A 23-year-old woman comes to the emergency department for evaluation of right lower abdominal pain and bloody vaginal discharge. Her symptoms began this morning and are progressively worsening. She is sexually active with 1 male partner. The patient takes no daily medications and has no known drug allergies. Her last menstrual period was 5 weeks ago, and she has never been pregnant. Blood pressure is 112/70 mm Hg while supine and 96/60 mm Hg while standing. The patient is tachycardic and ill appearing. On pelvic examination, the uterus is small and mobile, and there is right adnexal tenderness. Laboratory results are as follows: This patient's clinical presentation is most likely due to a prior infection with which of the following pathogens?

Question

A 23-year-old woman comes to the emergency department for evaluation of right lower abdominal pain and bloody vaginal discharge.  Her symptoms began this morning and are progressively worsening.  She is sexually active with 1 male partner.  The patient takes no daily medications and has no known drug allergies.  Her last menstrual period was 5 weeks ago, and she has never been pregnant.  Blood pressure is 112/70 mm Hg while supine and 96/60 mm Hg while standing.  The patient is tachycardic and ill appearing.  On pelvic examination, the uterus is small and mobile, and there is right adnexal tenderness.  Laboratory results are as follows:  This patient's clinical presentation is most likely due to a prior infection with which of the following pathogens?

Quizplus · Accepted Answer

11ec160b_37f5_80c5_9249_39598587302b_MD0001_00 This patient with lower abdominal pain, bloody vaginal discharge, hemodynamic instability (eg, tachycardia, orthostatic hypotension), and a positive pregnancy test most likely has a ruptured ectopic pregnancy. Ectopic pregnancies occur due to extrauterine pregnancy implantation, typically in the ampulla of the fallopian tube. The most common risk factor for ectopic pregnancy is tubal scarring, which impedes normal migration of the fertilized embryo through the fallopian tube and into the uterus. Tubal scarring usually occurs due to prior upper genital tract infection (ie, pelvic inflammatory disease [PID]) associated with either Neisseria gonorrhoeae or Chlamydia trachomatis. Both pathogens cause cervicitis, which compromises the cervix barrier and allows vaginal bacteria to ascend into the normally sterile upper genital tract, resulting in tubal inflammation and scarring. (Choice A) Escherichia coli, an enteric bacteria, can ascend the urethra to cause a urinary tract infection. Although E coli may be found in the vagina, it does not commonly cause PID in premenopausal women. (Choices B and G) Gardnerella vaginalis (bacterial vaginosis) and Trichomonas vaginalis (trichomoniasis) can cause vaginal discharge due to lower genital tract inflammation (ie, vaginitis). Neither is associated with increased risk of ectopic pregnancy. (Choices C and D) Herpes simplex virus (HSV) and human papillomavirus (HPV) typically cause lower genital tract disease. HSV causes multiple small, vesicular genital ulcers and HPV causes genital warts or cervical/vaginal/perianal neoplasia. Neither causes upper genital tract infection or inflammation; therefore, neither is associated with ectopic pregnancy. (Choice F) Treponema pallidum infection (ie, syphilis) usually begins in the lower genital tract as a single, painless genital chancre (ie, the transmission site). However, it does not cause PID. Educational objective: A ruptured ectopic pregnancy can cause abdominal pain, vaginal bleeding, and hemodynamic instability. A common risk factor is tubal scarring from a prior upper genital tract infection (ie, pelvic inflammatory disease) due to Neisseria gonorrhoeae or Chlamydia trachomatis. __________ References: Current knowledge of the aetiology of human tubal ectopic pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/20071358) Pathogenesis of Neisseria gonorrhoeae and the host defense in ascending infections of human fallopian tube. (http://www.ncbi.nlm.nih.gov/pubmed/30524442)

A 23-Year-Old Woman Comes to the Emergency Department for Evaluation