- *Division of Adolescent Medicine, Nationwide Children’s Hospital, Columbus, OH
- †Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
AUTHOR DISCLOSURE
Drs Roden and McKnight have disclosed no financial relationships relevant to this article. Dr Berlan is a consultant and Nexplanon Clinical Trainer for Merck Inc. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.
Presentation
A 19-year-old woman with a history of abnormal uterine bleeding requiring blood transfusion presents for care in an adolescent medicine clinic for 2 weeks of generalized abdominal pain. She reports loose stools at onset and constipation at the time of the visit. Her menses are regular and typically light; however, the previous month’s cycle was uncharacteristically heavy and prolonged. She reports vaginal intercourse with 5 male partners in the past year and consistent condom use. She has never had a sexually transmitted infection (STI). She had a 52-mg levonorgestrel-containing intrauterine device (LNG-IUD) placed under sedation approximately 1 year earlier for contraception and treatment of abnormal uterine bleeding.
On physical examination she is comfortable and her vital signs are normal. Abdominal examination reveals distention and diffuse tenderness. Genital examination reveals a copious gray-white vaginal discharge. The cervix, adnexa, and uterus are nontender. Microscopy of the discharge demonstrates the presence of white blood cells and positive amine odor (“whiff”) test results without clue cells. The clinician orders a urine pregnancy test (which is negative) and urine nucleic acid amplification testing for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis, in addition to blood cell counts, liver function tests, amylase level, and lipase level. During her visit to the clinic, the patient receives a clinical diagnosis of bacterial vaginosis and starts a 7-day course of metronidazole, and the clinician orders an outpatient abdominal sonogram.
Testing for chlamydia is reported as positive 2 days after the index visit. The clinician notifies the patient of her test results. The patient starts a prescription for 14 days of oral doxycycline, and 1 intramuscular dose of ceftriaxone 250 mg was administered the following day, with improvement in abdominal pain but persistent complaints of bloating. Testing for T vaginalis and N gonorrhoeae is negative.
Five days after the index visit and 3 days after starting treatment for chlamydia, the patient completes her abdominal sonogram and blood work, which reveals the cause of her abdominal distention.
Discussion
Differential Diagnosis
Large-volume ascites in the otherwise well adolescent girl is uncommon, and the differential diagnosis is broad: in those with injection drug use, infectious hepatitis is a frequent cause; in those with an exposure or travel history, tuberculosis peritonitis may also be seen. STIs, including syphilis and human immunodeficiency virus, may contribute to abdominal distention. Autoimmune diseases, including lupus and autoimmune hepatitis, may contribute to ascites, although more symptoms would be expected, such as weight loss, fatigue, rashes, or fever, all of which were absent in this case. Malignancy and heart failure are also important causes of ascites, although these are far more common in older women.
Diagnosis and Management
Five days after the index visit the patient has her blood work collected and the clinician notes elevations of several liver function test results, including alkaline phosphatase (197 U/L [3.29 μkat/L]) (reference range, 50–136 U/L [0.83–2.27 μkat/L]), alanine aminotransferase (52 U/L [0.87 μkat/L]) (reference range, <40 U/L [<0.67 μkat/L]), aspartate aminotransferase (55 U/L [0.92 μkat/L]) (reference range, 15–50 U/L [0.25–0.83 μkat/L]), and total protein (9.4 g/dL [94 g/L]) (reference range, 6.4–8.4 g/dL [64–84 g/L]). Amylase, lipase, and C-reactive protein levels; platelet count; and white blood cell count with differential count are not outside of their respective reference ranges. The hemoglobin level is 8.7 g/dL (87 g/L) (reference range, 12–16 g/dL [120–160 g/L]). Results of testing for human immunodeficiency virus, syphilis, and infectious hepatitis are negative.
The patient has her abdominal sonogram performed that afternoon, which reveals an unspecified large volume of free fluid in the abdomen and a cystic lesion arising from the right ovary. The radiologist recommends an urgent computed tomographic (CT) scan of the abdomen (Figure). This study reveals a large amount of fluid in the abdomen and pelvis, with stranding suggestive of thin septations adjacent to the left lateral margin of the liver, and a right adnexal cystic lesion measuring 3.3 cm. The volume of fluid was not specified. The liver demonstrates normal enhancement with mild scalloping of the hepatic margin and was surrounded by fluid. The spleen is mildly enlarged for age, and the remainder of the abdominal structures are normal. CT findings are suggestive of Fitz-Hugh-Curtis syndrome and a hemorrhagic ovarian cyst. The patient’s LNG-IUD is noted to be in proper position at the uterine fundus, and the decision was made to leave it in situ because placement required sedation and the patient reported subjective improvement in symptoms despite imaging findings. She is directly admitted to the adolescent medicine inpatient hospital service due to concerns for pelvic inflammatory disease (PID) with Fitz-Hugh-Curtis syndrome complicated by large ascites, according to Centers for Disease Control and Prevention (CDC) recommendations for management of PID in which a need for surgical intervention cannot be excluded. (1)
Coronal section of a computed tomographic scan of the abdomen and pelvis demonstrating a levonorgestrel-containing intrauterine device at the uterine fundus (o) and large ascites (*).
As an inpatient, the patient was treated with cefoxitin 2,000 mg intravenously every 6 hours, doxycycline hyclate 100 mg orally every 12 hours, and metronidazole 500 mg orally every 12 hours according to CDC recommendations for the treatment of complicated PID to reduce the future risk of ectopic pregnancy and infertility related to possible anaerobic or polymicrobial infection. (1) On admission her erythrocyte sedimentation rate was greater than 130 mm/h (reference range, 0–20 mm/h), with a normal absolute neutrophil count of 3,440/μL (3.44×109/L) (reference range, 1,500–8,000/μL [1.50–8.00×109/L]). She was noted to have both a fluid wave and shifting dullness on physical examination. Her abdominal pain improved during the course of her hospitalization. After 60 hours of intravenous antibiotic drug therapy the patient noted that her distention was markedly reduced, and her fluid wave and shifting dullness were diminished on physical examination. A repeated abdominal sonogram revealed large ascites, similar in quantity to the previous sonogram, and a decrease in the size of the cystic lesion noted on the right adnexa.
During the patient’s inpatient stay, the hospital team discussed with her expedited partner therapy (EPT), or the provision of antibiotic medication or prescription for the partner of a person with an STI without the need for seeing a provider first. (2)(3) She was offered EPT for chlamydia, as permitted by law in the state of Ohio, (4) which she declined due to lack of contact with her previous partner.
On hospital day 4, a total of 8 days after the index visit, the patient was discharged to complete 21 days of oral doxycycline 100 mg twice daily and metronidazole 500 mg twice daily per CDC recommendations, (1) which she tolerated well. Her LNG-IUD was left in place throughout treatment, as the patient reported improving symptoms with each intervention. At outpatient follow-up 1 week after discharge she reported resolution of abdominal pain and less abdominal distention. Her abdomen was soft, with minimal distention and absent fluid wave and shifting dullness noted on physical examination. A repeated abdominal sonogram 3 weeks after initial hospitalization revealed small amounts of free fluid in the right upper and lower quadrants, with significant improvement in ascites. At her follow-up visit 7 weeks after her initial hospitalization, the patient reported having completed her course of antibiotics without issue and complete resolution of all abdominal symptoms. Chlamydia nucleic acid amplification testing from urine was negative, and her aspartate aminotransferase and alanine aminotransferase values had normalized at that visit. Her total protein level was improved but still mildly elevated at 8.7 g/dL (87 g/L).
The Condition
C trachomatis is the most common bacterial STI in the United States, with an annual incidence of greater than 450 cases per 100,000 people. (5) It can be transmitted through oral, (6) anal, and vaginal intercourse, and it commonly is a cause of PID. (1)(5) A known but uncommon correlate of PID is inflammation of the liver capsule and a subsequent perihepatitis, with a characteristic finding of “violin-string” adhesions on laparoscopy or laparotomy, known as Fitz-Hugh-Curtis syndrome. (7)
EPT is the provision of medication or prescriptions and health information directly to a patient to give to a sexual partner, without the health-care provider examining the partner first. EPT is a useful option to facilitate treatment for partners of heterosexual females with N gonorrhoeae and/or C trachomatis, (3) as this practice is equivalent or superior to routine care for reduction of reinfection rates with chlamydia and gonorrhea. (2) Importantly, recommendations about EPT use are particular to the organism and the patient population; EPT is not recommended for T vaginalis infections and syphilis, or for men who have sex with men. (3) Our patient declined use of EPT for her sexual partner.
Our case of a 19-year-old woman with abdominal pain and large ascites associated with C trachomatis genitourinary infection is unique for several reasons. Chlamydia PID with large ascites as a prominent feature of disease exists in the literature, but it is quite rare. (8)(9)(10)(11)(12)(13)(14) Ages of affected women in case reports range from 17 to 40 years. Each case in the medical literature involves a patient noted to have abdominal ascites who then underwent an evaluation for ovarian cancer, complete with paracentesis and operative management, before evaluation and treatment for STIs. In all cases the patients were not found to have a malignancy. Our patient did not require a paracentesis for diagnosis or management, and her ascites had significant clinical improvement within 7 days of antibiotic drug treatment.
In addition, this patient had an LNG-IUD, which was placed for contraception and for treatment of abnormal uterine bleeding. The patient had required placement of her IUD under sedation due to difficulty tolerating office-based placement. Retaining the IUD if at all possible was prioritized by her medical team, and per CDC guidelines is appropriate for the management of PID in patients using an intrauterine device where previously reported cases have required removal if an IUD was present. (1) Her disease responded to treatment, and she had resolution of symptoms with her IUD remaining in situ. Finally, this patient improved with a 21-day course of oral antibiotics after hospitalization. Previous documented cases have required longer courses, documented between 28 days and multiple episodes of 42-day courses. Accordingly, the shortened duration of successful outpatient therapy using oral agents is notable.
Lessons for the Clinician
Testing for Chlamydia trachomatis infection should be included in the initial evaluation of ascites in sexually active female adolescents because this is a very common infection that requires unique management compared with other conditions giving rise to ascites, and testing is recommended routine care for sexually active adolescent females. (1)(5)(15)
Chlamydia-associated ascites improves with medical management alone and does not require drainage, operative management, or prolonged antibiotic drug therapy through any route.
Expedited partner therapy is a useful option for male partners of girls and young women with chlamydia and/or gonorrhea infection (3) and should be considered as permitted by law. (4)
Removal of an intrauterine device is not required in the treatment of pelvic inflammatory disease if there is improvement in symptoms. (1)
Reference
- © American Academy of Pediatrics, 2020. All rights reserved.
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