A sexually active woman with fever, lower abdominal pain, cervical motion tenderness, and purulent cervical discharge. What is the most likely diagnosis and initial treatment?

• A. Pelvic inflammatory disease; treat with ceftriaxone plus doxycycline (± metronidazole)
• B. Gonorrhea infection only
• C. Ectopic pregnancy
• D. Endometritis

Answer: (A)

Pelvic inflammatory disease is the likely diagnosis here. In a sexually active person, fever with lower abdominal pain, cervical motion tenderness, and purulent cervical discharge strongly points to infection of the upper reproductive tract rather than simple cervicitis. PID typically results from ascending infection by Neisseria gonorrhoeae and/or Chlamydia trachomatis, often with other bacteria involved, making broad coverage essential.

The preferred initial treatment for mild to moderate outpatient PID is ceftriaxone given by injection to cover gonorrhea, plus doxycycline to cover chlamydia. Adding metronidazole can be useful to broaden coverage to anaerobes and other organisms if indicated. This combination is chosen because it addresses the most common pathogens and reduces the risk of long-term complications such as infertility, chronic pelvic pain, and ectopic pregnancy. If the patient were more severely ill, pregnant, or unable to tolerate oral meds, inpatient IV therapy with a cephalosporin (like cefoxitin or cefotetan) plus doxycycline would be used instead.

Gonorrhea infection alone would not explain the full picture here, since PID involves spread to the upper genital tract and requires treatment that also covers chlamydia and other organisms. Ectopic pregnancy would require ruling out pregnancy and has different signs and management, and endometritis is more typical postpartum or post-abortal and has a different presentation.