The rare and painful condition, Fitz-Hugh-Curtis Syndrome (FHCS), or sometimes referred to as perihepatitis, is often related to pelvic inflammatory disease (PID) concerns the liver. Recurrence, both the ensuing pain and complications, can be even more distressing than the initial diagnosis. Due to the pain and discomfort associated with the disease, understanding the causes and strategies of management is important knowledge for anyone dealing with this condition. Whether it be anyone experiencing recurrent symptoms or in support of someone else, this article will equip people with a comprehensive understanding to better manage and alleviate the impact of recurrent FHCS.

As previously stated, the liver is the primary organ of concern in relation to FHCS, as the condition occurs due to inflammation of the liver’s outer capsule (perihepatitis). This inflammation, in the case of recurrent FHCS is associated with the condition following reappearance after initial incidence. The inflammation occurs without the involvement of the liver parenchyma, with adhesion formation, as well as the cause of the distressing pain, pain in the right upper quadrant. Spurred on by persistent or reactivated underlying infections, the recurrence is observed, notably from sexually transmitted infections (STIs) such as Chlamydia or Gonorrhoea.¹ Antibiotic therapy is crucial in the management of recurrent FHCS when treating the underlying infection, followed by preventive measures and strategies to avoid reinfection, alongside support in the alleviation of both pain and inflammation. Principal strategies are as follows:

• Timely and appropriate antibiotic therapy: Immediate antibiotic treatment allows for the specific pathogens of the underlying infection that encouraged the recurrence to be targeted
• Reinfection prevention: Safe sex practices and regular screening and treatment of their partner are all necessary to prevent recurrence
• Pain management: NSAIDs (nonsteroidal anti-inflammatory drugs) are often prescribed alongside other pain management strategies for severe cases
• Monitoring and follow-up: Routine follow-ups with healthcare professionals and providers, ensuring that the infection has cleared and is responding well to treatments. It also allows for monitoring for any signs of infection recurrence

Awareness of the nuances of recurrent FHCS is crucial for effective management and prevention. The following sections shall delve deeper into the causes, symptoms, risk factors and long-term management strategies to best help self and loved ones in navigating this condition as smoothly and confidently as possible.

Introduction

Fitz-Hugh-Curtis syndrome (FHCS) occurs when the liver capsule, the tissue around the liver, is inflamed. Following disease onset is a substantial degree of pain, commonly within the area below the ribs on the right side. The condition itself is rare but often witnessed in people also suffering from pelvic inflammatory disease (PID). The relationship between the two diseases is the occurrence of one on the setting of the other. Bacterial infection results in the reproductive tract swelling and becoming painful after infection. This inflammation spreads to the surrounding tissues, specifically the liver, and the surrounding liver capsule. Adhesion of the liver capsule to the inside of the belly or diaphragm (the muscle that supports breathing) via sticky string-like strands.²

The infectious result that is PID is by way of a sexually transmitted infection (STI); similarly, these same infections, whether reintroduced or persistent, cause the recurrence of FHCS. Now, as earlier stated, antibiotic therapy is the primary and crucial player in the management of recurrent FHCS, and it is for this reason, alongside the following, that understanding FHCS is necessary:

• Prevention of long-term complications: FHCS infection alone is cause for concern; thus, recurrent FHCS infections raise more concern, as if left untreated, there are severe complications, possibilities like chronic pelvic pain, infertility, and even liver damage²
• Improved quality of life: Recurrent FHCS can notably impact a person’s quality of life in varying ways, but especially regarding continual pain and discomfort
• Early Detection: Greater understanding of the conditions allows for recognition of early warning signs that can support both early detection and prevention of the condition becoming chronic, recurring again, or simply further and more severe damage

These are just some of the reasons why insight into and education of FHCS, specifically recurrent FHCS is crucial. Further understanding FHCS requires in-depth understanding of the causes and underlying infections that play a part in onset.

Causes of recurrent FHCS

As previously stated, recurrence of FHCS is a result of persistent infection or reintroduction via a similar STI. The two most notable underlying infections are Chlamydia and Gonorrhoea. It is these underlying infections caused by their respective bacterium Chlamydia trachomatis and Neisseria gonorrhoeae, with most cases of FHCS noted to have onset following infection caused by Chlamydia than that caused by Gonorrhoea.³ Now, although we know that it's these infections that aid in FHCS onset, the exact process by which the actual onset of FHCS occurs, in spite of ever-increasing research, is not completely understood. It is speculated that the syndrome possibly occurs via the transperitoneal spread of the STD infecting the person as a result of an improper immune system response of autoimmunity.^3,4

Now, autoimmune disorders are a result of the body’s immune system, the natural defenses against invading organisms begins to attack non-foreign and invading organisms, they begin to attack the body’s healthy tissue and organs. Several studies have shown that people with FHCS regularly had high levels of antibodies against the bacterium Chlamydia trachomatis. This, though initially probably regarded as a positive as it reflects the body's effective functioning against infection, in regard to autoimmunity, it’s not such a positive.³

A vigorous immune response can spell trouble as this can lead to an autoimmune reaction, causing the body’s healthy tissue to be under attack. If the antibodies produced against the Chlamydia bacterium are produced in vigorous abundance, then they go on to cross-react with the body’s own cells. This reaction possibly results in the recorded inflammations noted in FHCS, allowing for the onset or exacerbation of inflammation of the liver capsule. The persistent high antibody levels also align with the cases of persistent infection, wherein the exposure is ongoing or repeated, which causes the recurrence of FHCS to begin with. Indicated is an ongoing immune response that brings forth recurrence that could onset via an autoimmune mechanism, although more research into STI effects and role in onset and recurrence of FHCS, as well as the autoimmune implications for a clear conclusion to be drawn.^3,5

Risk factors for recurrence:

• Multiple sex partners
• Unprotected sex
• History of STIs
• History of PID
• Intrauterine device (IUD) user
• Vaginal douching
• Assigned female at birth and under the age of 25
• Inadequate treatment
• Antibiotic resistance

Some symptoms are noted in both FHCS and PID (with the symptom highlighted in red being experienced with PID alone); hence, further diagnostic testing and observations are required by healthcare professionals. These include:

• Pain in the lower abdomen
• Back pain
• Pelvic pain
• Fever
• Chills
• Vaginal discharge
• Nausea and vomiting
• Pain during sexual intercourse
• Pain while urinating
• Cramping
• Post-sexual intercourse bleeding
• Headaches
• Hiccups
• Irregular periods or spotting, or cramping throughout the month^2,6

Diagnosis of FHCS

As stated above, symptoms of FHCS are similar to not only those of PID but many other conditions such as viral hepatitis, ectopic pregnancy, appendicitis, and kidney infection, thus, diagnosis is often hard, requiring many laboratory tests to conclude an accurate diagnosis. Alongside laboratory tests, radiological exams may also be carried out to aid in diagnostic accuracy. Some laboratory tests may include:

• Pregnancy test
• Vaginal smear
• Tests for STIs (in cases of knowledge of a partner being infected with a specific STI, for example, that test would be carried out first)
• Complete blood count
• Comprehensive metabolic panel (a blood test that informs the functional state of the body)

Some radiological exams may include:

• CT scan
• Transvaginal ultrasonographic scan
• MRI²

The medical conditions with similar symptoms to FHCS, mentioned earlier, are just a few, and it's clear how different each condition is, thus, accurate diagnosis is crucial to effectively and accurately provide treatment and management of the specific condition.

Management, treatment and prevention

With bacterial infections being the underlying cause of FHCS, antibiotics are used to treat the specific underlying infection, as well as pain relief medication where needed. In cases of antibiotic resistance or other reasons for the antibiotics not working, such as allergies, the sticky strands will need to be removed in surgery, either laparoscopic or traditional surgery.

To prevent both FHCS and recurrent FHCS, the best course of action is as follows:

• Practice safe sex (use condoms)
• Regular STIs testing if one is sexually active (as well as whenever there is change in partners)
• Avoid douching
• Ask the sexual partner to also get tested regularly for STIs²

It is worth noting that usually, antibiotics alone cure FHCS without any further side effects.

FAQs

Is Fitz-Hugh-Curtis syndrome an STI?

No, Fitz-Hugh-Curtis syndrome (FHCS) is not an STI, but it is related to pelvic inflammatory disease (PID), which STIs usually cause. PID can lead to FHCS and the two most common STIs that bring forth these two diseases are Chlamydia and Gonorrhoea. In short FHCS is not an STI but rather the body’s reaction to an STI infection whether that be a first time infection or recurring infection.

Summary

Recurrent Fitz-Hugh-Curtis Syndrome (FHCS) is a condition in which the liver capsule experiences repeated inflammation and is often associated with pelvic inflammatory disease (PID). These two conditions are often caused by sexually transmitted infections, the most common bacterium and infection being Chlamydia’s Chlamydia trachomatis. Persistent or reintroduced infection results in recurrence, which is commonly followed by right upper abdominal pain alongside other symptoms.

Prompt antibiotic therapy is the primary start of effective management, supported by pain management and preventive measures such as practising safe sex and regular STI tests. Understanding the causes, risk factors, and treatment strategies allows for complication prevention and improved patient outcomes. Regular follow-up and patient education both play crucial roles in reducing recurrence, thus ensuring long-term health.