Fitz-Hugh-Curtis Syndrome: Symptoms, Causes, Types, Diagnosis, and Treatments
Fitz-Hugh-Curtis Syndrome (FHCS) is a rare but significant complication of pelvic inflammatory disease (PID), predominantly affecting women of childbearing age. Despite being relatively uncommon, its symptoms can be quite painful and distressing. What makes FHCS particularly intriguing is that while it originates from a pelvic infection, it primarily affects the liver’s capsule, not the liver itself.
This article aims to provide a comprehensive overview of Fitz-Hugh-Curtis Syndrome, including its symptoms, underlying causes, types, diagnostic procedures, and available treatment options. Whether you’re a healthcare professional, a student, or someone experiencing unexplained right upper abdominal pain, this guide will help deepen your understanding of this condition.
What is Fitz-Hugh-Curtis Syndrome?
Fitz-Hugh-Curtis Syndrome is an inflammation of the liver capsule, also known as perihepatitis, that occurs as a complication of pelvic inflammatory disease (PID). Although the liver tissue is not infected, the surrounding capsule becomes inflamed and can develop adhesions—fibrous bands that form between tissues and organs.
The syndrome was named after Dr. Thomas Fitz-Hugh Jr. and Dr. Arthur Curtis, who first described it in the early 20th century. It is often associated with sexually transmitted infections (STIs) like Chlamydia trachomatis and Neisseria gonorrhoeae.
Epidemiology
- Prevalence: FHCS affects up to 10–14% of women with PID.
- Gender: Almost exclusively seen in biological females, although rare cases in men have been reported.
- Age Group: Most common in women aged 15 to 44.
- Geographic Trends: Higher prevalence in regions with high STI rates.
Symptoms of Fitz-Hugh-Curtis Syndrome
The hallmark of FHCS is sharp pain in the right upper quadrant (RUQ) of the abdomen. This pain may mimic that of gallbladder or liver diseases, which often leads to diagnostic confusion.
Primary Symptoms
- Sharp, stabbing RUQ pain
- Often worsens with breathing, coughing, or movement.
- May radiate to the right shoulder or back.
- Pelvic pain
- Resulting from underlying PID.
- Often bilateral, cramping in nature.
- Fever and chills
- May indicate an active infection.
- Nausea or vomiting
- Secondary to severe abdominal discomfort.
- Pain during intercourse (dyspareunia)
- Irregular vaginal bleeding or discharge
- A classic sign of PID.
- Menstrual irregularities
Secondary Symptoms
- Fatigue
- Loss of appetite
- General malaise
- Painful urination or bowel movements
In some cases, symptoms may be subtle, especially in mild PID cases. This makes early detection challenging.
Causes of Fitz-Hugh-Curtis Syndrome
FHCS is most often caused by a bacterial infection that ascends from the female genital tract to the upper abdomen. It is strongly associated with PID, which itself results from sexually transmitted infections.
Primary Causes
- Chlamydia trachomatis
- Responsible for ~50–60% of FHCS cases.
- Often asymptomatic, making diagnosis tricky.
- Neisseria gonorrhoeae
- Historically the main cause, now less common due to improved STI screening.
- Polymicrobial infections
- Involving anaerobic bacteria, Mycoplasma genitalium, or Ureaplasma urealyticum.
Pathophysiology
- The bacteria ascend from the vagina and cervix through the uterus and fallopian tubes.
- They then travel to the peritoneal cavity and inflame the Glisson’s capsule (the outer layer of the liver).
- This leads to perihepatitis and the formation of “violin-string” adhesions between the liver capsule and the peritoneum.
Types and Classifications
FHCS is not usually classified into distinct types in clinical practice, but for a better understanding, we can consider a functional classification based on severity and presentation:
1. Acute FHCS
- Sudden onset RUQ pain
- Often accompanied by PID symptoms
- May present with fever and leukocytosis
- Severe adhesions not yet formed
2. Chronic FHCS
- Long-standing adhesions
- May occur after untreated or partially treated PID
- Less systemic symptoms but persistent RUQ pain
- May mimic chronic gallbladder disease or IBS
3. Atypical FHCS
- Occurs without noticeable pelvic symptoms
- RUQ pain is the primary complaint
- Easily misdiagnosed as cholecystitis, hepatitis, or appendicitis
Diagnosis of Fitz-Hugh-Curtis Syndrome
Diagnosing FHCS is challenging due to its similarity to other abdominal conditions. A high index of suspicion is essential, especially in women of reproductive age with RUQ pain and recent or active PID.
1. Medical History and Physical Exam
- Sexual history
- Symptoms of PID or recent STI
- Abdominal tenderness in RUQ and lower abdomen
- Cervical motion tenderness (classic PID sign)
2. Laboratory Tests
- CBC (Complete Blood Count): Elevated white blood cells (leukocytosis)
- CRP/ESR: Inflammatory markers may be elevated
- STD panel: To detect Chlamydia, Gonorrhea, etc.
- Urinalysis and pregnancy test: Rule out other causes
3. Imaging Studies
- Ultrasound (Abdominal and Pelvic):
- May show PID features but often normal for liver capsule.
- CT Scan:
- May show inflammation or enhancement around the liver capsule.
- MRI:
- More detailed view of adhesions and perihepatitis.
4. Laparoscopy (Gold Standard)
- Direct visualization of liver capsule
- Identifies characteristic “violin string” adhesions
- Can confirm diagnosis and allow for treatment
Differential Diagnosis
Due to the vague and overlapping symptoms, FHCS may be confused with:
- Cholecystitis
- Hepatitis
- Gallstones
- Appendicitis
- Right lower lobe pneumonia
- Ectopic pregnancy
- Endometriosis
- Irritable bowel syndrome
Treatment of Fitz-Hugh-Curtis Syndrome
Treatment aims to eradicate the underlying infection and manage symptoms. Prompt treatment is essential to prevent long-term complications like infertility or chronic pain.
1. Antibiotic Therapy
The cornerstone of FHCS treatment is broad-spectrum antibiotics targeting PID pathogens.
Common Regimens:
- Ceftriaxone (IM or IV) + Doxycycline (oral) ± Metronidazole
- Duration: 10–14 days
- Hospitalization may be needed for IV therapy in severe cases
2. Pain Management
- NSAIDs (e.g., Ibuprofen, Naproxen) for mild to moderate pain
- Opioids in severe cases (short-term use only)
- Antipyretics if fever is present
3. Surgical Intervention
- Reserved for cases with severe adhesions or when diagnosis is uncertain
- Laparoscopy can be both diagnostic and therapeutic
- Adhesiolysis may be performed to release adhesions
4. Follow-Up and Partner Treatment
- Re-test for STIs after treatment
- Treat sexual partners to prevent reinfection
- Counsel on safe sex practices
- Encourage routine gynecologic follow-ups
Complications
If untreated or inadequately treated, FHCS can result in:
- Chronic pelvic pain
- Infertility due to fallopian tube damage
- Adhesions causing bowel obstruction
- Recurrent PID or FHCS
- Liver capsule fibrosis (rare)
Prevention of Fitz-Hugh-Curtis Syndrome
1. STI Prevention
- Consistent use of condoms
- Regular STI screening
- Limiting the number of sexual partners
- Prompt treatment of STIs
2. Early Treatment of PID
- Don’t ignore pelvic or abdominal pain
- Complete the full course of prescribed antibiotics
- Follow up with healthcare provider
3. Public Health Education
- Raise awareness among adolescents and young adults
- School-based sexual health programs
- Encourage open discussion about reproductive health
Prognosis
With prompt diagnosis and appropriate antibiotic treatment, the prognosis for Fitz-Hugh-Curtis Syndrome is excellent. Most patients recover fully without long-term damage. However, delay in diagnosis or treatment may lead to chronic pain, recurrent infections, or reproductive issues.
Fitz-Hugh-Curtis Syndrome in Men: A Rare Phenomenon
Although traditionally associated with women, there are rare reports of FHCS in men. These cases usually result from intra-abdominal infections like appendicitis or tuberculosis rather than PID. Diagnosis in males is even more challenging due to the rarity and lack of awareness.
Case Example
A 24-year-old sexually active woman presented with sharp right upper quadrant pain, mild fever, and vaginal discharge. Labs showed elevated WBC count and positive Chlamydia PCR. Imaging was inconclusive. Laparoscopy confirmed FHCS with visible “violin-string” adhesions. She was treated with doxycycline and ceftriaxone and made a full recovery within two weeks.
Conclusion
Fitz-Hugh-Curtis Syndrome is a lesser-known yet significant complication of pelvic inflammatory disease. Characterized by sharp upper abdominal pain and associated with sexually transmitted infections, it demands a high level of clinical suspicion for timely diagnosis and treatment.
Education, prevention, and early intervention remain key strategies to reduce the burden of this condition. Through awareness and proactive sexual health management, FHCS can often be prevented or treated before causing serious long-term effects.
Frequently Asked Questions (FAQs) About Fitz-Hugh-Curtis Syndrome
What is Fitz-Hugh-Curtis Syndrome?
Fitz-Hugh-Curtis Syndrome (FHCS) is a rare condition where inflammation affects the liver capsule due to an infection originating in the pelvis, most commonly from pelvic inflammatory disease (PID).
What causes Fitz-Hugh-Curtis Syndrome?
The primary causes are bacterial infections like Chlamydia trachomatis and Neisseria gonorrhoeae, which spread from the reproductive organs to the upper abdomen, leading to inflammation around the liver.
What are the early signs of Fitz-Hugh-Curtis Syndrome?
Early symptoms typically include sharp pain in the right upper abdomen, fever, pelvic discomfort, and abnormal vaginal discharge. These signs often mimic other abdominal conditions.
Can men get Fitz-Hugh-Curtis Syndrome?
While extremely rare, men can develop a similar condition due to other abdominal infections, but classic FHCS is predominantly seen in women with PID.
Is Fitz-Hugh-Curtis Syndrome contagious?
No, FHCS itself is not contagious, but the underlying sexually transmitted infections (STIs) that cause it—like chlamydia and gonorrhea—are contagious.
How is Fitz-Hugh-Curtis Syndrome diagnosed?
Diagnosis involves a combination of medical history, pelvic examination, STD testing, and imaging studies. In some cases, laparoscopy is used to confirm the diagnosis by directly viewing liver adhesions.
Can Fitz-Hugh-Curtis Syndrome be cured?
Yes. With prompt antibiotic treatment, FHCS can be fully cured. Early treatment reduces the risk of long-term complications such as infertility or chronic pelvic pain.
What is the best treatment for Fitz-Hugh-Curtis Syndrome?
The best treatment includes a combination of antibiotics, often doxycycline and ceftriaxone, which target the underlying bacterial infection. Pain management may also be needed.
How long does Fitz-Hugh-Curtis Syndrome last?
With appropriate treatment, symptoms typically improve within 1 to 2 weeks. However, adhesions may take longer to resolve or may persist in some cases.
Can Fitz-Hugh-Curtis Syndrome cause infertility?
Yes, if left untreated, the underlying PID can cause fallopian tube damage, leading to infertility or increased risk of ectopic pregnancy.
What are ‘violin-string’ adhesions in FHCS?
These are thin, fibrous bands that form between the liver capsule and the abdominal wall or diaphragm, resembling violin strings. They are a classic sign seen during laparoscopy.
Can Fitz-Hugh-Curtis Syndrome come back?
Yes. Recurrence can occur if there’s a new or unresolved STI, or if sexual partners aren’t treated at the same time.
How can Fitz-Hugh-Curtis Syndrome be prevented?
Prevent FHCS by practicing safe sex, getting regular STI screenings, and ensuring prompt treatment of pelvic infections like PID.
Is surgery required for Fitz-Hugh-Curtis Syndrome?
Surgery is rarely needed but may be considered in severe or chronic cases where adhesions cause persistent pain or complications.
What is the long-term outlook for someone with Fitz-Hugh-Curtis Syndrome?
With timely diagnosis and treatment, the outlook is generally excellent. Most people recover fully, especially if the infection is caught early and properly managed.
For more details keep visiting our Website & Facebook Page.