Intern Report Case 4.2

Case Presentation by Dr. Deepa Japra
A 25-year-old woman presents to the emergency department with persistent nausea and vomiting for 6 days. She complains of pain in the lower chest and upper abdomen that she rates as a 6/10.  She describes the pain “like a heart beating real hard”, which is constant and throbbing in character. She is unable to tolerate a regular diet and states she vomits everything she eats.  The vomitus is described as white and yellowish without hematemesis.  The patient had a small bowel movement today, which was soft with no gross blood.  She denies any genitourinary symptoms including no polyuria, dysuria, or hematuria. She does describe a vaginal discharge X 6 days. She is sexually active with one partner, and does not use protection.  Her LMP ended 9 days ago. She has also had subjective fevers and chills, and lightheadedness, but without any syncopal episodes.
Past medical history is significant for genital herpes infection.
VS: BP: 122/75, P: 59, R:18, T: 36.5, O2 saturation 100% on RA
GENERAL:  Pt is conscious, alert, and cooperative
HEENT:  Conjunctivae are pink without pallor, sclera anicteric. Mouth without intraoral lesions.  Pharyngeal soft tissues are normal.
NECK:  Supple. Trachea midline. No thyromegaly or lymphadenopathy.
RESPIRATORY:  Clear symmetric breath sounds. Good air exchange in all lung fields. No accessory muscle use.
CARDIOVASCULAR:  Normal S1 and S2.  No S3 or S4 gallops.  No murmurs or rubs.  CHEST WALL:  Nontender.
ABDOMEN:  Soft, nondistended, bowel sounds present. mild discomfort to palpation in the epigastric and suprapubic areas, but there is no guarding, masses or rebound tenderness.
BACK:  No spinal or paraspinal tenderness. No CVA tenderness.
MUSCULOSKELETAL:  FROM, symmetrical strength, no acutely inflamed joints. SKIN:  No rashes or lesions.
NEUROLOGIC:  No gross focal motor or sensory deficits.
PELVIC EXAM: External genitalia are normal. Slight discharge in vaginal vault, cervical os is closed. Positive cervical motion tenderness. Mild uterine and adnexal tenderness, no masses.
Laboratory Studies are as follows:
CBC: Hb 15.5, Hct 43.1, WBC 9.2, Pl 234
Electrolytes: Na 139, K 3.7, Cl 101, HCO3 26, BUN 21, Cr 1.0, Glu 90, Ca 9.5
Lipase 294
ALT 30, AST 19, Alk Phos 77, TBili .8, DBili .2,
Urine Pregnancy negative
UA: trace glucose, 3+ ketones, 1+ blood, 1+ protein, Positive nitrite, 1+ leukocyte esterase, RBC 2-5, WBC 5-10, 1+ mucus, 1+ bacteria
Rapid HIV negative
Gonorrhea PCR positive, Chlamydia PCR negative
Questions:
Question 1
Which of the following is the greatest risk factor for development of pelvic inflammatory disease?
a.     age
b.     intrauterine device usage
c.     multiple sexual partners
d.     previous PID
e.     sexually transmitted disease status of sexual partner
Question 2:
According to CDC guidelines, which of the following is essential in the diagnostic criteria for empirical treatment of PID?
a.     abnormal cervical or vaginal mucopurulent discharge
b.     history of Gonorrhea/Chlamydia infection
c.     lower abdominal or pelvic pain with cervical motion tenderness or uterine/adnexal tenderness
d.     numerous WBCs on microscopy of vaginal secretions
e.     oral temperature > 38.3 C
Question 3:
In addition to clinical symptoms and physical exam findings, which of the following criteria suggests a confirmed case of PID?
a.     confirmed N. gonorrhea infection in the past
b.     confirmation of ectopic pregnancy on vaginal ultrasound
c.     demonstration of N. gonorrhea in the genital tract
d.     elevated serum WBC count
e.     positive Pregnancy test
Answers: 1) c, 2) c, 3) c
Discussion:
The patient in this case is suffering from Pelvic inflammatory disease (PID) caused by Neisseria gonorrhoeae infection.  PID includes a spectrum of diseases of the female upper genital tract including endometritis, salpingitis, pelvic peritonitis, and tubo-ovarian abscess. It is an ascending infection most commonly caused by N. gonorrhoeae and Chlamydia trachomatis where the bacteria spread from the cervix and vagina to the upper portions of the female genital tract. PID is responsible for approximately 30% of female infertility and 50% of ectopic pregnancies.
Risk factors for PID include multiple sexual partners, STD status of the sexual partner(s), age, and history of previous PID. Numerous studies have shown that having multiple sexual partners resulted in increased risk of PID ranging from 4.6 to 20 fold. (Question 1c). In one study which compared 712 women hospitalized for PID to 2,719 controls, the risk of PID was increased 3.4 times in patients with four or more sexual partners during the previous six months, and 3.2 times in patients who had intercourse with one partner six or more times per week. Having a partner with symptomatic gonococcal infection including dysuria and urethral discharge also increases a woman’s risk of PID (Question 1e). PID is more common in the 15 to 25 year old age group, with the incidence in women greater than 35 years old being only one-seventh of that in younger women. (Question 1a). Women with previous PID have increased risk of subsequent episodes, with one study citing an increase by a factor of 2.3. (Question 1d). However, caution should be used in diagnosing a woman who presents with abdominal pain in the ED with PID based on a previous diagnosis of PID. IUD usage (Question 1b) causes minimal risk of PID, and risk is usually limited to the first 3 weeks after IUD insertion. There is no evidence indicating that an IUD should be removed in a patient with acute PID.
The clinical features of PID can vary widely, with lower abdominal or pelvic pain being the most common presenting symptom to the ED. Patients may also present with dyspareunia, abnormal bleeding, and/or vaginal/cervical discharge. Physical examination can demonstrate lower abdominal tenderness, cervical motion tenderness, unilateral or bilateral adnexal tenderness on bimanual exam, and/or fever (>38 C).  Though clinical examination has a low sensitivity for the diagnosis of PID, current recommendations by the CDC recommend empirical treatment based on clinical exam due to the long term sequelae, which include risk of ectopic pregnancy and infertility.
The CDC criteria for empirical treatment of PID include a minimum of cervical motion tenderness or adnexal/uterine tenderness in the presence of lower abdominal or pelvic pain (Question 2c). Additional criteria which are used to support a clinical diagnosis of PID includes oral temperature > 38.3 C (Question 2e), abnormal cervical or vaginal mucopurulent discharge (Question 2a), the presence of numerous WBCs on microscopy of a vaginal sample (Question 2d), elevated erythrocyte sedimentation rate (ESR), and elevated C-reactive protein (CRP). These additional criteria, however, are not necessary for empirical treatment. A history of gonorrhea/Chlamydia infection in the past (Question 2b) is not part of the CDC criteria indicating empirical treatment for acute PID.
Findings which confirm a diagnosis of PID in a patient that presents with clinical signs and symptoms suggesting PID include endometritis or acute salpingitis on histological evaluation of a biopsy, demonstration of N. gonorrhoeae in the genital tract (Question 3c), gross salpingitis seen during laparoscopy/laparotomy, isolation of pathogenic bacteria from a clean specimen in the upper genital tract, or inflammatory/purulent pelvic peritoneal fluid without another source of infection.  A confirmed diagnosis of N. gonorrhoeae infection in the past does not confirm acute PID (Question 3a). Though a patient with a positive pregnancy test and clinical symptoms of PID is at increased risk for ectopic pregnancy, a positive pregnancy test or a vaginal ultrasound demonstrating an ectopic pregnancy does not confirm PID (Question 3e and 3b). An elevated serum WBC count may suggest acute inflammation/infection, but is not in the diagnostic criteria to confirm PID (Question 3d).
As discussed above, empiric treatment of acute PID in the ED should be initiated in patients with lower abdominal pain and cervical motion tenderness, uterine tenderness, or adnexal tenderness due to the potential adverse consequences of untreated PID, which include infertility and ectopic pregnancy. Currently, CDC outpatient recommendations include ceftriaxone 250mg IM PLUS doxycycline 100mg BID for 14 days, with or without metronidazole 500mg BID for 14 days. An alternative regimen includes: cefoxitin 2g IM AND probenecid 1g oral PLUS doxycycline 100 mg BID for 14 days with or without metronidazole 500mg BID for 14 days. Metronidazole should be administered in patients with pelvic abscess, proven or suspected infection with Trichomonas vaginalis or bacterial vaginosis, or history of gynecological instrumentation in preceding 2-3 weeks.
Approximately 10 to 25% of women with PID require hospitalization. CDC recommendations for hospitalization include pregnancy, failure to respond to outpatient treatment, inability to tolerate oral medications, nonadherence to outpatient therapy, presence of pelvic abscess, or severe clinical illness including elevated fever, nausea/vomiting, and severe abdominal pain.  Inpatient treatment options include cefoxitin 2g IV q6h OR cefotetan 2g IV q12h PLUS doxycycline 100mg q12h. An alternative regimen is Clindamycin 900mg IV q8h PLUS gentamicin (2mg/kg) loading dose with maintenance dose of 1.5mg/kg q8h.
Clinical Pearls:
–  Pelvic Inflammatory Disease includes a spectrum of diseases of the female upper genital tract including endometritis, salpingitis, pelvic peritonitis, and tubo-ovarian abscess
–  Empiric treatment of acute PID in the ED should be initiated in patients with lower abdominal pain and cervical motion tenderness, uterine tenderness, or adnexal tenderness due to the potential adverse consequences of untreated PID, which include infertility and ectopic pregnancy
– Male sexual partners of women with PID should be treated if they have had sexual contact with the patient during the 2 months prior to patient’s onset of symptoms
– Patients with PID should be tested for other sexually transmitted diseases, including HIV

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