What's Your Diagnosis? Pelvic Inflammatory Disease

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got last month’s case on Emergency Department Management of Surgical Airway Complications correct.

Case Presentation: Pelvic Inflammatory Disease: Diagnosis and Treatment in the Emergency Department

A 30-year-old woman presents with abdominal pain…

You note mild left adnexal tenderness without cervical motion tenderness or adnexal masses. Her laboratory test results are notable for a urinalysis that is positive for small leukocyte esterase and nitrite-negative, and a wet mount is without clue cells, yeast, or Trichomonas vaginalis. The patient denies any urinary complaints or flank pain.
The patient’s ultrasound results contain the radiologist’s impression: “No radiological etiology of patient’s abdominal pain is found.” You review the chart and confirm there is no concern for any nongynecological etiologies for her pain.
As the patient asks, “Why am I having this pain? Can I just go home?” you wonder if there is something else you should do…

Case Conclusion

The well appearance of the patient, the minimal findings on physical examination, and the findings of leukocyte esterase in the urine could have been deceiving, but you correctly diagnosed the patient with PID. She was started on empiric outpatient therapy for PID, with a single dose of 500 mg ceftriaxone IM and 14 days of both 100 mg of oral doxycycline, twice per day, and 500 g of oral metronidazole, twice per day. You made arrangements for follow-up in 3 days in the gynecologic clinic to assess for clinical response.

When you followed up later, you found she had a good response, was found to have a positive N gonorrhoeae/C trachomatis NAAT, but she was HIV-negative. Two years later, she was able to get pregnant with a new partner and deliver without any difficulty or complications.