A case report of pelvic inflammatory disease – Streptococcus pneumoniae

Pelvic inflammatory disease (PID) is an infection that affects the upper genital tract in women, causing conditions like endometritis and salpingitis. Most cases are associated with STDs. Commonly associated pathogens are Neisseria gonorrhoeae, Chlamydia trachomatis, and Mycoplasma genitalium; Streptococcus pneumoniae infection is a rare cause.

A 32-year-old lady presented with a 4-day history of lower abdominal pain and nausea during her periods. She did not have a fever or urinary syndrome.

The woman had been pregnant 6 times and had undergone five vaginal births. She had undergone tubal ligation in 2015. Other surgical history suggested – cholecystectomy in 2014 and sleeve gastrectomy in 2020. Detailed history-taking suggested no risky sexual behavior, recent gynecological intervention, or examination.

On palpation, her abdomen was soft, depressible, and painful. Speculoscopy emanated periods of bleeding. Gynecological examination rendered pain on pressure at the recto-uterine pouch.
Her initial investigations included – blood analysis, transvaginal ultrasound, CT scan, and vaginal culture:

C-reactive protein

185 mg/L

Leucocyte count

16.7 × 10.3/mm^3

Neutrophils

78.9%

HCG-β

negative

Uterus (Transvaginal ultrasound)

Anteversion; heterogeneous image 59 × 47 mm - right adnexa (cystic abscess); heterogeneous image of 57 × 25 mm - left adnexa (abscess)

CT scan

para-uterine pelvic abnormalities

vaginal smear

commensal vaginal flora

Laparotomy

purulent fluid in the pouch of Douglas; minor fluid collection at the right adnexa

Culture – purulent fluid

aerobic culture on Columbia, ANC, and Mc-Conkey agar and anaerobic culture on Schaedler 5 % blood agar

PCR

Chlamydia trachomatis – negative

Neisseria gonorrhoeae - negative

Mycoplasma hominis - negative

Ureaplasma urealyticum - negative

Alpha hemolytic colonies – after 24 hrs culture

Microscopy

Gram-positive cocci in chains

Matrix assisted laser desorption time-of-flight mass spectrometry (MALD-TOF)

Streptococcus pneumoniae – confirmed with an optochin test; serotype 3

Sensitivity test

S. pneumoniae was sensitive to penicillin G, amoxycillin, cefotaxime, erythromycin, clindamycin, moxifloxacin, tetracycline, trimethoprime + sulfamethoxazole

The symptoms and investigative findings led to a diagnosis of indicating pelvic inflammatory disease (PID). 

Treatment:

Empirical i.v. antibiotic therapy – ceftriaxone, metronidazole, and doxycycline. After S. pneumoniae identification, sensitivity test, and serotyping, the antibiotic therapy was modified to oral amoxicillin/clavulanic acid for 14 days.

The patient responded well to the treatment and was discharged after 5 days. 

Source: Alexe M, Benedicte L, Catherine S. Clinical Infection in Practice. 2023 Jan 1;17:100217.

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