A Sexually Active 30-Year-Old Woman With Rash and Wrist Pain

Amber M. Bokhari, MD


January 11, 2022

Physical Examination and Workup

Upon examination, the patient is febrile, with a temperature of 102.6° F (39.2° C). She has a blood pressure of 110/70 mm Hg, a heart rate of 115 beats/min, a respiration rate of 20 breaths/min, and an oxygen saturation of 96%.

Her right shoulder and left wrist joints are painful. No joint erythema is noted, but she has limited range of motion secondary to the pain. She appears to be in severe discomfort.

She has a rash on her body, including on the palms and soles, which has nearly resolved. Residual petechial macules and papules are visible on her wrist. Figure 1 shows a similar rash in a different patient. Similar lesions are noted on the bilateral thighs and perineum, but the degree of involvement is significantly less than it was 2 weeks earlier, according to the patient. The remainder of the physical examination results are unremarkable.

Figure 1.

A urine pregnancy test is negative. Routine laboratory studies are performed. A complete blood cell count reveals a white blood cell count of 9000 cells/µL (reference range, 4000-11,000 cells/µL), with predominantly elevated neutrophils. The urinalysis results are normal. The results of a comprehensive metabolic panel are within normal limits. A rapid plasma reagin  test, hepatitis B and C tests, HIV antigen/antibody test, and urine Neisseria gonorrhoeae/Chlamydia trachomatis nucleic acid amplification tests  are ordered. Because of the patient's unusual presentation, blood and urine cultures are also ordered.

Ultrasonography of her right upper quadrant does not show any signs of cholecystitis or cholelithiasis. Contrast CT of her abdomen and pelvis does not reveal hepatic inflammation or any fluid collections.

Gynecology is consulted, and speculum examination is negative for vulvovaginitis, cervicitis, or foreign body. Urine and serum beta human chorionic gonadotropin test results are negative for pregnancy. Physical examination does not reveal cervical or adnexal tenderness or mass. Additional testing includes pap smear, urine nucleic acid amplification test for chlamydia and gonorrhea, human papillomavirus polymerase chain reaction  test, and bacterial and fungal cultures. Results are pending.

Transvaginal ultrasonography is performed and does not reveal endometritis, salpingitis, tubo-ovarian abscess, ectopic pregnancy, hydrosalpinx, nor pyosalpinx. Some tubal scarring is noted bilaterally; however, the tubes are not disfigured. Contrast CT of the abdomen and pelvis shows increased perihepatic enhancement that is concerning for perihepatitis and minimal bilateral tubal scarring. The CT is negative for pyosalpinx, tubo-ovarian abscesses, and abdominal or pelvic abscesses.


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