21-year-old woman presents to the emergency depament complaining of pelvic pain, a yellow-green vaginal discharge, and fever, all of which have been worsening over the last 24 hours. She has no frequency or dysuria. She has no medical problems. Her past surgical history is significant for a cesarean delivery 2 years ago performed for a nonreassuring fetal hea rate tracing. She takes no medications and is allergic to sulfa drugs. She is sexually active with multiple male paners who sometimes use condoms. She works as a medical assistant. Her temperature is 38.2 Deg C (100.7 F), blood pressure is 100/60 mm Hg, pulse is 110/minute, and respirations are 12/minute. Her abdominal examination is significant for diffuse tenderness, rebound, and guarding. Speculum examination demonstrates a copious greenish vaginal discharge that appears to be coming from the cervix. Pelvic examination is significant for cervical motion tenderness and adnexal tenderness. Laboratory evaluation shows: Urine hCG: negative Urinalysis: negative Leukocytes: 15,000/mm3 Hematocrit: 39% Platelets: 200,000/mm3 Which of the following is the most likely diagnosis?
Pelvic inflammatory disease (PID) is a significant cause of morbidity among sexually active menstruating women. PID refers to an upper genital tract infection, especially of the endosalpingeal cells that line the fallopian tubes. When the infection involves the fallopian tubes only, it is referred to as a salpingitis. When it involves the ovaries as well, it is then referred to as a salpingo-oophoritis. The endometrium is also often involved (endometritis). The peak incidence of the disease is in the 15- to 24-year-old-group. This patient presents with the typical symptoms of PID, paicularly abdominal/pelvic pain. Fever and vaginal discharge are often present in gonococcal PID, but may be absent in other forms of PID. The diagnosis of PID is made when the patient has abdominal tenderness, cervical motion tenderness, and adnexal tenderness plus a temperature > 38 C (100.4 F), or leukocytosis (>10,000/mm3), or laboratory documentation of chlamydial or gonorrheal infection. Treatment is with antibiotics. Ectopic pregnancy is ruled out with the negative urine pregnancy test. An ectopic pregnancy is a pregnancy that is implanted abnormally, most often in the fallopian tubes. As a pregnancy, it secretes human chorionic gonadotropin (hCG), which can be found in the blood or urine. When this is not present, ectopic pregnancy is ruled out. Gonococcal cervicitis presents with findings localized to the cervix. This patient has findings that go beyond a cervicitis. Given her abdominal tenderness with rebound, cervical motion tenderness, and adnexal tenderness, she is manifesting involvement of the fallopian tubes and peritoneum. While the gonococcus may be the offending organism in this case, this patient has more than a gonococcal cervicitis. A patient with a spontaneous aboion can present in a variety of ways, but most commonly she will present with complaints of vaginal bleeding or the passage of tissue from the vagina. A spontaneous aboion represents a failed pregnancy and this patient has no evidence of a failed pregnancy, and an abundance of evidence for PID.
Ectopic pregnancy
Gonococcal cervicitis
Pelvic inflammatory disease (PID)
Spontaneous aboion