Fitz-Hugh Curtis: A Rare Cause of Ascites

Abstract

Clinical Presentation: A 16-year-old, previously healthy female presented to an outside hospital with right upper quadrant (RUQ) pain and hypotension requiring dopamine and norepinephrine. Exam was significant for RUQ tenderness without stigmata of chronic liver disease. Significant labs were: WBC 11 with 56% bands, lactate 8.6, creatinine of 1.7, AST 151, ALT 225, alk phos 113, t.bili 3.5. Subsequent tests were negative for hepatitis A, B, C, ANA, and ASMA. She was treated empirically with vancomycin, zosyn, and doxycycline, and was transferred to our ICU. Abdominal ultrasound was notable for moderate ascites and diffusely thickened edematous gallbladder wall with thickening measuring up to 1.5 cm without cholelithasisis, concerning for acute acalculous cholecystits. MRCP demonstrated gallbladder wall thickening without biliary dilation and moderate free peritoneal fluid. Gynecological examination revealed purulent cervical discharge and cervical motion tenderness. Gonorrhea and chlamydia PCR was negative. Sepsis was attributed to culture negative pelvic inflammatory disease (PID) with peri-hepatitis and gallbladder abnormalities due to Fitz-Hugh Curtis syndrome. Her liver enzymes normalized and abdominal pain improved over 5 days. She was discharged on a 14-day course of oral metronidazole and doxycycline, and on follow-up 3 weeks later, she had no complaints and had normal liver enzymes. Discussion: Fitz-Hugh-Curtis(FHC) is a syndrome of perihepatic inflammation that can occur in up to 14% of PID cases. It typically affects young, sexually active women who present with acute RUQ pain. Causative organisms are typically Chlamydia trachomatis or Neisseria gonorrhea, although in up to 25% of cases, etiology is unknown. Ultrasound is the usual initial test to evaluate the gallbladder and liver for other common cause of RUQ pain. Typically, hepatic capsular enhancement in the arterial phase on CT is helpful in making the diagnosis and avoiding laparoscopic evaluation. Broad spectrum antimicrobial treatment with anaerobic coverage is recommended if FHC is suspected. Most patients recover completely after appropriate treatment. FHC should be considered when a young woman presents with RUQ pain and pelvic examination is obligatory in this setting. Ascites is an extremely rare finding in patients with FHC, and other causes of ascites should be excluded prior to attributing it to FHC.