A 26-year-old woman, para 3, gravida 5, with 2 miscarriages, developed a rapid onset of fever, chills, nausea, vomiting, and severe pelvic pain, as well as heavy vaginal bleeding not associated with her normal menses. During presentation to the emergency department, she was found to have a white blood cell count of 18,000 with a left shift, urinalysis positive for leukocytes and nitrites. Abdominal CT scan was negative for any abscess or appendiceal signs. Her most recent miscarriage was 4 months prior, after which she had a progestin-eluting LARC inserted. Oral antibiotics were prescribed, and she was released to home. After 5 days, however, her symptoms were not improved and she saw her gynecologist, who immediately recommended removal of the LARC device and also changed the antibiotic. The patient began to rapidly improve. The gynecologist believed that the etiology of this unusual presentation of PID was due to retained tissue after the last miscarriage (in spite of a D&C) and the progestin LARC, which inhibited natural endometrial sloughing.


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