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REPORT712
REPORT712
FITS-HUGH-CURTIS SYNDROME
perihepatic inflammation found in 5-10% of woemnt with acute PID
condition is often mistakenly diagnosed as either pnuemonia or acute cholecytiti
s
persistent symptons and signs
- right upper quadrant pain - may radiate to the shoulder on into the back
- pleuritic pain
- tenderness in the right upper quadrant when theliver is palpated
- elevated liver transaminases.
develops from transperitoneal or vascualar dissemination of either the gonococcu
s or Chlamdia organism to produce the perihepatic inflammation
Chalamydia produces the majority of cases
Other organisms:
- Neisserua gonorrhea
- anaerobic streptococci
- coxsackievirus
Diagnosis: Laparoscopy
][IMAGE]
liver capsule will apear inflamed, with classic "violin string" adhensions to th
e parietal peritoneum beneath the diaphragm.
ACUTE SALPINGITIS
Critiera
[All 3 necessary for diagnosis]
Abdominal direct tenderness, with or without rebound tenderness
Tenderness with motion of cervix and uterus
Adnexal tenderness
[plus] [ 1 or more necessary for diagnosis]
Gram stain of endocervix - positive for gram-negative intracellular diplococci
Temperature (<38C)
Leukocytosis (> 10,000)
Purulent material ( white blood cells present) from peritoneal cavity by culdoce
ntesis or laparoscopy
Pevic abscess or inflammatory complex on bimanual examination or on sonography
Diagnosis of PID
CDC Guidelines for Daiagnosis of Acite PID Clinical Criteria for Initiating Ther
apy
Minimum Critera
Empriric treatment of PID should not be initiated in sexually active young women
and others at risk for STDs if all the following minimum criteria are present a
nd no other cause(s) for the illness can be identified:
Lower abdominal tenderness or
Adnexal tenderness or
Cervical motion tenderness
Laboratory findings
- not a relaiable indicator of acute PID nor does it correlate with the need for
hospitalization or the severity of tubal inflammation
- <50% of women with PID: white blood cell count of greater than 10,000 cells pe
r milliliter
- in approximately 75% of woment with laparoscopically confirmed acute pelvic in
fection: elevated ESR (>15 mm/hr)
- C-reactive proteins
- hCG - since 3 - 4 of every 100 women who are admitted to a hospital with a dia
gnosis of acute pelvic infection have an ectopic pregnancy
Gram staining
- First: obtain edocervical mucus for inflammatory cells and perform NAAT for b
oth N. gonorrhoeae and C. trachomatis
- C. trachomatis has surpassed N. gonorrhea as the most prevalent sexually tran
smitted bacteria-producing upper tract infection in the developed world
Endometrial biopsy
- for evidence of endometritis
- primarily used to help confirm a clinical suspicion
Ultrasonography
- of limited value for patients with mild or moderate PID due to its low sensiti
vity
- helpful in documentaing an adnexal mass and differentiating between a tuboovar
ian abscess and tuboovarian complex
- also a noninvasive diagnostic aid for patients who are so tender during pelvic
examination that the pysician cannot determine the presence or absence of a pel
vic mass
MANAGEMENT
Two ost important goals of the medical therapy of acute PID:
1. resolution of symptoms
2. preservation of tubal function
Indications for Hospitalizing Patients with Acute Pelvic Inflammatory Disease
1. Surgical emergencies (e.g. appendicitis) cannot be excluded
2. The patient is pregnant
3. The patient does not respond clinically to oral antimicrobial therapy
4. The patient is unable to follow or tolerate an outpatient oral regimen
5. The patient has severe illness, nausea and vommiting, or high fever
6. The patient has a tuboovarian abscess
Centers for Disease Contral Ambulatory Management of ACUTE PID
Regimen A
Levofloxacin 500mg PO once daily for 14 days
or
Ofloaxcin 400mg PO once daily for 14 days
with or without
Metrondazole 500mg PO bid for 14 days
Regimen B
Ceftriaxone 250mg IM in a single dose
or
Cefoxitin 2 g IM in a single does and probenecid 1 g PO adminstered concurrently
in a single dose
or
Other parental third-generation cephalosporin (e.g. ceftizoxime or cefotaxime)
plus
Doxycycline 100mg PO bid for 14 days
with or without
Metronidazole 500mg PO bid for 14days
Advantage
* excellent for community- acquired infection because it treats bith gonorrhea
and chlamydial infection
* doxycycline and cefoxitin provide excellent coverage for N. gonorrhoeae, C, t
rachomatis, and also penicillinase-producing N. gonorrhoeae
* cefoxitin is an excellent antibiotic against Peptococcus, Peptostreptococcus,
and E. colli
Disadvantage
* combination is that the two drugs are less than ideal for a pelvic abscess or
for anaerobic infections
Parenteral Regimen B
Clindamycin 900 mg IV every 8 hours
PLUS
Gentamicin loading dose IV or IM (2 mg/kg of body weight) followed by a maintena
nce dose (1.5 mg/kd) every 8 hours.
Singe daily dosing may be substituted.
* combination of clindamycin and an aminoglycoside (gentamicin)
Advanatage
* provides excellent coverage for anaerobic infections and facultative gram-neg
ative rods -> preferred for patients with
- an abscess
- IUD- related infections
- pelvic infections after a diagnostic or operative procedure
OPERATIVE TREATMENT
- life-threatening infections
- ruptured tuboovarian abscesses
- laparoscopic drainange of a pelvic abscess
- persistent masses in some older women for whom future childbearing is not a co
nsideration
- removal of a persistent symptomatic mass
Abscess
- is a collection of pus within a newly created space
Tuboovarian complex
- a collection of pus within an anatomic space created by adherence of adjacent
organs
- mixture of anaerobes and facultative or aerobic organisms
- environment of an abscess cavity results in a low level of oxygen tenstion ->
anaerobic organisms predominate
Treatment
- combinatio of clindamycin and an aminoglycoside (combination does not treat th
e enterococcus, and ampicillin should be added if there is suspicion that this o
rganism is involved)
- metronidazole alone is an effective alternative to clindamycin for anaerobic i
nfections but does not provide gram-negative coverage
- if abscesses do not respond to parenteral broad-spectrum antibiotics, drainage
is imperative
Sequelae
- rupture of tuboovarian abscesses
- involuntary infertility
- chronic pelvic pain
- hydrosalpinx
- a collection of sterile, watery fluid in the fallopian tube
- end-stage development of a pyosalpinx
- pelvic inflammatory disease after index episode
- ectopic pregnancy
ACTINOMYCES INFECTION
- a rare cause of upper genital tract infection
- caused by Actinomyces israelii
- gram positive anaerobic bacterium that is difficult to culture
- to sucessfully culture this organism, an anaerobic enviroment must be
maintained for 2 to 3 weeks
- discovered either by histologic examination or culture from women with
tuboovarian abscesses
- may produce a chronic endometritis with an associated foul-smelling discharge
- Manisfestations:
- widespread adhesions
- induration
- fibrosis
- Diagnosis of Actinomyces infection
- classic "sulfur granules" are observed histologically along with gram-
positive filaments.
- Treatment
* oral penicillin
* doxycycline
* fluoroquinolones
TUBERCULOSIS
- may be produced by either Mycobacterium tuberculosis or M. bovis
- primary site of infection for tuberculosis: lungs
- early in the course of pulmonary infection the bacteria spread hematogenously
-> infection becomes located in the oviduct -> bacilli usually spread to the en
dometrium and less commonly to the ovaries
- primary and predominant site of pelvic tuberculosis: oviducts
- clinical symptoms and signs of pelvic tuberculosis are similar to the chronic
sequelae of nontuberculous acute PID
- predominant presentations of this chronic infection:
- infertility
- abnormal uterine bleeding
- mild to moderate chronic abdominal and pelvic pain occur in 35% of women with
disease
- advanced cases are often accompanied by ascites
- some women may be asymptomatic
- finding at pelvic examination are normal in approximately 50% of cases (remain
ing patients have mild adnexal tenderness and bilateral adnexal masses, with an
inability to manipulate the adnexa because of scarring and fixation.
TUBERCULOSIS SALPINGITIS
- may be suspected when a patient is not responding to conventional antibiotic t
herapy for acute bacterial PID
- results of a tuberculin skin test will be positive
- Diagnosis: performing an endometrial biopsy late in the secretory phase of the
cycle
* findings of classic giant cells, granulomas, and caseous necrosis conf
irm the diagnosis
- laparotomy or celiotomy
- distal ends of the oviduct remain everted, producing a "tobacco pouch" appeara
nce
- chest radiographic examination
- IV pyelogram
- serial gastric washings
- urine cultures for tuberculosis
- Treatment:
- Medical: initial therapy in a patient with newly diagnosed tuberculos
is usually will include five drugs because of the emergence of multidrug-resista
nt organisms
-Operative (reserved for):
- women with persistent pelvic masses
- some women with resistant organisms
- women older than 40
- women whose endmetrial cultures remain positive