Acute pelvic inflammatory disease

Pelvic infections represent an important problem in gynecology and obstetric care for their frequency and, at times, their severity; P.I.D. can lead to a decrease in reproductive potential, sterility, and even death. Clinically, a wide range of symptoms may present themselves and may vary from illnesses without complications to ones that result in severe septicemia, depending upon the anatomical location and aggressiveness of the causative pathogen. This article attempts to take a comprehensive look at acute Pelvic Inflammatory Disease. Characteristics, signs, symptoms, and etiology are discussed, as well as the role of the nursing team in treating this important disease.     

Intrauterine devices and acute pelvic inflammatory disease

One of the most serious problems among women using the intrauterine device (IUD) has been pelvic inflammatory disease (PID). Subjects for the present investigation were chosen from 15- to 44-year-old women seeking emergency medical attention at a large city hospital. Febrile and afebrile patients with PID and appropriate controls were asked to complete a self-administered questionnaire concerning their demographic, reproductive, and contraceptive histories. Results showed a significantly higher proportion of IUD users among febrile cases of PID (38%) than among controls (11%). This implies that febrile PID is five times as likely to develop in an IUD user as in a nonuser.     

Preventing and managing pelvic inflammatory disease: key questions, practices, and evidence

Clinicians play a pivotal role in protecting women from pelvic inflammatory disease (PID), one of the most prevalent and serious diseases affecting women of reproductive age. This article examines PID prevention and management by critically addressing five questions: (1) What are the key risk factors for PID? (2) What are the principal microorganisms involved in PID? (3) What are the appropriate diagnostic criteria for PID? (4) What are the best treatment regimens for PID? and (5) What are the effective strategies for preventing PID? In addressing each of these questions, the quality of available evidence and recommended practice is discussed and gaps in the evidence are highlighted.     

Psychiatric side effects of ofloxacin used in the treatment of pelvic inflammatory disease

The Clinical Effectiveness Group of the Medical Society for the Study of Venereal Diseases and the Association of Genitourinary Medicine published guidelines on the management of pelvic inflammatory disease in 1999. Subsequently, the use of ofloxacin has increased in our department. However, ofloxacin can cause serious psychiatric side effects, particularly in those with a past psychiatric history. This is of relevance to genitourinary medicine (GUM) physicians as there is a high prevalence of psychiatric illness amongst patients attending GUM clinics. We present two cases of ofloxacin causing severe psychiatric symptomatology, in one case causing an acute psychotic reaction. It is recommended a psychiatric history is taken prior to prescribing ofloxacin and that consideration is given to alternative therapy for those with previous psychiatric illness.     

Chlamydia trachomatis, pelvic inflammatory diseases and sterility

The authors analyse the results of direct (cervical, urethral, tubal) and serological research of Chlamydia trachomatis in a sample population of 420 women undergoing celioscopy due to sterility and pelvic pain, paying particular attention to a group of 193 who were found to be suffering from PID (acute, sequelae). In terms of absolute numbers the correlation between chlamydial contact-PID-sterility is confirmed, whereas in an analysis of the levels of direct positivity it is only significant for acute PID, and in cases of sequelae and in sterility with chronic infection with or without tubal damage the direct identification of Chlamydia trachomatis does not differ much from controls. Salpingo-peritoneal isolation was found to be completely lacking in significance.     

MR imaging in pelvic inflammatory disease: comparison with laparoscopy and US

PURPOSE: To assess the value of magnetic resonance (MR) imaging in the diagnosis of pelvic inflammatory disease (PID) and to compare MR imaging with transvaginal ultrasonography (US) and laparoscopy. MATERIALS AND METHODS: Thirty consecutive patients hospitalized because they were clinically suspected of having PID underwent transvaginal US and T1-weighted spin-echo, T2-weighted turbo spin-echo, and inversion-recovery MR imaging at 1.5 T. All patients underwent laparoscopy after MR imaging. RESULTS: PID was laparoscopically proved in 21 (70%) patients. The MR imaging diagnosis agreed with that obtained with laparoscopy in 20 (95%) of the 21 patients with PID. The imaging findings for PID were as follows: fluid-filled tube, pyosalpinx, tubo-ovarian abscess, or polycystic-like ovaries and free pelvic fluid. Findings at transvaginal US agreed with those at laparoscopy in 17 (81%) of the 21 patients with PID. The sensitivity of MR imaging in the diagnosis of PID was 95%, the specificity was 89%, and the overall accuracy was 93%. For transvaginal US, the corresponding values were 81%, 78%, and 80%. CONCLUSION: MR imaging is more accurate than transvaginal US in the diagnosis of PID and provides information about the differential diagnosis of PID. MR imaging may reduce the need for diagnostic laparoscopy.     

Association of Ureaplasma urealyticum biovars with clinical outcome for neonates, obstetric patients, and gynecological patients with pelvic inflammatory disease

In this prospective study, the prevalence of the two Ureaplasma urealyticum biovars, parvo and T960, was determined in pregnant women and in gynecological patients colonized by ureaplasmas. Furthermore, we investigated the association of these biovars with gynecological complications and adverse pregnancy outcome. Isolates of U. urealyticum from 254 women were biotyped by a PCR method recently developed. The parvo biovar was found in 81% (206 of 254) of the patients, and the T960 biovar was found in 30% (76 of 254) of the patients; 6% (14 of 254) of the women were coinfected. Identical biovars were detected in mothers and their infants. Serial isolations or cultures from different sampling sites of the same individual revealed the same biovar. T960 was dominant in patients with pelvic inflammatory disease (57%) and patients who had had a miscarriage (42%), showed a higher rate of tetracycline resistance than did parvo isolates (55 versus 18%), and seemed to have more adverse effects on pregnancy outcome with regard to birth weight (2,500 versus 1,720 g), gestational age (35 versus 30 weeks), and preterm delivery (35 versus 77%).     

Antibody to chlamydial hsp60 predicts an increased risk for chlamydial pelvic inflammatory disease

To determine whether serum antibody to Chlamydia trachomatis antigens alters the risk of C. trachomatis pelvic inflammatory disease (PID), 280 female sex workers were prospectively evaluated over a 33-month period for incident C. trachomatis and Neisseria gonorrhoeae cervical infection and for clinical PID. At enrollment, women were tested for antibody to C. trachomatis elementary bodies by an indirect microimmunofluorescence assay and to recombinant chlamydial hsp60 (Chsp60) by an ELISA format. At each follow-up visit, women were tested for cervical chlamydial and gonococcal infection and were identified as having clinical PID if they complained of lower abdominal pain and were found to have uterine and adnexal tenderness on pelvic examination. The data demonstrate that antibody to Chsp60 predicts a 2- to 3-fold increased risk for C. trachomatis PID.     

Differentiating acute appendicitis from pelvic inflammatory disease in women of childbearing age

A retrospective study was performed to evaluate the usefulness of various historical, clinical, and laboratory findings in differentiating acute appendicitis from pelvic inflammatory disease (PID) in women of childbearing age. The records of all female patients presenting to the emergency department with abdominal pain who were found to have histologically proven appendicitis (n = 80) or PID confirmed on endocervical culture (n = 71) were reviewed. Clinically useful indicators favoring appendicitis included the presence of anorexia and the onset of pain later than day 14 of the menstrual cycle. Indicators favoring PID included a history of vaginal discharge, urinary symptoms, prior PID, tenderness outside the right lower quadrant, cervical motion tenderness, vaginal discharge on pelvic examination, and positive urinalysis. Despite these indicators, differentiating acute appendicitis from PID remains difficult.     

Iliopsoas abscess: etiology, diagnosis, and treatment

Iliopsoas abscess is a rarely encountered entity. Early diagnosis is hindered by a nonspecific clinical presentation. The resulting delays in therapy increase morbidity and mortality rates. Our recent experience with three cases of iliopsoas abscess is presented. Based on a review of the literature, diagnostic and treatment recommendations are made.     

Tuberculous Addison''s disease complicated by a recurrent subcutaneous cold abscess during treatment for tuberculosis

We describe the case of a patient with necrotizing fasciitis due to Vibrio alginolyticus in a patient with cirrhosis following an injury inflicted by a stingray. The patient was successfully treated with aggressive surgical debridement and a combination of ciprofloxacin and amoxicillin-clavulanate. Cases of invasive V. alginolyticus reported in the literature were reviewed.     

Personality, smoking and inflammatory bowel disease

OBJECTIVE: To quantify the hemodynamic effects of turning critically ill, mechanically ventilated patients to the extreme left and right lateral postures. DESIGN: Prospective investigation. SETTING: Eight-bed intensive care unit in a university hospital. PATIENTS: Twelve consecutive patients presenting with severe respiratory failure and requiring continuous positive inotropic support. INTERVENTIONS: All patients were mechanically ventilated and placed in a kinetic treatment system. They were positioned in the supine, left dependent, and right dependent postures, resting for 15 min in each position. MEASUREMENTS AND RESULTS: Hemodynamic measurements, assessments of right ventricular function, and determinations of intrathoracic blood volume were performed in three different positions. Concentrations of atrial natriuretic peptide in plasma were quantified. In three patients, the findings were controlled by transesophageal echocardiography. Cardiac index [median (range) 5.5 (3.2-8.1) vs 4.3 (3.2-7.5) l/min per m2, p < 0.01], intrathoracic blood volume [1125 (820-1394) vs 1037 (821-1267) ml/m2, p < 0.01], and right ventricular end-diastolic volume [130 (83-159) vs 114 (79-155) ml/m2, p < 0.05] increased significantly in the left dependent position compared to supine. Mean arterial pressure did not change. Atrial natriuretic peptide levels rose from 140 to 203 pg/ml. In the right dependent position, we found a marked decrease in the mean arterial pressure [85 mmHg (supine) to 72 mmHg (right dependent), p < 0.01]. Cardiac index and intrathoracic blood volume were unchanged, but right ventricular end-diastolic volume decreased from 114 to 102 ml/m2 (p < 0.05). Additionally, atrial natriuretic peptide levels decreased significantly (median delta value: 37 pg/ml). In echocardiographic controls we found an increase in right ventricular end-diastolic diameters in the left dependent position and shortened diameters in the right dependent position. CONCLUSIONS: Extreme lateral posture affects the cardiovascular system in critically ill, mechanically ventilated patients: in the left dependent position a "hyperdynamic state" is reinforced, while the right decubitus position impairs right ventricular preload and predisposes to hypotension. Echocardiography and changes in plasma atrial natriuretic peptide values indicate that these findings are due to altered distensibility of the right ventricle caused by regional intrathoracic gravitational changes. We conclude that the duration and the angle of lateral posture should be restricted in hemodynamically unstable patients.     

Evidence of genetic susceptibility to Chlamydia trachomatis-induced pelvic inflammatory disease in the pig-tailed macaque

The macaque model of chlamydial pelvic inflammatory disease (PID) demonstrates individual variability in the time of onset of intrapelvic adhesions. Some animals develop adhesions rapidly, within 2 weeks after a single tubal inoculation with Chlamydia trachomatis, while in others, adhesions are not observed until 2 weeks after a second tubal inoculation. To test whether this variability correlates with major histocompatibility complex (MHC) class I haplotype, we used macaque alloantisera and mouse anti-HLA monoclonal antibodies to determine the MHC class I haplotypes of 44 C. trachomatis-infected macaques (Macaca nemestrina). Macaques developing gross tubal adhesions after the first chlamydial inoculation were classified as susceptible (n = 29), while those not developing adhesions until after the second chlamydial inoculation were classified as relatively resistant (n = 15), to adhesion formation. Three antibody specificities correlated with susceptibility (odds ratio [OR] 5.2, P < 0.01; OR 6.1 and 4.3, P < 0.05), and two correlated with relative resistance to adhesions (OR 0.1, P < 0.05; OR 0.2, P < 0.01). Because several of these antibodies are cross-reactive, as many as five different MHC class I alleles (three increasing and two decreasing ORs) or as few as two different MHC class I alleles (one increasing and one decreasing OR) could be correlated with risk of adhesion formation. We conclude that in macaques, susceptibility or relative resistance to rapid formation of tubal adhesions is correlated with expression of MHC class I alleles, consistent with reports of MHC class I restriction of chlamydial immunopathology in humans.     

Brain abscess and congenital heart disease

The clinical features and management of 18 patients with congenital heart disease and a brain abscess are reviewed. Except for one patient all had cyanosis. All abscesses were large, containing at least 50-60 ml of pus, and mostly unilocular. Bilocular and multilocular abscesses were also encountered. The organisms cultured from the pus had little relation to the mortality. Tapping may be the final investigation, and is also the treatment of choice. The high mortality (50%) is attributed to the delay in referral of these patients to a neurosurgical unit.     

Current treatment of brain abscess in patients with congenital cyanotic heart disease

OBJECTIVE: The goal of this study was to define clearly the role of management in patients with cyanotic heart disease and brain abscesses by evaluating retrospectively the factors influencing poor outcome in these patients. METHODS: This study included 62 patients with cyanotic heart disease and brain abscesses diagnosed in the computed tomography era. Basic characteristic parameters (number, size, location, computed tomographic classification and organism type of abscess, convulsion, type of cyanotic heart disease, age distribution, immunocompromised status, pretreatment neurological state, and intraventricular rupture of brain abscess [IVROBA]) and therapeutic parameters (type of antibiotics and duration of administration, steroid medication and therapeutic modalities, aspiration with or without cerebrospinal fluid drainage, total extirpation after aspiration, or primary extirpation and medical treatment) were evaluated as independent predictors of poor outcome (totally disabled state or death) by using univariate and multivariate logistic regression analysis. We also statistically estimated the possible causes of IVROBA and the multiplicity of brain abscess. RESULTS: Although there were no statistically significant correlations between patients with good and poor outcomes in regard to other basic characteristic and therapeutic parameters, patients with poor outcomes were older (P < 0.02), more frequently had IVROBA (P < 0.005), and had a higher frequency of neurological deterioration (P < 0.01) than those with good outcomes. Multiple logistic regression analysis predicted that poor outcome increased the relative risk of IVROBA by a factor of 18.9 (odds rate, 18.9; 95% confidence interval, 1.7-211.6; P < 0.02). More patients with multiple abscesses had positive immunocompromised states than those with single abscesses (P < 0.01). Deep-located abscesses also more frequently had IVROBA (P < 0.005) and abscesses located in the parieto-occipital region ruptured into the occipital horn of the lateral ventricle in a short period (P < 0.02). CONCLUSIONS: Our findings suggest that IVROBA strongly influences poor outcome in patients with cyanotic heart disease. The key to decreasing poor outcomes may be the prevention and management of IVROBA. To reduce operative and anesthetic risk in these patients, abscesses should be managed by less invasive aspiration methods guided by computed tomography. Abscesses larger than 2 cm in diameter, in deep-located or parieto-occipital regions, should be aspirated immediately and repeatedly, mainly using computed tomography-guided methods to decrease intracranial pressure and avoid IVROBA. IVROBA should be aggressively treated by aspiration methods for the abscess coupled with the appropriate intravenous and intrathecal administration of antibiotics while evaluating intracranial pressure pathophysiology.