Expecting the Unexpected: An Unusual Presentation of Pelvic Inflammatory Disease

Background: Pelvic Inflammatory Disease (PID) is an acute infection of the female upper reproductive organs that can also involve neighboring abdominal and pelvic organs. Case Information: A 36-year-old female with a PMH of bipolar disorder and polysubstance use disorder, but no known history of STIs, presented to the ER with abdominal pain of 1 day. The pain was constant, diffuse, not worse with eating, and without relieving factors. She denied fever, chills, nausea, vomiting, diarrhea, urinary frequency or urgency, and vaginal discharge. However, she did complain of dysuria. Patient also used methamphetamines and marijuana 3 days prior to pain onset. On physical exam, she was tachycardic and diffusely tender to palpation in all quadrants but worse across the epigastrium; Murphy's and McBurney's signs were negative, but rebound tenderness was positive. General surgery performed an exploratory laparotomy during which a right tubo-ovarian abscess (TOA) was discovered along with diffuse adhesions, leading to a diagnosis of PID. OB-GYN was consulted because of salpingitis, but excision was not recommended, and the TOA was managed with IV antibiotics. Post-operatively, the patient opened up about, a recent sexual assault, and consuming a drugged alcoholic drink the previous night. Her symptoms improved and she was discharged on post-op day 4. Conclusion: This case demonstrates that PID, at advanced stages, can be difficult to distinguish from similarly presenting conditions. Current substance abuse, poor nutrition, and psychiatric conditions can prove challenging to obtaining a focused history and developing the differential diagnosis.