Collalti, Marco

Di Rocco, Giorgio

Frezzotti, Francesca

Giannotti, Domenico

Mele, Rita

Patrizi, Gregorio

Pontone, Stefano

Redler, Adriano

English

Cadernos Espinosanos (E-Journal)

CASE REPORTAcute abdominal pain in a 24-year-old woman: Fitz-Hugh-Curtis syndrome associated with pyelonephritisGiorgio Di Rocco, Domenico Giannotti, Marco Collalti, Rita Mele, Stefano Pontone, Francesca Frezzotti,Adriano Redler, Gregorio Patrizi‘‘Sapienza’’ University of Rome, Department of Surgical Sciences, Rome/IT.Email: stefano.pontone@uniroma1.itTel.: 00390649972446INTRODUCTIONFitz-Hugh-Curtis syndrome is an inflammatory disease ofthe liver capsule that occurs as a complication of pelvicinflammatory disease in approximately 25% of cases. Themost common etiological agents are Chlamydia trachomatisand Neisseria gonorrhoeae. Classically, it manifests as acuteright upper quadrant pain, which can sometimes beconfused with pyelonephritis or a primitive condition ofhepatobiliary origin or the digestive tract. A correctdiagnosis is often difficult. Ultrasonography and computedtomography (CT) may be helpful in the differentialdiagnosis of other forms of peritonitis localized in the rightabdominal quadrants, and serology, urine cultures andcervical swabs are generally used to isolate the responsibleorganism. The differential diagnosis could include Chilaiditisyndrome (interposition of a colonic segment between theliver and diaphragm with occlusion) or exudative peritoni-tis from salpingitis. We describe the clinical case of a 24-year-old Caucasian woman who presented with acute rightupper quadrant pain, positive Murphy’s sign, neutrophilicleukocytosis, and fever.CASE DESCRIPTIONWe report the clinical case of a 24-year-old Caucasianwoman who was treated in November 2011. She presentedwith pain in the right upper quadrant associated with feverand neutrophilic leukocytosis. She was a light smoker,nulliparous, and sexually active. In the previous two years,she had taken estrogen-progestin oral therapy for hypertri-chosis associated with a polycystic ovary. She reportedrecurrent episodes of vaginitis in the last year. The patientpresented to our hospital due to pain in the right upperabdominal quadrant that had lasted for three days, fever,abdominal distention, and obstipation of feces and gasesassociated with an episode of vomiting. These symptomsappeared to coincide with her menstrual cycle. The patientwas hemodynamically stable, and her abdomen appearedglobular, distended, and barely palpable, particularly in theright upper quadrant, with torpid peristalsis. Murphy’sand Blumberg’s signs were positive, but Rovsing’s andMcBurney’s signs were negative. Her blood test results wereas follows: Hb 12.7 g/dL,WBC 16,020, neutrophils 87.6%, PLT194,000, INR 1.05, ratio 1, urea 16 mg/dL, fibrinogen 858 mg/dL, creatinine 1.1 mg/dL, ALT 23 IU/L, AST 32 IU/L,amylase 20 IU/L, total bilirubin 1.35 mg/dL, direct bilirubin0.91 mg/dL, sodium 136 mEq/L, potassium 3.48 mEq/dL,LDH 281 IU/L, CRP 30.27 mg/dL, ferritin 450 ng/ mL, andESR 82 mm/h. A physical-chemical examination of her urineshowed rare lower urinary tract epithelial cells, rare urothelialcells, rare erythrocytes, and 3-4 leukocytes per field. Chest X-ray showed the accentuation of broncho-vascular markingsand mild obliteration of the sinuses bilaterally. An abdominalradiograph showed no free air or hydroaeric levels below thediaphragm. Despite the negative results of the blood tests, wesuspected that the pain had a hepatobiliary cause. Wetherefore performed liver ultrasonography, which showedan enlarged liver, no dilation of the intra- or extra-hepatic bileducts, and a gallbladder with thickened walls and a multi-layered appearance, which was similar to the findings ininflammatory disorders. Gallstones were not observed in thelumen of the gallbladder, which had a layer of perihepatic andpericholecystic effusion (Figure 1). A focal area of unclearnature with a lack of homogeneity was observed in the middlelayer of the left kidney (Figures 2 and 3). The patient wastransferred to our department for further investigation. MRIconfirmed the ultrasonographic results described previouslyand more clearly demonstrated that the alteration of the leftkidney was pyelonephritis. The patient was examined by agynecologist, who noted abundant leucorrhoea and vulvo-vaginal erythema and therefore performed trans-vaginalultrasonography, which showed a normal uterus and endo-metrium and ovarian polycystosis. Vaginal and cervical swabswere collected to identify pathogenic microorganisms; theseswabs were positive for Candida albicans and Ureaplasmaurealyticum. Gene amplification by PCR was positive forChlamydia trachomatis. Finally, we came to a conclusivediagnosis of pelvic inflammatory disease (PID) and perihepa-titis resulting in cholecystitis caused by C. trachomatis, whichconstituted FHC syndrome. Previous antibiotic treatment withpiperacillin and tazobactam was replaced by a singleintravenous dose of 2 g of azithromycin, which led to agradual decrease in pain and inflammation markers withinapproximately 72 hours. After three weeks, the patient was ingood general condition, with no pain on palpation in the rightCopyright  2012 CLINICS – This is an Open Access article distributed underthe terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided theoriginal work is properly cited.No potential conflict of interest was reported.CLINICS 2012;67(12):1493-1495 DOI:10.6061/clinics/2012(12)231493hypochondriac region, negative swab results and normal-ization of the ultrasound and laboratory results.DISCUSSIONClassically, pain in the right upper quadrant of theabdomen occurs as a result of hepatobiliary diseases, suchas gallstones, cholecystitis, hepatitis, hepatic or sub-phrenicabscess, and herpes zoster (1,2). Right upper quadrant pain,with or without hypogastric consequences, is due to Fitz-Hugh-Curtis (FHC) syndrome in 12-25% of cases, which ischaracterized by the inflammation of Glisson’s capsuleconcomitant with pelvic inflammatory disease (1,3). FHCsyndrome manifests as perihepatitis in association withpelvic inflammatory disease. The syndrome occurs predo-minantly in young women, who complain of severe rightupper quadrant pain during the acute phase that sometimessimulates pleurisy (1,4). In the chronic phase, numerousviscero-visceral and viscero-parietal adhesions are formed,initiating at Glisson’s capsule; such cases are diagnosedusing explorative laparotomy or laparoscopy (3,5). In theliterature, approximately 12-25% of pelvic inflammatorydisease cases occur concomitantly with FHC. The frequentlyinvolved etiological agents are of bacterial origin, and N.gonorrhoeae and C. trachomatis are among the most common(2,6,7). These microorganisms can travel from the pelvis toinfect the surface capsule of the liver or the spleen via theperitoneal fluid (4,8). The symptoms are varied, rangingfrom simple non-specific pain in the hypogastric region,dysuria and dyspareunia to excessive vaginal secretions(3,9). Although most cases show a normal number ofleukocytes, neutrophilic leukocytosis occurred in our case.Liver enzymes are typically normal or only mildly elevated,and ESV and CRP are elevated in almost all cases. Thestandard examination for the diagnosis is gene amplifica-tion by PCR, which has replaced the conventional bacterialcultures and allows for the isolation of microorganismsusing cervical, urethral, rectal and throat swabs. Diagnostictools play a key role in the diagnosis of FHC syndrome, andin particular, ultrasonography and CT are often conclusive,although in our case, MRI was used in consideration of theyoung age of the patient (10). The final diagnosis is made byintegrating several laboratory and instrumental tests toexclude other diseases that occur with acute right upperquadrant pain. We would like to emphasize the particularassociation between acute left pyelonephritis with urinecultures positive for C. trachomatis and FHC syndrome. Inrecent years, there has been a progressive increase in theincidence of this syndrome, which is likely due to thecontinuous improvement of diagnostic techniques. Thetreatment is pharmacological, and if properly performedafter a correct diagnosis, it leads to complete resolution ofthe clinical case, reducing the duration of hospitalization.Otherwise, incorrect diagnosis in the acute phase followedby inadequate antibiotic treatment may cause the disease tobecome chronic, with subsequent further complications; inthis case, only surgical treatment by laparotomy or laparo-scopy can lead to the correct diagnosis and therapy.AUTHOR CONTRIBUTIONSDi Rocco G and Giannotti D designed the study and were also responsiblefor the manuscript writing. Patrizi G was responsible for data analysis andinterpretation. Mele R, Collalti M and Frezzotti F were responsible fordata collection and management. Pontone S and Redler A wereresponsible for the critical revision of the manuscript for importantintellectual content.REFERENCES1. Rivero-Sa´nchez L, Lo´pez-Soriano EM, Guarner-Aguilar L. Fitz-Hugh-Curtis syndrome: abdominal pain in women of 26 years old. Rev EspFigure 1 - Perihepatic and pericholecystic effusion.Figure 2 - The focal area of pyelonephritis in the left kidney.Figure 3 - The focal area of pyelonephritis in the left kidney oncolor Doppler imaging.A Fitz-Hugh-Curtis variationDi Rocco G et al.CLINICS 2012;67(12):1493-14951494Enferm Dig. 2011;103(10):546-8, http://dx.doi.org/10.4321/S1130-01082011001000009.2. Huang HH, Tsai CM, Tyan YS. Unusual cause should be kept in mind ofabdominal pain in female patient. Fitz-Hugh-Curtis syndrome.Gastroenterology 2011;140(3):e7-8, http://dx.doi.org/10.1053/j.gastro.2010.02.067.3. Ricci P, Lema R, Sola´ V, Ferna´ndez C, Fabres C, Ferna´ndez E, Pardo J.Fitz-Hugh-Curtis syndrome: Three cases of incidental diagnosis duringlaparoscopy. J Obstet Gynaecol. 2008;28(3):352-4, http://dx.doi.org/10.1080/01443610802058411.4. Hong DG, Choi MH, Chong GO, Yi JH, Seong WJ, Lee YS, et al. Fitz-Hugh-Curtis Syndrome: single centre experiences. J Obstet Gynaecol.2010;30(3):277-80, http://dx.doi.org/10.3109/01443610903576282.5. Burton E, McKeating J, Stahlfeld K. Laparoscopic management of a smallbowel obstruction of unknown cause. JSLS. 2008;12(3):299-302.6. Le Moigne F, Lamboley JL, Vitry T, Salamand P, Milou F, Farthouat P.Usefulness of contrast-enhanced CT scan for diagnosis of Fitz-Hugh-Curtis syndrome. Gastroenterol Clin Biol. 2009;33(12):1176-8, http://dx.doi.org/10.1016/j.gcb.2009.09.002.7. Woo SY, Kim JI, Cheung DY, Cho SH, Park SH, Han JY, Kim JK. Clinicaloutcome of Fitz-Hugh-Curtis syndrome mimicking acute biliary disease.World J Gastroenterol. 2008;14(45):6975-80, http://dx.doi.org/10.3748/wjg.14.6975.8. Olson S, McComb PF. Formation of Fitz-Hugh Curtis adhesions due toperihepatitis associated with salpingitis. J Obstet Gynaecol Can. 2010;32(6):533-4.9. MecLean AB. Fitz-Hugh-Curtis syndrome. J Obstet Gynaecol. 2008;28(3):259-60, http://dx.doi.org/10.1080/01443610802042993.10. Wang CL, Guo XJ, Yuan ZD, Shi Q, Hu XH, Fang L. Radiologic diagnosisof Fitz-Hugh-Curtis syndrome. Chin Med J (Engl). 2009 20;122(6):741-4.CLINICS 2012;67(12):1493-1495 A Fitz-Hugh-Curtis variationDi Rocco G et al.1495

Acute abdominal pain in a 24-year-old woman: Fitz-Hugh-Curtis syndrome associated with pyelonephritis

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Acute abdominal pain in a 24-year-old woman: Fitz-Hugh-Curtis syndrome associated with pyelonephritis

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