Fitz-Hugh–Curtis Syndrome

This issue contains a paper by Ricci et al. (2008) describing this syndrome and illustrating it with laparoscopic views of the typical ‘violin string’ adhesions. These were described first by Stajano in 1920 but in a non-English publication. In the English literature, Arthur Curtis, Professor of Obstetrics and Gynecology at the Northwestern University Medical School, Chicago, described in 1930, these adhesions between the anterior surface of the liver and the anterior abdominal wall found at laparotomy in patients with atypical gallbladder attacks. No other upper abdominal pathology was noted, but residual gonococcal tubal changes were frequently noted. He believed that each pathology was not coincidental but that the adhesions were indicative of gonococcal infection (Curtis 1930).

Thomas Fitz-Hugh junior, from Pennsylvania, described three cases in 1934 which had presented with right upper abdominal pain. When the first underwent laparotomy an unusual, localised, fairly dry peritonitis involving the anterior surface and edge of the liver and adjacent peritoneal surface of the diaphragm and anterior abdominal wall was found. A biopsy of the liver was taken and a drainage tube inserted. He stated:

‘After cogitating overnight we decided that what we had seen was probably the acute stage of the process described in its chronic form by Curtis. Accordingly, smears were made from the drainage tract and we were promptly rewarded with the finding of a beautiful spread of typical Gram-negative intracellular biscuit-shaped diplococci’ (Fitz-Hugh 1934).

The other two cases had acute right upper abdominal pain in association with gonococci found on cervical smears. A friction rub, described as that heard while walking on freshly fallen snow and present along the right upper margin of the anterior abdominal wall was heard in the third patient. In the next 2 years Fitz-Hugh found six further cases (Fitz-Hugh 1936). He was unable to explain the localisation exclusively to the right side of the upper abdomen. Treatment recommended by him (in pre-antimicrobial days) was bed rest, local heat, liquid diet, sedatives and parenteral protein (Aolan) therapy.

The entity became known as the Fitz-Hugh–Curtis syndrome, or gonococcal perihepatitis. Kimball and Knee (1970) and Francis and Osoba (1972) have described the syndrome occurring in men with gonococcal urethritis or polyarthritis, which suggests that involvement of the upper abdomen cannot be from gonococcal pus spilling out of the tubal ostia and ascending in the right para-colic gutter.

It is now known that the syndrome is not confined to gonococcal infection, and has been reported in association with chlamydial pelvic infection (Wang et al. 1980; Wolner-Hanssen et al. 1980). The paper in this issue warns that it may be found in women with no previous history of pelvic infection.

My own clinical involvement with this syndrome was described after seeing two cases (MacLean and Platts 1977). The first presented with right upper abdominal pain and was admitted under the care of the surgeons. She had a mild pyrexia, tachycardia, leukocytosis, elevated ESR (between 50 and 110 mm/h) and sterile pyuria. Some 26 days after admission and many investigations later (but before the availability of diagnostic laparoscopy), she was referred to the gynaecology clinic. She had ‘cervicitis' and bilateral tubo-ovarian abscesses, and urethral, cervical and rectal swabs produced heavy growths of Neisseria gonorrhoeae. She became asymptomatic after penicillin, probenecid and metronidazole. At that time, I did not calculate what the cost of her sexually transmitted infection had been to her or the health service, but it must have been considerable. However, the lesson was to ensure that all surgeons were aware of this entity and should ask for gynaecological input when a female patient presents with otherwise unexplained upper (or lower) abdominal pain. Again, there is a plea that postgraduate education does not become so focused on superspecialisation that our trainees do not know about these cross-specialty clinical challenges.