Discussion

Both ultrasonography and computed tomography demonstrate normal results. The next best step in treatment is to conduct a pelvic exam, which demonstrated mild cervical motion tenderness. Consultation with a gynecologist is advised due to the patient’s high white blood cell count.

Pelvic inflammatory disease (PID) should always be included in the differential diagnosis for lower abdominal pain in a female patient, especially when there is no other obvious cause. PID often is missed or diagnosed late for a variety of reasons, including no vaginal discharge, no new sexual partner, not sexually active, older age, minimal tenderness, normal laboratory assessment, and no fever. However, PID is a common condition, especially in younger women, and is associated with significant short- and long-term morbidity and mortality.

Approximately 15% of PID cases do not result from a sexually transmitted infection. Fever is present in approximately 30% of patients, and laboratory assessment is often normal. Aside from screening for sexually transmitted infections, the next best step in management is to obtain a C-reactive protein (CRP) level. Advanced imaging is often indicated, primarily to rule out other conditions such as appendicitis or ovarian cyst; however, if imaging is negative, clinical suspicion for PID should rise sharply. Causes of PID can include anaerobes, Streptococcus species, and Staphylococcus aureus, but the most common causative organism is Chlamydia trachomatis.

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Remember to also consider chlamydia in a female patient presenting with right upper quadrant pain and an otherwise negative clinical presentation, even if no pelvic symptoms are present and the pain is pleuritic. Fitz-Hugh-Curtis syndrome is often missed because isolated right upper quadrant pain may be present without vaginal or pelvic symptoms, a presentation similar to that seen in a patient with pyelonephritis and no dysuria. Assessment of CRP level and presence of chlamydia should always be considered with such presentation.

For the patient in this case, a gynecologic examination found no cervical motion tenderness, and the patient was discharged. She then returned to the ED when her temperature spiked to 103.4°F, and she was admitted to the ED for a nongynecologic cause of fever and abdominal pain. Additional laboratory testing found a normal erythrocyte sedimentation rate; however, CRP was elevated at 85 mg/L. Examination was negative for gonorrhea but positive for chlamydia. The patient was transferred back to the gynecology service.

Reference

Pregerson DB. Emergency Medicine 1-Minute Consult Pocketbook. Emresource.org; 2017;5.