A 29-year-old woman presents to the clinic with lower abdominal pain that has developed over the past 2 days. Her last menstrual period was 13 days ago, during which she had mild cramps. She denies any vaginal bleeding or pain during intercourse. She is sexually active and uses a progestin subdermal implant for contraception. She has had 5 sexual partners in the past year. She drinks 2 glasses of wine on the weekend. She does not use tobacco or any recreational drugs. Vital signs are temperature 39.1° C (102.4° F), blood pressure 129/71 mmHg, pulse 128 beats/min, and respirations 17/min. On physical examination, there is cervical motion tenderness and diffuse adnexal tenderness. Speculum examination reveals a small amount of purulent discharge from the cervix. A pregnancy test is negative. Laboratory results are as follows:
Which of the following is the patient at greatest risk of developing?
The correct answer is:
D) Inflammation of the liver capsule
This patient has findings consistent with a diagnosis of pelvic inflammatory disease (PID) including fever, pain in the lower abdomen, purulent discharge from the cervix, and adnexal and cervical motion tenderness. PID refers to inflammation and infection of the upper genital tract in females and can include endometritis, salpingitis, hydrosalpinx, and tubo-ovarian abscess. It typically manifests as an ascending infection from the cervix. The most common causative organisms are Neisseria gonorrhoeae and Chlamydia trachomatis. Most cases of PID are sexually transmitted. This patient has a history of multiple sexual partners and does not use barrier contraceptives (e.g., condoms), increasing her risk of contracting sexually transmitted infections.
A potential complication of PID is Fitz-Hugh-Curtis syndrome (FHCS), characterized by inflammation of the liver capsule (perihepatitis) without involving the liver parenchyma and the development of adhesions between the peritoneum and the liver. The rate of FHCS in PID is between 4% and 14%.
Salpingitis in PID can cause some notable long-term complications, including infertility, ectopic pregnancies, and chronic pelvic pain.
Answer choice A: Alternating strictures and dilation of bile ducts, is incorrect. This finding is seen in primary sclerosing cholangitis, a disease of the biliary tract that usually develops in middle-aged males with ulcerative colitis. It results in the development of concentric ‘onion skin’ fibrosis on histology and characteristic ‘beading’ (alternating strictures and dilation) of the bile ducts on endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonance cholangiopancreatography (MRCP).
Answer choice B: Bridging sclerosis and regenerative nodules in the liver, is incorrect. This finding is seen in patients with cirrhosis. Risk factors for cirrhosis include alcohol abuse, infection with hepatitis B or hepatitis C virus, nonalcoholic steatohepatitis, hemochromatosis, Wilson disease, α-1 antitrypsin deficiency, and autoimmune hepatitis. Complications of cirrhosis include portal hypertension (ascites, splenomegaly, and portosystemic shunts); decreased detoxification (hyperestrogenism causing spider angiomas, palmar erythema, and gynecomastia; increased bilirubin causing jaundice; hyperammonemia resulting in impaired mental status, asterixis, and coma; and decreased protein synthesis (hypoalbuminemia causing edema and decreased synthesis of clotting factors leading to coagulopathy).
Answer choice C: Damaged keratin filaments in hepatocytes, is incorrect. Many patients with sustained, long-term consumption of alcohol develop alcoholic hepatitis. A liver biopsy demonstrates acute inflammation with swelling and necrosis of hepatocytes. Mallory bodies (intracytoplasmic eosinophilic inclusions of damaged keratin filaments) are characteristic.
Answer choice E: Portal and periportal lymphoplasmacytic infiltration, is incorrect. This finding is seen in patients with autoimmune hepatitis, a chronic, progressive inflammatory condition of the liver due to an unknown cause. It usually presents as an asymptomatic elevation of liver enzymes and is characterized by positive antinuclear, anti-smooth muscle, and anti-liver/kidney microsomal-1 antibodies.
Key Learning Point
Pelvic inflammatory disease is a sexually transmitted infection of the upper genital tract in females that classically presents with fever, lower abdominal pain and/or purulent cervical discharge. Commonly implicated organisms include Chlamydia trachomatis and Neisseria gonorrheae. Long-term complications include infertility, ectopic pregnancies, and chronic pelvic pain. Patients can also develop Fitz-Hugh-Curtis syndrome, characterized by perihepatitis (inflammation of the liver capsule) and adhesions between the liver and the peritoneum.
