Fitz–Hugh–Curtis syndrome as a result of genital tuberculosis: a report of three cases

Fitz–Hugh–Curtis syndrome is the presence of perihepatitis with violin-string adhesions between the liver and the anterior abdominal wall in association with gonococcal or chlamydial salpingitis. The syndrome is associated with salpingitis and is manifested as right upper quadrant pain and tenderness, possibly resulting from irritation of Glisson's capsule of the liver. It usually subsides with an appropriate antibiotic regimen for salpingitis. Until now, only gonococcal and chlamydial salpingitis have been blamed for this syndrome. We present a report of three cases with proven genital tuberculosis who were found to have Fitz–Hugh–Curtis syndrome on laparoscopy. The details of the three cases are shown in Table 1. An 18-year-old unmarried female who presented with chronic pelvic and abdominal pain and primary amenorrhoea. Although she was unmarried, she was not a virgin and had had a few sexual encounters with one boyfriend. She had taken a full course of isoniazid, rifampicin, ethambutol and pyrazinamide for abdominal tuberculosis. She did not have withdrawal bleeding with a 7-day course of progestogen therapy and 21-day course of combined oral contraceptive pill (Ovral). On examination her secondary sex characters were well developed. Her height was 161 cm. General physical examination was normal. Hymen was not intact. Vagina was well developed. Uterus and cervix were normal in size and shape. Reports of the investigation and laparoscopy findings are shown in Table I. Diagnosis of Fitz–Hugh–Curtis syndrome as a result of abdominal tuberculosis was made. As she had already completed a course of antituberculosis treatment, she was given only broad spectrum antibiotics. She was started on a combined sequential pill for suspicion of endometrial atrophy and had a period 2 months later. A 28-year-old female who had salpingectomy for ectopic pregnancy 4 years ago and has since had secondary infertility and a painful abdomen. She was moderately built and well nourished and had mild pallor. Heart and chest were normal. Slight tenderness was present in the right hypochondrium and abdomen but there were no masses. Vaginal examination revealed induration and tenderness in the right fornix for which she was given a 2-week course of doxycycline. Reports of the investigation and laparoscopy are shown in Table I, and were suggestive of Fitz–Hugh–Curtis syndrome. Multiple adhesions throughout the peritoneal cavity with tubercles were observed. Biopsy from peritoneal tuberculosis confirmed tuberculosis, and she was started on antituberculosis treatment to which she responded well. A 28-year-old female who presented with primary infertility, chronic pelvic pain and right hypochondrium discomfort. On examination, she was of thin build and had mild pallor. Heart and chest were normal. Vaginal examination revealed indurations in both fornices. Findings of the investigations and laparoscopy are shown in Table I, and confirmed it to be typical of Fitz–Hugh–Curtis syndrome. Polymerase chain reaction from peritoneal biopsy of adhesions confirmed it to be tuberculosis. The patient was started on antituberculosis treatment to which she responded well. Perihepatic adhesions between the liver capsule and the diaphragm or the anterior peritoneal surface characterizes Fitz–Hugh–Curtis syndrome, and is an extrapelvic manifestation of pelvic inflammatory disease as a result of gonorrhoea or chlamydia. Tulandi and Falcone (3) found incidental liver abnormalities in 4.7% of their cases, with the most common being Fitz–Hugh–Curtis syndrome. Diagnostic laparoscopy has been used to diagnose Fitz–Hugh–Curtis syndrome and also to treat the adhesions by laparoscopic adhesiolysis (1, 5). Until now, only gonorrhoea and chlamydia have been blamed for the syndrome. Our three cases are unequivocal examples of Fitz–Hugh–Curtis syndrome as a result of tuberculosis, as proven by biopsy, and in all three cases chlamydia and gonorrhoea testing were negative, as tested by an ELISA test for chlamydial antibodies and by microscopic examination and culture for gonorrhoa in all three cases. It is, of course, possible that these patients previously had a chlamydia or gonorrhoea infection and were later infected with tuberculosis Table I. Address for correspondence: Jai Bhagwan Sharma, MD, MRCOG AI/61, Azad Apartments Sri Aurobindo Marg New Delhi – 110 006 India e-mail: [email protected]