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Fitz-Hugh-Curtis and Peritonitis: Sorting Through the Features that Define This Syndrome

      To the Editor:
      Fitz-Hugh–Curtis syndrome (FHCS) is defined by the sign of perihepatic (violin-string) adhesions extending from the parietal peritoneum of the anterior abdominal wall to the anterior liver (Glisson) capsule and symptoms of right upper quadrant abdominal pain as well as those, most commonly, referable to a pelvic inflammatory disease (PID) process. Lam et al reported the case of a 19-year-old female diagnosed with FHCS presenting with diffuse abdominal pain.
      • Lam R
      • Jamidar PA
      • Aslanian HR
      • Muniraj T
      Fitz-Hugh-Curtis Syndrome presenting as acute abdomen.
      We believe that this case may represent an “atypical” presentation of a pyogenic PID complicated by peritonitis with secondary small bowel involvement and perihepatic adhesion but not FHCS. Herein we review the original papers by Arthur H. Curtis (1881-1955)
      • Curtis AH.
      A cause of adhesions in the right upper quadrant.
      ,
      • Curtis AH.
      Adhesions of the anterior surface of the liver.
      and Thomas Fitz-Hugh Jr (1894–1963)
      • Fitz-Hugh T.
      Acute gonococci peritonitis of the right upper quadrant in women.
      where they described the specific acute and chronic signs.
      In 1929, Curtis presented at the annual Baltimore Obstetrical and Gynecological Society meeting and published in 1930 and 1932, the chronic intraoperative findings:Anterior liver surface to anterior abdominal wall adhesions usually occupy an area several inches in diameter, are ordinarily numerous, and are usually of sufficient length to allow considerable play between the liver and the parietal peritoneum (p. 1221).
      • Curtis AH.
      A cause of adhesions in the right upper quadrant.
      . . . The pain in the right upper quadrant incident to violin-string adhesions is sometimes slight, similar to a stitch in the side, but quite often it stimulates a more serious attack of pleurisy (p. 2011).
      • Curtis AH.
      Adhesions of the anterior surface of the liver.
      In 1934, Fitz-Hugh reported the acute findings in 3 cases, 2 that showed confirmed gram-negative diplococcus from gram stains obtained from cervical smears. The early acute features of this disease:At some indefinite time presumably following a previous gonorrheal infection, or possibly a reinfection, there occurs a brief period of leukorrhea, slight transient dysuria, cramps and perhaps a somewhat abnormal menstrual epoch. This train of symptoms suggests that a mild pelvic reactivation has occurred. Vague low abdominal pain, distention and slight irregular fever follow promptly. Within from one to three weeks, sometimes after a brief interval of apparent quiescence, there occurs acute severe pain in the upper part of the abdomen with distention and rigidity, which quickly localizes in the right upper quadrant. . . . After this the “chronic stage” begins, which may be symptomless or characterized by the later manifestations described by Curtis (p. 2096).
      • Fitz-Hugh T.
      Acute gonococci peritonitis of the right upper quadrant in women.
      Peritonitis emanating from acute pyogenic PID is suggestive by the presence of diffuse abdominal pain, small bowel thickening, and mesenteric fat stranding. A syndrome is defined by at least 2 signs or symptoms. Therefore, the pain in this case was not localized to the right upper quadrant and, therefore, consistent with a secondary diffuse peritonitis and not a focal perihepatitis or FHCS.

      References

        • Lam R
        • Jamidar PA
        • Aslanian HR
        • Muniraj T
        Fitz-Hugh-Curtis Syndrome presenting as acute abdomen.
        Am J Med. 2020; 133: e596
        • Curtis AH.
        A cause of adhesions in the right upper quadrant.
        JAMA. 1930; 94: 1221-1222
        • Curtis AH.
        Adhesions of the anterior surface of the liver.
        JAMA. 1932; 99: 2010-2012
        • Fitz-Hugh T.
        Acute gonococci peritonitis of the right upper quadrant in women.
        JAMA. 1934; 102: 2094-2096