# Clinical Cases: STIs and Pelvic Inflammatory Disease

## 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
![Tubo-ovarian Abscess on Ultrasound](case_01_image.jpg)

**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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## Case 2: Disseminated Gonococcal Infection

### Patient Demographics
- **Age:** 19 years
- **Sex:** Female
- **Occupation:** Retail worker

### Chief Complaint
"I have painful joints in my hands and a rash on my legs for the past week."

### History of Present Illness
The patient presents with a 7-day history of migratory joint pain that began in her right knee, then moved to her left wrist, and is now affecting multiple small joints of her hands. She developed a rash on her lower extremities 4 days ago consisting of scattered painful bumps, some of which have developed central pustules. She reports low-grade fever, malaise, and fatigue. Upon specific questioning, she recalls having a mild vaginal discharge approximately 3 weeks ago that resolved spontaneously without treatment. Her last menstrual period was 10 days ago and was heavier than usual. She is sexually active with three partners over the past 3 months and uses condoms inconsistently.

### Past Medical History
- No significant medical history
- No prior STIs diagnosed
- Menarche at age 12, regular cycles

### Physical Examination Findings
- **Vital Signs:** Temperature 38.2 degrees Celsius, HR 92 bpm, BP 118/72 mmHg
- **General:** Alert young woman appearing mildly ill
- **Skin:** Multiple scattered pustular lesions on an erythematous base on the lower extremities and dorsum of hands, some with central necrosis, approximately 15 lesions total
- **Musculoskeletal:** Tenosynovitis of right wrist extensors with pain on passive extension, tenderness and mild swelling of the second and third MCP joints bilaterally, no frank effusion in large joints
- **Pelvic Examination:** Minimal mucopurulent cervical discharge, no cervical motion tenderness, no adnexal tenderness or masses

### Diagnostic Workup
- **Urine Pregnancy Test:** Negative
- **Complete Blood Count:** WBC 12,800/microL with 78% neutrophils
- **ESR:** 45 mm/hr (elevated)
- **CRP:** 68 mg/L (elevated)
- **Blood Cultures:** Pending (ultimately negative)
- **Cervical NAAT:** Positive for Neisseria gonorrhoeae, negative for Chlamydia trachomatis
- **Pharyngeal NAAT:** Positive for Neisseria gonorrhoeae
- **Rectal NAAT:** Negative
- **Skin Lesion Gram Stain:** Gram-negative diplococci identified
- **Joint Fluid (right wrist aspiration):** WBC 28,000/microL with 90% neutrophils, no crystals, Gram stain with gram-negative diplococci, culture pending

### Diagnosis
**Disseminated Gonococcal Infection (DGI)** presenting with the classic triad of:
1. Dermatitis (pustular skin lesions)
2. Tenosynovitis (wrist extensor involvement)
3. Migratory polyarthralgia with septic arthritis

### Management Plan

**Hospitalization for IV Therapy:**
1. Admit for parenteral antibiotic therapy and joint monitoring
2. Orthopedic consultation for possible joint washout if large joint septic arthritis develops

**Antibiotic Regimen:**
1. **Ceftriaxone** 1 gram IV every 24 hours (weight-based dosing for DGI)
2. Continue parenteral therapy for 24 to 48 hours after clinical improvement
3. Transition to oral therapy: cefixime 400 mg twice daily to complete at least 7 days total therapy (some experts recommend 10 to 14 days for DGI)
4. Add **azithromycin** 1 gram orally single dose for presumptive chlamydia co-treatment (even with negative chlamydia NAAT given high co-infection rates)

**Supportive Care:**
1. NSAIDs for pain and inflammation
2. Rest and immobilization of affected joints
3. Serial joint examinations

**Partner Notification:**
1. All sexual partners from preceding 60 days should be evaluated and treated presumptively
2. Expedited partner therapy where legally permissible

**Additional Testing:**
1. HIV testing (DGI is an AIDS-defining illness consideration)
2. Syphilis serology (RPR)
3. Hepatitis B and C serologies

**Follow-up:**
1. Test of cure NAAT at 7 to 14 days (particularly for pharyngeal infection which has higher treatment failure rates)
2. Repeat NAAT for gonorrhea and chlamydia at 3 months
3. Counseling on consistent condom use and STI prevention

### Prognosis
With appropriate antibiotic therapy, disseminated gonococcal infection carries an excellent prognosis. The dermatitis and tenosynovitis typically resolve within days of starting treatment. Joint damage is uncommon with early treatment.

### Clinical Image
![Disseminated Gonococcal Infection Skin Lesions](image_02.jpg)

**Image Description:** Clinical photograph demonstrating the characteristic pustular skin lesions of disseminated gonococcal infection. The lesions appear as papules and pustules on an erythematous base, with some showing central necrosis or hemorrhagic centers. These lesions are typically few in number (less than 40), distributed on the extremities, and may be painful.

**Attribution:** Image from Wikimedia Commons, Category: Neisseria gonorrhoeae (https://commons.wikimedia.org/wiki/Category:Neisseria_gonorrhoeae). Licensed under Creative Commons.

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## Case 3: Primary Genital Herpes in Pregnancy

### Patient Demographics
- **Age:** 26 years
- **Sex:** Female
- **Occupation:** Elementary school teacher
- **Gestational Age:** 34 weeks

### Chief Complaint
"I have extremely painful sores on my genital area and it hurts to urinate."

### History of Present Illness
The patient, currently 34 weeks pregnant with her first child, presents with a 4-day history of multiple painful genital lesions. The pain began as tingling and burning in the vulvar area, followed by the appearance of small blisters that have now ruptured into painful ulcers. She reports severe pain with urination (dysuria), describing it as "like pouring acid on the sores." She has noticed bilateral inguinal lymph node swelling and tenderness. She also reports fever, body aches, and malaise for the past 2 days. She denies any prior history of genital herpes or similar lesions. Her pregnancy has been uncomplicated until now. She has been in a monogamous relationship with her husband for 3 years; however, her husband reports a history of "cold sores" on his lips.

### Past Medical History
- G1P0, current pregnancy at 34 weeks
- No prior genital herpes diagnosis
- No other STIs
- No chronic medical conditions

### Physical Examination Findings
- **Vital Signs:** Temperature 38.1 degrees Celsius, HR 98 bpm, BP 112/70 mmHg
- **General:** Uncomfortable-appearing pregnant woman
- **Abdomen:** Gravid uterus consistent with 34 weeks, soft, non-tender, fetal heart tones 145 bpm
- **Inguinal Lymph Nodes:** Bilateral tender inguinal lymphadenopathy
- **External Genitalia:** Multiple bilateral grouped vesicles and shallow ulcers on the labia majora and minora, perianal area spared, lesions on erythematous base, some vesicles intact, others ruptured with shallow ulcer base, significant edema of vulvar tissues
- **Speculum Examination:** Deferred due to severe pain; cervix visualized without visible lesions

### Diagnostic Workup
- **HSV PCR from Lesion Swab:** Positive for HSV-2
- **HSV Type-Specific Serology (IgG):** HSV-1 IgG positive, HSV-2 IgG negative (indicating primary HSV-2 infection as patient has not yet seroconverted)
- **Complete Blood Count:** WBC 9,800/microL (normal), Hemoglobin 11.2 g/dL
- **Urinalysis:** Unable to obtain clean catch due to severe dysuria; catheterized specimen normal
- **Fetal Non-Stress Test:** Reactive, reassuring

### Diagnosis
**Primary Genital Herpes Simplex Virus Type 2 (HSV-2) Infection** at 34 weeks gestation
- Classified as primary infection based on:
  - First clinical episode
  - Negative HSV-2 IgG indicating no prior exposure
  - Severe systemic symptoms typical of primary infection

### Management Plan

**Antiviral Treatment:**
1. **Acyclovir** 400 mg orally three times daily for 7 to 10 days (extended course for primary episode)
2. If unable to tolerate oral intake due to pain: IV acyclovir 5 mg/kg every 8 hours
3. Acyclovir is safe in pregnancy (FDA Category B)

**Symptomatic Management:**
1. Sitz baths with warm water for comfort
2. Topical lidocaine 2% gel for pain relief
3. Oral analgesics (acetaminophen)
4. If unable to void: Foley catheter placement may be necessary for urinary retention
5. Adequate hydration

**Suppressive Therapy:**
1. Begin daily suppressive therapy at 36 weeks gestation (acyclovir 400 mg three times daily) to reduce risk of recurrence at delivery and viral shedding
2. Continue until delivery

**Delivery Planning:**
1. Serial assessment for lesions as delivery approaches
2. **Cesarean delivery is indicated if:**
   - Active genital lesions present at onset of labor
   - Prodromal symptoms (tingling, burning) present at labor onset
3. Primary infection near term carries highest risk of neonatal transmission (30-50% if vaginal delivery with active lesions)
4. Discuss with patient that cesarean delivery significantly reduces but does not eliminate neonatal herpes risk

**Partner Counseling:**
1. Husband likely source given history of oral HSV (HSV-1 can cause genital herpes through oral-genital contact)
2. Counsel on transmission risk and suppressive therapy for partner
3. Avoid sexual contact until lesions completely healed

**Neonatal Considerations:**
1. Pediatrics notification of maternal HSV status
2. If vaginal delivery occurs, neonatal HSV surveillance
3. Highest risk period is primary maternal infection at delivery

### Clinical Image
![Primary Genital Herpes](image_01.jpg)

**Image Description:** Clinical photograph of primary genital herpes showing multiple grouped vesicles on an erythematous base on the vulvar surface. Some vesicles have ruptured to form shallow, painful ulcers with irregular borders. The surrounding tissue shows significant edema. Primary episodes typically present with more numerous bilateral lesions compared to recurrent episodes.

**Attribution:** Image for educational purposes demonstrating primary genital herpes presentation. Similar images available in medical literature and Wikimedia Commons.

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## Summary of Key Learning Points

1. **PID with TOA** requires hospitalization, IV antibiotics with anaerobic coverage, and close monitoring with consideration for drainage if no improvement at 48-72 hours

2. **Disseminated gonococcal infection** presents with the classic triad of dermatitis, tenosynovitis, and migratory polyarthralgia; more common in women, especially during menstruation

3. **Primary genital herpes in pregnancy** requires:
   - Antiviral treatment for the acute episode
   - Suppressive therapy starting at 36 weeks
   - Cesarean delivery if active lesions or prodrome at labor onset
   - Highest neonatal transmission risk with primary infection near term

4. **Partner notification and treatment** is essential for all STIs to prevent reinfection and ongoing transmission

5. **NAAT testing** is the gold standard for chlamydia and gonorrhea diagnosis; test all exposure sites (cervix, pharynx, rectum) based on sexual history