Imaging Uganda/Africa

2nd, April, 2025

Ultrasound Case: Pelvic Inflammatory Disease (PID)

A 28-year-old female with lower abdominal pain and fever

Case Presentation

History

  • Chief Complaint: Lower abdominal pain x 5 days, fever (38.5°C), and vaginal discharge
  • History of Present Illness:
    • Bilateral lower abdominal pain, worse on the right
    • Increased yellowish vaginal discharge
    • Dyspareunia (pain during intercourse)
    • No urinary symptoms
  • Past Medical History: Previous chlamydia infection (treated 2 years ago)
  • Sexual History: Multiple partners, inconsistent condom use

Physical Examination

  • Abdomen: Tenderness in lower quadrants, rebound tenderness on the right
  • Pelvic Exam: Cervical motion tenderness (CMT), purulent cervical discharge
  • Vital Signs: Temp 38.5°C, HR 98, BP 110/70
Clinical Suspicion: Given the history of STIs, multiple partners, fever, and cervical motion tenderness, PID is highly suspected. Ultrasound is requested to assess for complications (tubo-ovarian abscess, pyosalpinx).

Ultrasound findings

  • Thickened, fluid-filled tubes ("cogwheel" or "beads-on-a-string" appearance)
  • Incomplete septations within dilated tubes (suggesting pyosalpinx)
  • Free pelvic fluid
  • Tubo-ovarian complex (ovary and tube adherent but still distinguishable)
  • Hypervascularity on Doppler (increased flow due to inflammation)
cogwheel sign

1. Right fallopian tube

  • Thickened, fluid-filled tubes
  • Incomplete septations
  • Hypervascularity
Free fluid

2. Free fluid

  • Complex free fluid (due to pus)
Diagnosis: Pelvic Inflammatory Disease (PID) with Pyosalpinx

Based on clinical findings (fever, CMT, vaginal discharge) and ultrasound features (dilated tubes, hypervascularity and complex free fluid).

Differentials

  • Ectopic Pregnancy: β-hCG positive, no fever, may see adnexal mass with ring of fire on Doppler.
  • Appendicitis: RLQ pain, fever, but no CMT or vaginal discharge.
  • Ovarian Torsion: Sudden severe pain, absent venous flow on Doppler.
  • Endometriosis: Chronic pain, dysmenorrhea, may see endometriomas but no fever.
  • Diverticulitis: LLQ pain, fever, but GI symptoms predominate.