A 22-year-old woman comes to the emergency department with right upper quadrant pain that has worsened over the past day. The pain initially began in the lower abdomen 5 days ago, after she returned from a trip to South America. The right upper quadrant pain increases with deep breathing. She now has fevers, chills, and vomiting. The patient has no diarrhea, constipation, or changes in stool color. She has no medical conditions or previous surgeries. The patient is sexually active with a male partner and does not use contraception. She is currently on her menstrual period but reports increasingly irregular menses over the last 3 months, with occasional spotting. The patient does not use tobacco, alcohol, or illicit drugs. Temperature is 38.9 C (102 F), blood pressure is 100/70 mm Hg, and pulse is 104/min. BMI is 21 kg/m². Examination shows right upper quadrant tenderness, and the lower abdomen is diffusely tender without guarding. Bowel sounds are present. There is no costovertebral angle tenderness. Skin is normal without rash. A urine pregnancy test is negative. Which of the following is the most likely diagnosis for this patient?

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11ec25c8_d9db_56a5_bc81_c3f51b264495_MD0003_00 This young woman has fever, chills, and right upper quadrant pain, findings that suggest hepatic infection or inflammation. The additional history of intermenstrual spotting and lower abdominal pain makes the most likely diagnosis pelvic inflammatory disease (PID) complicated by perihepatitis (also known as Fitz-Hugh-Curtis syndrome). In women, the initial infection of the cervix with Neisseria gonorrhoeae or Chlamydia trachomatis can be asymptomatic or subtle (eg, irregular intermenstrual bleeding). Untreated cervicitis allows polymicrobial vaginal flora to ascend into the upper reproductive tract (eg, uterus, fallopian tubes), causing fever and lower abdominal pain, as in this patient. As the infection spreads farther into the intraperitoneal cavity, it can cause inflammation of the liver capsule (ie, perihepatitis or Fitz-Hugh-Curtis syndrome in 6%-10% of patients), resulting in vomiting and right upper quadrant tenderness. The pain is often pleuritic (ie, worsened with inspiration) due to fibrinous adhesion formation on the anterior liver surface. Treatment of PID complicated by perihepatitis includes hospitalization and broad-spectrum intravenous antibiotics (eg, cefoxitin plus doxycycline). (Choice A) Appendicitis can cause fever, vomiting, and lower abdominal pain; however, patients typically have periumbilical pain that migrates to the right lower (not right upper) quadrant. In addition, appendicitis is not associated with intermenstrual spotting. (Choice B) Acute cholecystitis can cause fever and localized right upper quadrant tenderness; it is not typically associated with diffuse lower abdominal pain or abnormal vaginal bleeding. In addition, affected women are typically age >40 and obese, in contrast to this patient. (Choice C) Acute viral hepatitis can cause fever, vomiting, and right upper quadrant pain in patients with recent travel to endemic regions. However, patients typically develop jaundice and changes in stool color, and there is no association with intermenstrual spotting. (Choice E) Ruptured ectopic pregnancy can cause diffuse lower abdominal pain, but an acute abdomen (eg, rebound, guarding) usually develops due to hemoperitoneum. This diagnosis is unlikely in this patient with a negative pregnancy test. (Choice F) Ruptured ovarian cysts typically cause sudden-onset, severe, lower abdominal pain provoked by activity. However, ruptured ovarian cysts typically occur in the middle of the menstrual cycle (this patient is menstruating) and do not cause a high fever. Educational objective: Pelvic inflammatory disease (PID) can spread to the intraperitoneal cavity and cause perihepatitis (ie, Fitz-Hugh-Curtis syndrome). PID complicated by perihepatitis typically causes fever, vomiting, and pain in the right upper quadrant and lower abdomen. References: Clinical features of Fitz-Hugh-Curtis syndrome in the emergency department. (http://www.ncbi.nlm.nih.gov/pubmed/22665342) Chlamydia trachomatis-induced Fitz-Hugh-Curtis syndrome: a case report. (http://www.ncbi.nlm.nih.gov/pubmed/28057084) Chlamydia trachomatis-induced Fitz-Hugh-Curtis syndrome presenting as inspiratory dyspnea. (http://www.ncbi.nlm.nih.gov/pubmed/32670702)

A 22-Year-Old Woman Comes to the Emergency Department with Right