Obgyn · Year 3 · from Obgyn

Case 1: Pelvic Inflammatory Disease with Tubo-Ovarian Abscess

Patient Demographics

  • Age: 22 years
  • Sex: Female
  • Occupation: College student

Chief Complaint

"I have severe lower abdominal pain and fever for the past 3 days."

History of Present Illness

The patient presents with bilateral lower abdominal pain that began gradually 5 days ago and has progressively worsened over the past 3 days. She describes the pain as constant, dull, and aching, rated 8 out of 10 in severity, worsened by movement and intercourse. She reports fever with measured temperatures up to 39.2 degrees Celsius, chills, nausea without vomiting, and a new yellow-green vaginal discharge with foul odor. Her last menstrual period was 2 weeks ago and was normal. She has had two sexual partners in the past 6 months and uses oral contraceptives for birth control. She reports inconsistent condom use. She denies dysuria or urinary frequency.

Past Medical History

  • Chlamydia infection treated 18 months ago
  • No prior surgeries
  • No chronic medical conditions

Social History

  • Sexually active with two partners in the past 6 months
  • Denies tobacco, alcohol, or illicit drug use
  • No history of intravenous drug use

Physical Examination Findings

  • Vital Signs: Temperature 39.0 degrees Celsius, HR 112 bpm, BP 108/68 mmHg, RR 18
  • General: Ill-appearing young woman in moderate distress, lying still
  • Abdomen: Soft but diffusely tender in lower quadrants, voluntary guarding present, mild rebound tenderness bilaterally, no distension, bowel sounds hypoactive
  • Pelvic Examination: Mucopurulent cervical discharge, marked cervical motion tenderness, bilateral adnexal tenderness with a palpable 6-cm tender mass in the right adnexa, uterine tenderness

Diagnostic Workup

  • Urine Pregnancy Test: Negative
  • Complete Blood Count: WBC 18,200/microL with 85% neutrophils and 8% bands (left shift), Hemoglobin 12.4 g/dL, Platelets 312,000/microL
  • C-Reactive Protein: 156 mg/L (markedly elevated)
  • Erythrocyte Sedimentation Rate: 68 mm/hr (elevated)
  • Cervical NAAT: Positive for Chlamydia trachomatis, negative for Neisseria gonorrhoeae
  • Urinalysis: Trace leukocyte esterase, otherwise unremarkable
  • Transvaginal Ultrasound: Right adnexal complex mass measuring 6.2 x 5.8 x 5.4 cm with thick irregular walls, internal septations, and echogenic debris consistent with tubo-ovarian abscess; left ovary normal; small amount of free fluid in the cul-de-sac

Diagnosis

Pelvic Inflammatory Disease with Right Tubo-Ovarian Abscess (TOA) secondary to Chlamydia trachomatis infection

Management Plan

Hospitalization (meets criteria for inpatient management):

  1. Admission criteria met: tubo-ovarian abscess on imaging, high fever, systemic illness
  2. IV fluid resuscitation
  3. NPO status pending clinical response

Intravenous Antibiotic Regimen:

  1. Cefotetan 2 grams IV every 12 hours (or cefoxitin 2 grams IV every 6 hours)
  2. Doxycycline 100 mg orally every 12 hours (oral preferred over IV due to equivalent bioavailability and less phlebitis)
  3. Consider adding metronidazole 500 mg IV every 8 hours for enhanced anaerobic coverage

Monitoring:

  1. Serial vital signs every 4 hours
  2. Daily abdominal examination
  3. Serial WBC and CRP at 48 to 72 hours to assess response

Reassessment at 48 to 72 hours:

  • If clinical improvement (defervescence, decreased pain, improving labs): Continue IV antibiotics until 24 to 48 hours afebrile, then transition to oral doxycycline 100 mg twice daily plus metronidazole 500 mg twice daily to complete 14-day total course
  • If no improvement: Interventional radiology consultation for image-guided percutaneous drainage of TOA

Partner Management:

  1. Notify all sexual partners from preceding 60 days
  2. Empiric treatment of partners for chlamydia regardless of their test results
  3. Patient and partners to abstain from intercourse until treatment complete

Follow-up:

  1. Re-evaluation 2 weeks after completing treatment
  2. Repeat NAAT testing at 3 months to detect reinfection
  3. Counseling regarding future fertility implications, ectopic pregnancy risk, and STI prevention

Clinical Image

Image Description: Transvaginal ultrasound image demonstrating a tubo-ovarian abscess. The complex adnexal mass shows thick irregular walls, internal septations, and echogenic debris representing purulent material. The adjacent ovary is incorporated into the inflammatory mass. Free fluid is visible in the cul-de-sac.

Attribution: Image for educational purposes. Tubo-ovarian abscess ultrasound appearance as described in Radiopaedia (https://radiopaedia.org/articles/pelvic-inflammatory-disease).

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