A Sexually Active 30-Year-Old Woman With Rash and Wrist Pain

Amber M. Bokhari, MD


January 11, 2022

PID occurs in sexually active females of childbearing age. About 750,000 cases of PID are reported each year in the United States. Fitz-Hugh-Curtis syndrome occurs in 4% of sexually active adolescents and is an uncommon manifestation of PID. C trachomatis is the most common pathogen implicated, but the syndrome may also be caused by N gonorrhoeae infection.[7,8,9] In the patient in this case, blood cultures revealed the presence of Gram-negative N gonorrhoeae intracellular diplococci. Figure 3 is a photomicrograph showing similar findings in a different patient.

Figure 3.

Patients with Fitz-Hugh-Curtis syndrome typically present with acute pain or tenderness in the right upper abdomen caused by perihepatic inflammation and adhesions. In addition, they may have a history of chronic mild abdominal discomfort that has escalated recently and may mimic acute abdomen resulting from other etiologies. Patients may also report lower abdominal, pelvic, or back pain with concurrent fever, chills, nausea, vomiting, vaginal discharge, dyspareunia, dysuria, cramping, and post-coital bleeding.

The past medical history may be significant for high-risk behaviors with multiple sex partners without the use of appropriate protective barriers; previous miscarriages; or recurrent STIs. Patients may also report symptomatic or new sex partners. Other risk factors in sexually active women include age younger than 25 years, early sexual activity, a history of PID, IUD or oral contraceptive use, recent IUD insertion, and vaginal douching.

Significant physical examination findings may include fever (temperature higher than 100.4° F [38° C]), right upper quadrant tenderness or discomfort, and guarding. Patients may present with pelvic pain or cervical motion tenderness. The pelvic examination may reveal mucopurulent cervicitis or vaginal discharge.[5,7,10,11,12]

Ruling out ectopic pregnancy is also important. Baseline testing consists of urinalysis and a complete blood cell count, which reveals leukocytosis in about 50% of cases. A comprehensive metabolic panel can detect any electrolyte, renal, or hepatic derangements that point to a different etiology. Blood cultures may be positive in patients with disseminated disease. If the patient has vaginal discharge, bacterial cultures may be ordered. Urine N gonorrhoeae/C trachomatis nucleic acid amplification testing via gonococcal and chlamydial DNA probe can be initiated to confirm asymptomatic infection. It is also essential to test for other STIs, including syphilis, hepatitis B and C, and HIV infection.

Relevant imaging studies are necessary to rule out other causes of right upper quadrant pain. CT and/or MRI of the abdomen shows increased perihepatic enhancement. Tubal scarring due to PID, pyosalpinx, tubo-ovarian abscesses, and abdominal or pelvic abscesses may also be visualized. Transvaginal ultrasonography can be used to detect hydrosalpinx, pyosalpinx, endometritis, tubo-ovarian abscess, oophoritis, and ectopic pregnancy.

Laparoscopy is the criterion standard for the diagnosis of Fitz-Hugh-Curtis syndrome secondary to PID. The diagnosis is made by direct visualization of adhesions between the liver and the abdominal wall or diaphragm, without evidence of parenchymal liver disease. Laparoscopy may reveal scarring from chronic infection, purulent salpingitis, ectopic pregnancy, or tubo-ovarian abscess. Endometrial, liver, and tubo-ovarian biopsy can aid in establishing a definitive diagnosis.

The most important part of the management of Fitz-Hugh-Curtis syndrome is timely and concurrent treatment of PID. Patients with one STI should be aggressively and simultaneously treated with outpatient antibiotic therapy for other STIs to minimize the long-term sequelae of chronic asymptomatic infection, including infertility and ectopic pregnancy. Antibiotic therapy should cover the most common organisms: C trachomatis, N gonorrhoeae, Trichomonas vaginalis, urogenital pathogens, anaerobes, and streptococci.


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