Overview of Fitz-Hugh-Curtis syndrome

Fitz-Hugh-Curtis syndrome (FHCS) is a well-known but rare complication of pelvic inflammatory disease (PID) occurring in approximately 4-14% of patients. It almost exclusively affects people assigned female at birth (AFAB), of reproductive age, who may partake in risky sexual behaviours.¹ 

Acute pain in the upper right quadrant of the abdomen is the most frequent manifestation of FHCS. This pain is due to the inflammation of the tissues surrounding the liver (perihepatitis) and of the peritoneum (the membrane lining of the abdominal cavity). Sometimes the diaphragm may also be affected. More symptoms include: A high fever, headache and a general feeling of suboptimal health.¹

FHCS was first described in 1920 by Stajano, and further investigated in 1930, by Curtis via a laparoscopy of the abdominal cavity in patients presenting with right upper quadrant pain. Curtis discovered adhesions of the liver, to the lining of the abdominal cavity, were responsible for the pain. Both Curtis and Fitz-Hugh Jr. found evidence of gonorrhoea and chlamydia infection.²

Chlamydia, gonorrhoea and mycoplasma genitalium are sexually transmitted infections (STIs) implicated in the subsequent progression of PID to FHCS. Here, we will explore these STIs and link them back to PID and FHCS. 

The spread of the microbes causing FHCS, from the lower reproductive tract to the abdominal cavity, is thought to occur in three potential ways:¹ 

• Spontaneous ascending infection along the reproductive tract 
• Spread through the lymph vessels 
• Spread via the blood vessels (hematogenous spread)

Pelvic Inflammatory Disease

PID is an infection of the female reproductive system, including the fallopian tubes, ovaries and uterus, usually as a result of an infection spreading up from the vagina. Chronic PID is strongly linked to infertility as the infection can cause severe damage, and occlusion, of the reproductive tract.³ 

Symptoms

Symptoms of PID can vary in severity, with some people AFAB displaying no symptoms. Consequently, some individuals may be unaware that they are suffering from PID until they have difficulty becoming pregnant or develop chronic pain.³

For patients who display symptoms, symptoms may include:³

• Lower abdominal pain 
• Pungent, heavy vaginal discharge 
• Pain during intercourse 
• Fever
• Irregular bleeding from the vagina
• Abnormal urination (pain, frequency)

Causes

Untreated STIs that spread from the vaginal tract up towards the reproductive organs are the most common cause. Gonorrhoea and chlamydia are the most likely causes, but other STIs, like mycoplasma genitalium, have also been implicated in the cause of PID.⁴ 

Between gonorrhoea and chlamydia, gonorrhoea usually causes the more severe symptoms seen in PID, whereas PID caused by Chlamydia can often go unnoticed. However, both infections can lead to long-term adverse complications.⁴ 

Complications of PID

Inflammation caused by infection of the female genital tract can lead to scarring, adhesions and obstruction of the reproductive tract resulting in a range of complications. Including:³

• Infertility
• Ectopic pregnancy
• Pelvic Pain 
• Tubo-ovarian or pelvic abscess 

The spread of the microorganisms causing PID may reach the abdominal cavity, causing inflammation and the development of FHCS.³ 

Prevention

Individuals can take steps to minimise the risk of contracting the STIs associated with PID. Some preventative measures that may be taken are:^1,4 

• Barrier protection (condoms) during sexual encounters
• Regular sexual health screenings for both you and your partners
• Don’t practice vaginal douche, as this can upset the bacterial balance in your vagina, which will make you more susceptible to infection 

Chlamydia 

According to WHO, in 2020 there were 128.5 million new cases of chlamydia reported globally in people aged 15-49 years old. The infection is caused by the bacterium chlamydia trachomatis transmitted via vaginal, anal and oral sex. 

Many cases of chlamydia are asymptomatic but if symptoms do occur they often present themselves several weeks after the initial infection.⁴ 

In women, symptoms can include:⁴

• Unusual vaginal discharge 
• Irregular bleeding
• Pain in the lower abdomen 
• Burning feeling whilst urinating 

Symptoms in men include:⁴

• Pain in the testicles
• Discharge from the penis 
• Burning sensation whilst urinating
• Bleeding 

Luckily, chlamydia is easily treated and unlikely to cause long-term effects if diagnosed and treated early. A course of an antibiotic called doxycycline is the preferred method of treatment.⁴ 

In women, if left untreated, the infection can ascend the reproductive tract and cause PID. FHCS may occur as a consequence of PID. Infertility, and increased probability of ectopic pregnancy, are potential long-term effects of a chronic chlamydia infection.^1,3,4  

Chlamydia is easy to diagnose by collecting urine samples or performing a swab test. The samples are tested in a lab, and results become available quickly. Regular sexual health screens, and the use of condoms, will drastically reduce the chance of a long-term chlamydia infection.^3,4 

Gonorrhea

After chlamydia, gonorrhoea is the second most common STI seen globally. In the UK, in 2020 57.084 new cases were diagnosed, with young people being the most at risk. The infection is caused by a bacterium called Neisseria Gonorrhoeae spread mainly via contact with infected discharge usually from the penis or vagina. The disease most often affects the reproductive tract and rectum, but can also affect the throat and eyes. A pregnant individual with gonorrhoea poses a significant threat to their unborn child as the infection is linked to permanent blindness in newborn babies.^4,5 

Common symptoms of a gonorrhoea infection are:⁴

• Burning sensation whilst urinating
• Thick green/yellow discharge 
• Unusual bleeding in women

Similarly to chlamydia, many cases of gonorrhoea infection are asymptomatic and may go unnoticed. Approximately 10% of men and 50% of women won’t show any symptoms or have very mild ones. 

Treatment for gonorrhoea involves an antibiotic injection directly into the buttocks or leg. Symptoms should clear up in a couple of days. Individuals are advised to retest to ensure the infection has been completely cleared.^4,5 

There are some significant complications of gonorrhoea infection:^3,4,5 

• PID affects 33% of women with a gonorrhoea infection
• Fitz-Hugh-Curtis Syndrome
• Pregnancy complications: ectopic pregnancy, miscarriage, premature labour and gonococcal conjunctivitis  

Diagnosing and treating Fitz-Hugh-Curtis syndrome 

FHCS often presents a diagnostic challenge due to the overlapping symptoms between other more common conditions, such as acute appendicitis, and urinary tract infections. For a definitive diagnosis, the gold standard is a laparoscopic exploration to visualise the violin-string adhesions of the liver to the lining of the abdomen, characteristic of FHCS.⁶

However, the laparoscopic procedure is not the primary choice for diagnosing, as many physicians aim to recognise underlying symptoms of PID first. A CT scan can illustrate pathological signs typical of a PID diagnosis, such as tubo-ovarian abscess. Ultrasonography and MRI may also be used.⁶ 

Upon diagnosis of FHCS, IV antibiotics are the gold standard for treating the underlying infections. The disintegration of the adhesions of the liver to the lining of the abdominal cavity may also be required, to relieve symptoms.⁶  

Frequently Asked Questions

What is Fitz-Hugh-Curtis Syndrome?

A complication of pelvic inflammatory disease which causes inflammation of the liver capsule. 

What do sexually transmitted infections have to do with FHCS?

Untreated chlamydia and gonorrhoea infections can spread from the lower reproductive tract resulting in PID and subsequent FHCS. 

What are some of the symptoms?

Right upper quadrant pain is the most common symptom. Other symptoms include: Fever, vaginal discharge and pain when urinating. 

Can FHCS be treated?

Your doctor will start by treating the sexually transmitted infection with antibiotics. If pain persists, surgery can be used to remove the adhesions of the liver capsule to the abdominal cavity wall.   

Summary 

In conclusion, STIs play a significant role in the development of PID, and the subsequent complication of FHCS. Chlamydia and gonorrhoea infections can spread ascending the reproductive tract. Diagnosing the syndrome can often be a challenge, but they can be achieved using imaging techniques, or a laparoscopic investigation. Antibiotics can treat the microorganisms responsible for PID, and the breakdown of the violin-string-like adhesions in the abdominal cavity may help reduce the symptoms. 

Practising safe sex techniques, such as condom use, is vital to maintain optimal sexual health. Regular screening for STIs can ensure that any infections are caught early before they become a risk to your long-term health.