometriosis presentations, the limitations of non-histological diagnosis and the importance of multidisciplinary assessment, radiological expertise and longitudinal follow-up in complex presentations.