Discussion
In this case, the patient comes with right sided lower abdominal pain and fever. There are many conditions can lead to lower abdominal pain. Here based on the history and examination findings, the possible differential diagnosis is:
- Pelvic inflammatory disease (PID)
- Urinary tract infection
- Ovarian cyst
- Appendicitis
The most possible diagnosis is PID. This is because from the history itself the patient denied any dysuria, hematuria, loin pain, frothy urine and lower urinary tract symptoms, but urine examination for culture and sensitivity need to be done to rule out urinary tract infection. On examination, he found to have adnexal tenderness and cervical motion tenderness during vaginal examination. Her transvaginal ultrasound also shows thickened, fluid-filled oviducts which favours PID. For the ovarian cyst, commonly it is asymptomatic but if symptomatic it can present with mild abdominal pain and low grade fever. Ovarian cyst if large enough can be palpable but in this case there is no palpable mass per abdomen plus ultrasound done in this patient do not reveal any cyst on the ovaries. Appendicitis is less likely in this case as the pain presentation is normally very acute and severe where it is started on the paraumbilical region and then shift to the right iliac fossa.
Pelvic inflammatory disease is an infection of a woman’s reproductive organs. It is a complication often caused by sexually transmitted diseases, like Chlamydia Trachomatis and Neisseria gonorrhea [1, 2]. Other infections that are not sexually transmitted can also cause PID. Examples of non-sexually transmitted disease that can cause PID are Gardnerella vaginalis, anaerobes (including Prevotella, Atopobium and Leptotrichia) and Mycoplasma genitalium [3]. Untreated gonorrhea and chlamydia cause about 90% of all cases of PID. Other causes include abortion, childbirth, and pelvic procedures. PID can lead to irreversible damage to the uterus, ovaries, fallopian tubes, or other parts of the female reproductive system, and is the primary preventable cause of infertility in women. In this case, she’s been married since 20 years old. She claimed that there is no history of sexual promiscuity. But, there are possibilities that she or her partner already infected with the disease prior to the marriage because some of the genital tract infections are asymptomatic. Another possibility is because she had a salpingectomy in 1998 due to ruptured ectopic pregnancy. Pelvic procedures are one of the non- infectious causes for the PID.
In a normal female, the cervix prevents bacteria that enter the vagina from spreading to the internal reproductive organs. This is because normal cervical mucus affords protection against the invading microorganisms [5]. If the cervix is exposed to a sexually transmitted disease such as gonorrhea or chlamydia, the cervix itself becomes infected and less able to prevent the spread of organisms to the internal organs. PID occurs when the disease-causing organisms travel from the cervix to the upper genital tract. Breach of the cervical epithelium following procedures like endometrial biopsy, termination of pregnancy and insertion of IUCD can lead to ascending infections as well [5].
Women with PID may present with symptoms like dull pain or tenderness in the stomach or lower abdominal area, or pain in the right upper abdomen. They may also come with abnormal vaginal discharge that is yellow or green in colour that associated with malodor. They may even have dysuria, fever with chills and rigors, nausea and vomiting and pain during sexual intercourse. In this case, she presented with lower abdominal pain and fever. She denied the other symptoms. This might be due to despite of PID being the common clinical problem, many causes go unnoticed as clinical features have low sensitivity and specificity with positive predictive value ranging from 65% to 90% [ 5]. On abdominal examination, patient normally has lower abdominal tenderness which is usually bilateral, abnormal discharge may be seen in per speculum examination, adnexal tenderness and cervical motion tenderness on bimanual vaginal examination. However, this signs are non-specific and we might want to always consider ectopic pregnancy in women of reproductive age presenting with lower abdominal pain.
To diagnose PID, we need to do vaginal and cervical swab to determine the microorganism responsible even though it is normally polymicrobial. Two organisms commonly implicated in PID, Neisseria gonorrhea and Chlamydia trachomatis. The gram negative Neisseria gonorrhea is fastidious intracellular diplococci that require swabs of the endocervix to be obtained for culture. Chlamydia is also isolated from the endocervix and tested using polymerase chain reaction and immunofluorescence techniques. However, the absence of infection at this site does not exclude PID [2, 4, 6].High vaginal swabs are taken for lower genital tract infections as concomitant infection from this site is not uncommon. The absence of endocervical or vaginal pus cells has a good negative predictive value (95%) for diagnosis of PID but their presence is non- specific (poor positive predictive value of 17%) . An elevated ESR or C-reactive protein also supports the diagnosis but it is non-specific . Thus, in this patient even though most of the investigations findings are normal but it does not exclude PID. However, lab result shows positive for candida sp.Delayed treatment in case of PID can increases the long term sequelae like ectopic pregnancy, infertility and chronic pelvic pain. Due to this reason and the lack of definitive diagnosis criteria, a low threshold for empiric treatment of PID is recommended if PID case is suspected. Broad spectrum antibiotic therapy is required to cover the polymicrobial causative agents. For the impatient regimens, intravenous therapy should be continued until 24 hours after clinical improvement and then switched to oral. The drugs recommended are [ 7, 8 ]
- IV ceftriaxone 2g daily
- IV doxycline 100mg twice daily (oral doxycycline may be used if tolerated)
- Followed by oral doxycycline 100mg twice daily + oral metronidazole 400mg twice daily for a total of 14 days.
The indications for the admission of patient should be considered in the following situations
- A surgical emergency cannot be excluded
- Lack of response to oral therapy
- Clinically severe disease
- Presence of tuboovarian abscess
- Intolerance to oral therapy , Pregnancy
If the patient is stable with clinically mild to moderate PID, outpatient therapy can be given. The recommended regimens for outpatient are:
- IM Ceftriaxone 500mg single dose followed by oral doxycycline 100mg twice daily + metronidazole 400mg twice daily for 14