No individual or combination of blood tests can reliably diagnose pelvic inflammatory disease (PID)(strength of recommendation [SOR]: A, metaanalysis). The combination of white blood cell count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and vaginal white blood cells can reliably exclude PID if results for all 4 tests are normal (sensitivity=100%) (SOR: B, cohort study, reference standard not uniformly applied)

Hall, Mary N.

Leach, Laura

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C L I N I C A L  I N Q U I R I E S326 APRIL 2004 / VOL 53, NO 4 · The Journal of Family PracticeBoth guidelines list leukotriene inhibitors asa potential adjunct to corticosteroids for moder-ate persistent asthma, as an alternative to cor-ticosteroids plus long-acting beta2-agonist. Theguidelines also list leukotriene inhibitors as analternative treatment to inhaled corticosteroidsfor mild persistent asthma in patients aged >5years. Montelukast (Singulair) is approved foruse in children aged >12 months, zafirlukast(Accolate) is approved for children aged >5years, and zileuton (Zyflo) is approved only forchildren aged >12 years.Nancy E. Morden, MD, Department of Family Medicine,University of Washington, Seattle; Leilani St. Anna,MLIS, AHIP, University of Washington Health SciencesLibrary, Seattle■ CLINICAL COMMENTARYAn inhaled corticosteroid controller should be the first stepUntil evidence supports a different conclu-sion, I think we should continue to followcurrent national and global guidelines. Themost important concept in both is that once achild is diagnosed with persistent asthma,starting an inhaled corticosteroid controllershould be the first step. Leukotriene inhibitors should be consideredas second or third choice as a controller. Themain indications for using a leukotrieneinhibitor are aspirin-sensitive, exercise-induced, and nocturnal asthma. I would use aleukotriene inhibitor as a controller only if apatient could not comply with inhaled corti-costeroids.Lawrence S. Slotnick, MD, Moses Cone HealthSystem, Greensboro, NCREFERENCES1. Ducharme F, Hicks G, Kakuma R. Addition of anti-leukotriene agents to inhaled corticosteriods for chronicasthma. Cochrane Database Syst Rev 2002; (1):CD003133.2. Ducharme FM, Hicks GC. Anti-leukotriene agents com-pared to inhaled coritcosteriods in the management ofrecurrent and/or chronic asthma in adults and children.Cochrane Database Syst Rev 2002; (3):CD0023143. Simons FE, Villa JR, Lee BW, G et al. Montelukast addedto budesonide in children with persistent asthma: a randomized, double-blind, crossover study. J Pediatr2001; 138:694–698.4. Maspero JF, Duenas-Meza E, Volovitz B, et al. Oral mon-telukast versus inhaled beclamethasone in 6- to 11- year-old children with asthma: results of an open-label extensionstudy evaluating long-term safety, satisfaction and adher-ence with therapy. Curr Med Res Opin 2001; 17:96–104.5. Busse W, Wolfe J, Storms W, et al. Fluticasone propionatecompared with zafirlukast in controlling persistent asth-ma: a randomized double-blind, placebo-controlled trial. J Fam Pract 2001; 50:595–602.6. National Asthma Education and Prevention Program.Expert Panel Report: Guidelines for the Diagnosis andManagement of Asthma. 1997 (rev 2002). Available at:www.nhlbi.nih.gov/guidelines/asthma/. Accessed onMarch 5, 2004.7. Global Initiative for Asthma. Global Strategy for AsthmaManagement and Prevention. Rockville, Md: NationalHeart, Lung, and Blood Institute. 1995 (revised 2002).Available at: www.ginasthma.com/wr.html. Accessed onMarch 5, 2004.Which blood tests are most helpful in evaluating pelvic inflammatory disease?■ EVIDENCE-BASED ANSWER No individual or combination of blood tests can reli-ably diagnose pelvic inflammatory disease (PID)(strength of recommendation [SOR]: A, meta-analysis). The combination of white blood cellcount, C-reactive protein (CRP), erythrocyte sedi-mentation rate (ESR), and vaginal white blood cellscan reliably exclude PID if results for all 4 tests arenormal (sensitivity=100%) (SOR: B, cohort study,reference standard not uniformly applied). The combination of CRP and ESR is helpful inexcluding PID (sensitivity=91%) and may beespecially useful in distinguishing mild from com-plicated cases (SOR: B, small cohort study).Individual tests do not appear to significantlyimprove diagnostic accuracy, although the CRPand ESR are somewhat useful to rule out PID(SOR: B, small cohort study).■ EVIDENCE SUMMARYBecause of the significant inflammatory sequelaeof PID, it is the standard of care to treat womenwith suggestive signs and symptoms. ClinicalC O N T I N U E DC L I N I C A L  I N Q U I R I E S330 APRIL 2004 / VOL 53, NO 4 · The Journal of Family Practicediagnosis has a positive predictive value of 65% to90% compared with laparoscopy.1 While no singletest is both sensitive and specific, a combinationof biochemical tests for inflammation mayimprove the ability to rule out PID.A prospective cohort study of 120 women pre-senting to an ambulatory center with symptoms ofPID evaluated the tests commonly used to sup-port the clinical diagnosis of PID.2 The objectivecriteria used for diagnosis included histologic evi-dence of acute endometritis via endometrial biop-sy, purulent exudates in the pelvis on laparoscopy,or microbiologic evidence of Neisseris gonorrhea orChlamydia trachomatis from the upper genitaltract. The Table shows the sensitivities, specifici-ties, and predictive values for an elevated whiteblood cells (>10,000/mm), ESR (>15 mm/hr),CRP (>5 mg/dL), and increased vaginal whiteblood cells (>3 white blood cells/high-power field)for detection of PID. If all 4 test results are nega-tive, PID is reliably ruled out with a sensitivity of100%. These results may be an overestimate, asthe gold standard was not uniformly applied. The role of CRP and ESR in the diagnosis ofacute PID was studied in 41 women with clinical-ly suspected acute PID who presented to a uni-versity department of obstetrics and gynecology.3Women underwent laparoscopy, endometrial sam-pling, and cultures of the upper genital tract toconfirm the diagnosis. When considered together,a positive value in either the ESR (cutoff level of15 mm/hr) or CRP (cutoff >20 mg/dL) had a sen-sitivity of 91% and a specificity of 50%. Another report looked at the ability of ESR andCRP to differentiate between mild, moderate, andsevere PID in 72 women undergoing laparoscopyat a university department of gynecology.4 Thecutoff levels were ESR >40 mm/hr and CRP >60Diagnostic performance of blood tests for pelvic inflammatory diseaseSn (%) Sp (%) PPV (%)* NPV (%)*WBC (>10,000/mm3)2 57 88 88 58ESR (>15 mm/hr)2 70 52 69 54CRP (>5 mg/dL)2 71 66 76 60Vaginal WBCs2 78 39 66 540 of 4 of the above positive2 100 18 100 654 of 4 of the above positive2 29 95 90 47CRP >20 or ESR >153 91 50 N/A N/ACRP >60 or ESR >404 97 61 70 96CRP (metaanalysis)5 74%–93% 50%–90%ESR (metaanalysis)5 64%–81% 43%–69%*Prevalence=60%. SN, sensitivity; Sp, specificity; PPV, positive predictive value; NPV, negative predictive value; WBC, white bloodcells; ESR, erythrocyte sedimentation rate; CRP, C-reactive protein.TA B L EC L I N I C A L  I N Q U I R I E SAPRIL 2004 / VOL 53, NO 4 · The Journal of Family Practice 331mg/dL. If either test was abnormal, the sensitivi-ty and the negative predictive value for severe dis-ease were 97% and 96%, respectively (Table). Allpatients with tuboovarian abscess or perihepatitisand 6 of 7 patients who had anaerobic bacteriaisolated from the fallopian tubes tested positivewith these cutoff levels.A meta-analysis from 1991 found 12 studies,not including any of the above studies, andassessed the laboratory criteria for the diagnosisof PID. No single or combination diagnostic indi-cator was found to reliably predict PID. However,the CRP and the ESR were useful in ruling out PID, with good sensitivities for CRP in 4 of 4 studies analyzed (74%–93%) and for the ESR in4 of 6 studies (64%–81%). Ten of 12 studies usedlaparoscopy as the gold standard.5■ RECOMMENDATIONS FROM OTHERSThe Centers for Disease Control and Preventionmakes no specific recommendation for the use ofspecific blood tests in the diagnosis of PID.1 TheAssociation for Genitourinary Medicine statesthat an elevated ESR or CRP supports the diag-nosis of PID.6Mary N. Hall, MD, Laura Leach, MLIS, CarolinasHealthcare System, Charlotte, NCREFERENCES1. Sexually transmitted diseases treatment guidelines.MMWR Recomm Rep 2002; 51(RR-6):48–52.2. Peipert JF, Boardman L, Hogan JW, Sung J, Mayer KH.Laboratory evaluation of acute upper genital tract infec-tion. Obstet Gynecol 1996; 87:730–736.3. Lehtinen M, Laine S, Heinonen PK, et al. Serum C-reactive protein determination in acute pelvicinflammatory disease. Am J Obstet Gynecol 1986;154:158–159.4. Miettinen AK, Heinonen PK, Laippala P, Paavonen J.Test performance of erythrocyte sedimentation rate andC-reactive protein in assessing the severity of acutepelvic inflammatory disease. Am J Obstet Gynecol 1993;169:1143–1149.5. Kahn JG, Walker CK, Washington AE, Landers DV,Sweet RL. Diagnosing pelvic inflammatory disease. Acomprehensive analysis and considerations for develop-ing a new model. JAMA 1991; 266:2594–2604.6. 2002 Guidelines for the management of pelvic infectionand perihepatitis. London: Association for Genito-urinary Medicine (AGUM); Medical Society for the Studyof Venereal Disease (MSSVD); 2002. Available at:www.agum.org.uk/ceg2002/pid0601.htm. Accessed onMarch 5, 2004.■ CLINICAL COMMENTARYWhen diagnosing PID, a clinician must have a high index of suspicionPID is a difficult diagnosis to make, withoutclear-cut diagnostic guideposts. The sequelaeof PID can be so serious that clinicians mustnot miss this diagnosis. If results of all 4 testsdescribed above are negative, this can reliablyrule out the diagnosis. Unfortunately, no set of tests can reliablyconfirm the diagnosis in all cases. The tradi-tional triad of lower abdominal pain, cervicalmotion tenderness, and adnexal pain are stilltaught as the classic findings for diagnosingPID. The clinician must also have a high indexof suspicion, particularly with teen-agers withabdominal pain, and when the pain is indolentand lingering.Nonetheless, a recent study concludes thereis insufficient evidence to support existingclinical diagnostic criteria and recommendsthat the clinical criteria for PID be redefined.In a group of patients with laparoscopicallyconfirmed PID, no variable (abnormal vaginaldischarge, fever >38°C, vomiting, menstrualirregularity, ongoing bleeding, symptoms ofurethritis, rectal temperature >38°C, markedtenderness of pelvic organs on bimanualexamination, adnexal mass, and ESR >15mm) reliably predicted the disease, and found,rather, that most had low specificity and sen-sitivity. The chance of having PID based on thepresence of lower abdominal pain was 79%.Three variables predicted 65% of the cases ofPID: elevated ESR, fever, and adnexal tender-ness. When evaluating patients for admission,some authors add “the desire to bear children”to the standard admission criteria, whichinclude severity of sickness, pregnancy, possi-ble need for surgical intervention, lack ofresponse to oral medications, or immuno-suppression.Ellen Beck, MD, University of California–San Diego

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