Chlamydia

Patient Presentation
A.B, an 18 year-old college student, presented to the clinic seeking contraceptive advice.  She had never had a pelvic exam, has had two sex partners in the past six months, and was not using condoms or any other contraceptives.  Pt states that her periods are regular, but has recently noticed some spotting between periods.  Her LMP was 4 weeks ago. Pt denies vaginal discharge, dyspareunia, genital lesions, or sores. Pt’s vital signs were 118/78, pulse 74, RR 18, and temperature was 37.1C. Breasts, thyroid, and abdominal exam did not show any abnormalities.  The genital exam revealed an inflamed cervix that bleeds easily, with a purulent discharge coming from the cervical os.  The bimanual exam was normal without cervical motion pain, uterine or tenderness of  adnexa.

Diagnosis
Initially the pt was diagnosed with endocervicitis from the physical and history portion.

Laboratory tests included:

• pregnancy test: negative
• NAAT for Chlamydia trachomatis: positive
• NAAT for Neisseria gonorrhea: non-reactive
• wet mount: pH 4.2, no clue cells (epithelial cells of the vagina that are covered in bacteria, sign of bacterial vaginosis) or trichomonads (parasitic microorganism that causes trichomoniasis)
• KOH preparation (mixes vaginal discharge with potassium hydroxide that kills everything but yeast): negative for whiff test (means there was not a strong fishy odor)
• HIV antibody: negative

Final diagnosis is Chlamydia cervicitis

Treatment
The patient was treated at the initial visit with azithromycin 1 gram orally in a single dose along with ceftriaxone 125 mg IM in a single dose.  The pt was also offered counseling for risk reduction and prevention, prescribed a hormonal contraceptive, and asked to refer her sex partners (in the last 60 days) in for evaluation, testing, and treatment.  Because Chlamydia is a reportable STI in all 50 states the local health department was notified.  Pt was instructed to return in four months.

Outcome
Pt returned for 4-month follow-up, and a repeat Chlamydia rest returned positive.  The pt was give azithromycin 1 gram orally in a single dose, and was counseled to not resume sexual intercourse until all partners were evaluated and treated.