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

Amber M. Bokhari, MD


January 11, 2022

The most frequently used regimen includes ceftriaxone and azithromycin for gonococcal and chlamydial infections. Complicated PID may be treated with ceftriaxone, doxycycline, and metronidazole. Inpatient antibiotic therapy is warranted for patients with severe acute symptoms, sepsis, pregnancy, pelvic abscess, serious comorbidities or immunosuppression, and the lack of improvement on an outpatient antibiotic regimen.

Patients with persistent fever, chills, or worsening abdominal pain or cervical motion tenderness after 72 hours of treatment should be reevaluated for possible surgical intervention. Diagnostic laparoscopy is recommended for mild to moderate Fitz-Hugh-Curtis syndrome and PID, with lysis of adhesions in patients with symptomatic disease. Laparoscopy can also be therapeutic in PID, with abscess drainage or unilateral salpingo-oophorectomy. Laparotomy is usually reserved for patients who experience surgical emergencies, such as those with acute abdomen or ruptured abscesses or ovarian cysts, and for patients who are not suitable candidates for laparoscopic intervention. The ultimate goal is to preserve fertility and minimize morbidity and mortality.

The patient and the sex partner must be treated and educated about safe sex practices. Close follow-up is required until all of the symptoms have subsided and the cultures are negative. Management must include retreatment if necessary.[13,14,15]

Fitz-Hugh-Curtis syndrome responds well to antibiotic treatment. Thus, the Centers for Disease Control and Prevention recommends aggressive and prompt therapy for PID.[16]

The most common complications encountered in patients with PID as well as Fitz-Hugh-Curtis syndrome are infertility, abdominal abscesses, and bowel obstruction due to adhesion formation in the peritoneal cavity.[10,16] Infertility may be secondary to changes in the fallopian tubes, including scarring after chronic gonococcal infection.

This patient was treated with intravenous ceftriaxone and oral metronidazole and doxycycline for 2 weeks as outpatient antibiotic therapy for PID and concurrent Gram-negative bacteremia. She met most of the criteria of mild disease: white blood cell count less than 11,000 cells/µL, no evidence of peritonitis or abdominal abscess, and ability to tolerate food. Diagnostic laparoscopy was performed, with lysis of adhesions. Her prognosis remains good; she had mild disease with no tubo-ovarian scarring or peritoneal adhesions or abscesses. A transthoracic echocardiogram was negative. A follow up appointment was setup with gynecology for workup of fertility and gynecologic issues.


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