Case 5 :

A 20 year old woman comes to the polyclinic because of increasing lower abdominal pain for 3 days. The pain began insidiously, but now she is unable to walk comfortably. She has had a few chills, but no rigor. She is nauseated and vomited once this morning, but she has held down some water and tea since then. There is no diarrhea or dysentery. She developed a mild vaginal discharge during the past week.

She states that she had one other episode like the current illness the previous year. A review of her polyclinic chart indicates that she was also treated 4 months ago for mucopurulent cervicitis. The past history is otherwise unremarkable.

She is G0P0. Her last menstrual period began 5 weeks ago and was scantier than usual; menses normally occurs at 28 day intervals. The patient has had two recent sexual contacts. She is unaware that either has had any STD.

Physical Examination

  • Vital signs: temperature = 37.8C, heart rate = 96/min (supine) and 104/min (standing).
  • The heart and lungs are unremarkable
  • The abdominal exam reveals normal bowel sounds. The abdomen is not distended. The liver and spleen are not palpable. There is diffuse lower quadrant tenderness with mild rebound noted in the right lower quadrant.



Q1: At this point, which of the following should be included in your differential diagnosis?
A. acute appendicitis
B. ectopic pregnancy
C. pelvic inflammatory disease (PID)
D. ruptured diverticulum
E. vaginitis due to Trichomonas vaginalis
F. torsion of the ovary
  Click here for discussion of the question.
 

Case 5 (continued)
A pelvic examination is performed. There is significant pain with passage of the speculum. The cervix is reddened, and there is pus in the cervical os. A sample is taken with a swab. On digital examination, manipulation of the cervix cause exquisite pain. There is also fullness of the right adnexa, and you suspected that there is enlargement of the right Fallopian tube. A rapid pregnancy test is negative.

The cervical pus is negative for motile protozoa on a wet prep. A Gram stain is also performed and has the following appearance:

(click to enlarge photomicrograph)
 
Q2: Which of the following organism or combinations of organisms may be contributing to this patient’s symptoms?
A. N. gonorrhoeae only
B. C. trachomatis and various intestinal facultative and anaerobic bacteria
C. Various intestinal facultative bacteria and Prevotella species
D. Group B streptococcus (S. agalactiae) only
E. N. gonorrhoeae, C. trachomatis, and various facultative and obligate anaerobic bacterial species
 

Q3: How will you treat this patient with antibiotics?

A. Admit her to the hospital and give intravenous clindamycin 900mg every 8 hours and gentamicin 5 mg/kg daily.
B. Admit her to the hospital and give cefoxitin 2 grams every 6 hours and doxycyline 100mg orally every 12 hours.
C. Give her ceftriaxone 250mg IM once, followed by doxycycline 100mg and metronidazole 500mg twice daily for 14 days to take at home.
D. Give her levofloxacin 500mg orally daily with metronidazole 500mg twice daily to take at home for 14 days.
E. Give her amoxicillin 500mg and metronidazole 500mg orally three times a day for 14 days.
  Click here for discussion of the question.
 

Case 5 (continued)
In addition to the prescription for medication, you advise the patient to rest for the next few days and to refrain from any sexual activity until she returns for follow-up in 1 week. You also instruct her to have her sexual contacts come to the clinic for examination and treatment and advise her to refrain from having intercourse with either of them until they complete a course of treatment. You obtain blood for an HIV serology from the patient.

The patient returns for follow-up the next week. She has taken her medication as prescribed. Her pain and discharge are resolved. She has no fever, and there is only minimal right lower quadrant tenderness on abdominal examination
 
Q4: In further counseling this patient, what other concerns should you raise with her related to her repeated episodes of pelvic inflammatory disease?
A. the possibility of infertility
B. the risk of acquiring HIV
C. the risk of cervical cancer
D. the possibility of chronic pelvic pain
E. the risk of ectopic pregnancy
 
This is the end of Case 5