Thanks to Jake Martin and Malcolm Kearns for presenting a perplexing case of a young woman with several days of high fevers and abdominal pain, which later progressed to include transaminases in the 400s, a CK >1000, and RUQ pain–> all of which was ultimately thought to be due to pelvic inflammatory disease (although that’s not completely confirmed)!
What is pelvic inflammatory disease?
- PID is an ascending infection that goes up from the cervix up to the uterus, fallopian tubes, ovaries and can even spread intraperitoneally, leading to liver capsule inflammation (Fitz-Hugh-Curtis syndrome)
- PID can lead to high rates of infertility despite treatment: in one study, ~20% of women with treated PID reported infertility or ectopic pregnancy, suggesting that inflammation itself could lead to long-term damage despite adequate antimicrobial treatment
- PID encompasses a broad spectrum of clinical manifestations (see table below)
- Acute symptomatic PID: acute lower abdominal/pelvic pain, pelvic organ tenderness, possibly abnormal uterine bleeding or dyspareunia, RUQ pain if perihepatitis. Fever may not be present.
- Subclinical PID: more indolent, with more atypical manifestations
- Chronic PID: low grade fever, abdominal pain and weight loss over a long period, particularly associated with TB and Actinomyces (?association w/ IUDs)
PID is a clinical diagnosis, requiring:
- Pelvic organ tenderness (CMT, uterine compression tenderness on bimanual exam, adnexal pain) PLUS
- Lower GU tract inflammation (endocervical exudate or as yellow/green mucus on swab placed gently into the cervical os (positive “swab test”); cervical friability or increased WBCs on wet mount of vaginal secretions
The presence of fever or leukocytosis can help, but are not necessary. Imaging (TVUS, CT, MRI) can also be helpful: thickened, fluid-filled tubes/oviducts with or without free pelvic fluid could represent salpingitis, or tubo-ovarian abscess.
Unfortunately this clinical diagnosis only about 60-70% sensitive, which highlights the importance of empiric treatment given the high risk of withholding antibiotics.
All patients w/ suspected PID should undergo: vaginal exam w/ wet mount of secretions (to evaluate for increased WBCs), GC testing, HIV, RPR, pregnancy test, +/- ESR/CRP
We touched on the testing characteristics of GC testing. You can test for GC using NAAT (= gold standard), culture or gram stain.
- For women, NAAT screening obtained by vaginal swab is best; endocervical swab is fine if you’re doing a pelvic exam anyway, but not necessary to do one just for NAAT
- NAAT is >99% sensitive and specific for urogenital gonorrhea from cervical specimens (urine is about 10% less sensitive)
Lastly, treatment options
Treatment duration is usually 14 days. Interestingly, removal of an indwelling IUD does not hasten resolution (and may even worsen it)
- Pelvic Inflammatory Disease. NEJM 2015.