A 19-year-old woman comes to the office due to a persistent sore throat, fever, and mild lower abdominal discomfort for the past few days. She has no associated fatigue, chills, dysphagia, rhinorrhea, cough, or sick contacts. The patient has no changes in bowel or bladder function and no other medical conditions. She started college 4 months ago and lives with 3 roommates. The patient is sexually active and has 2 new sexual partners; she uses combination oral contraceptives. She does not use tobacco, alcohol, or illicit drugs. Temperature is 38.3 C (100.9 F), blood pressure is 120/70 mm Hg, and pulse is 68/min. The oral mucosa has no ulcerative lesions or petechiae. The pharyngeal arches are erythematous without exudate. Bilateral nontender cervical lymphadenopathy is present. The abdomen is tender to deep palpation in the lower quadrants; there is no splenomegaly. Urine pregnancy test is negative. Which of the following is the most likely pathogen responsible for this patient's symptoms?

Question

A 19-year-old woman comes to the office due to a persistent sore throat, fever, and mild lower abdominal discomfort for the past few days.  She has no associated fatigue, chills, dysphagia, rhinorrhea, cough, or sick contacts.  The patient has no changes in bowel or bladder function and no other medical conditions.  She started college 4 months ago and lives with 3 roommates.  The patient is sexually active and has 2 new sexual partners; she uses combination oral contraceptives.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 38.3 C (100.9 F), blood pressure is 120/70 mm Hg, and pulse is 68/min.  The oral mucosa has no ulcerative lesions or petechiae.  The pharyngeal arches are erythematous without exudate.  Bilateral nontender cervical lymphadenopathy is present.  The abdomen is tender to deep palpation in the lower quadrants; there is no splenomegaly.  Urine pregnancy test is negative.  Which of the following is the most likely pathogen responsible for this patient's symptoms?

Quizplus · Accepted Answer

11ec25c8_d452_4190_bc81_3fd797b8cc3c_MD0003_00 This patient with fever and persistent sore throat likely has acute pharyngitis. A specific pathogen may be difficult to identify based solely on examination. However, this patient's age (ie, <25), recent sexual history (eg, 2 new partners), new social environment (eg, college), and associated clinical findings (eg, lower abdominal tenderness) raise the concern for gonococcal pharyngitis due to Neisseria gonorrhoeae infection. N gonorrhoeae is a common sexually transmitted infection. In women, it may be asymptomatic (most common) or involve the lower (ie, cervicitis) and upper (ie, pelvic inflammatory disease) genital tract, causing fever, mucopurulent cervical discharge, and pelvic pain (as in this patient with lower abdominal tenderness on examination). cervicitis Gonococcal pharyngitis occurs due to inoculation of the pharynx during orogenital contact. Patients typically have pharyngeal edema, erythema, and nontender cervical lymphadenopathy, as seen in this patient. Tonsillar exudates may or may not be present. Diagnosis is confirmed by nucleic acid amplification testing on an oropharyngeal sample. (Choices A and B) Epstein-Barr virus, the cause of infectious mononucleosis, is transmitted in saliva and can present with fever, exudative or nonexudative pharyngitis, and splenomegaly (a potential cause of upper but not lower abdominal tenderness). However, patients with infectious mononucleosis typically have severe fatigue and tender (rather than nontender) cervical lymphadenopathy. Cytomegalovirus causes prolonged fever and malaise (eg, fatigue) but is less likely to be associated with prominent pharyngitis or abdominal pain. infectious mononucleosis (Choice C) Group A Streptococcus is the most common cause of bacterial pharyngitis, particularly in adolescents and young adults. However, it typically causes pharyngeal exudates and tender (rather than nontender) cervical lymphadenopathy. In addition, it is not associated with lower abdominal pain. (Choice D) Herpes simplex 1 virus is a cause of acute pharyngitis, which can present with pharyngeal edema and exudates. However, mucocutaneous ulcerative lesions are typically present. Educational objective: Neisseria gonorrhoeae is a common sexually transmitted infection that can cause pharyngitis (due to orogenital contact) and pelvic inflammatory disease (due to ascending infection from the lower to the upper genital tract). References: Otorhinolaryngology manifestations secondary to oral sex. (http://www.ncbi.nlm.nih.gov/pubmed/27793330)

A 19-Year-Old Woman Comes to the Office Due to a Persistent