A case of fitz-hugh-curtis syndrome complicated by appendicitis conservatively treated with antibiotics.

A 27-year-old woman developed a low grade fever and increased vaginal discharge that persisted for 2 weeks. Intermittent abdominal pain in the right upper quadrant had been experienced over the previous few days. Due to her clinical manifestations and typical abdominal computed tomography (CT) findings, including hepatic capsular enhancement and hepatomegaly, a diagnosis of Fitz-Hugh-Curtis syndrome was made. The early empirical use of antibiotics, azithromycin and levofloxacin, partially improved her symptoms. However, the low grade fever persisted and additional abdominal pain developed in the right lower quadrant. Based on the radiological evidence of an enlarged appendix with wall thickening, a diagnosis of appendicitis was additionally made, which was thought to occur secondarily to the genital tract infection. Following the administration of antibiotics ceftriaxone and cefditoren pivoxil, her symptoms were completely resolved without the need for any surgical intervention. Here, we report the first case of Fitz-Hugh-Curtis syndrome complicated by appendicitis, which was conservatively managed with antibiotic treatment alone. In this case, the overgrowth of pathogens within the genital tract and their direct penetration into the appendix was thought to be responsible for the development of appendicitis.

Introduction

Fitz-Hugh-Curtis syndrome is perihepatitis that develops secondarily to genital tract infections.1 The syndrome is characterized by inflammation of the liver and adjacent peritoneal surfaces, and occurs in as high as 14% of cases with pelvic inflammatory disease (PID).2,3 In the 1970’s, the syndrome was thought primarily attributable to Neisseria gonorrhoeae infection.4 However, later studies using modern assessments revealed the principal involvement of Chlamydia trachomatis infection in the pathogenesis.5 Although these organisms are regarded as the two major pathogens responsible for the syndrome,6,7 the mechanism by which they specifically cause inflammation in the liver is not fully understood.8,9 According to some reports, the organisms can disseminate to the liver hematogenously10 or lymphaticly.5 However, most studies support the hypothesis that the organisms spread intraperitoneally from genital tracts to the liver capsule.3,11 Since the organisms are preferentially absorbed by the liver capsule,12 they are not supposed to cause inflammation in the other intra-abdominal organs.5 Anatomically, however, because organs such as the appendix and cecum are closely located to the ends of the fallopian tubes, they could be affected depending on the severity of infection within the genital tract.13 Here, we describe a patient with Fitz-Hugh-Curtis syndrome complicated by appendicitis that was conservatively managed with antibiotic treatment alone. The overgrowth of the pathogens within the genital tract and their direct penetration into the appendix was thought to be responsible for the development of appendicitis.

Case Report

A 27-year-old woman came to our outpatient clinic because of a low grade fever and increased vaginal discharge that developed 2 weeks prior to her visit (Fig. 1). Over the previous few days, she had also noticed intermittent abdominal pain in the right upper quadrant. Her menstrual periods were usually regular in interval and she rarely suffered from menorrhagia. She had a single sex partner and her sexual history was otherwise unremarkable. She had no apparent past medical history of sexually transmitted diseases. On physical examination, the patient appeared exhausted. Her body temperature was 37.3 °C, blood pressure was 110/73 mmHg, and pulse rate was 86 beats/min. She weighed 60 kg and was 163 cm tall. Her eyes were slightly inflamed and the oropharynx was swollen and red. She had right upper abdominal tenderness without rebound pain or guarding, but costovertebral angle tenderness was absent on both sides. Her bowel sounds were normal, and the liver and spleen were not palpable. Laboratory data showed an increased peripheral white blood cell count (10,000/μL) and a slightly elevated C-reactive protein level (0.42 mg/dL). Liver enzymes, such as alanine aminotransferase (ALT) and aspartate aminotransferase (AST), were both slightly elevated (ALT58IU/l, AST 44 IU/l), although other routine laboratory investigations, including blood glucose level, electrolytes, and renal function tests, were normal. Although ultrasound investigation of the uterus and adnexa was unremarkable, an abdominal computed tomography (CT) scan showed hepatomegaly with a hepatic capsular enhancement in the arterial phase (Fig. 2), indicating perihepatitis. However, it did not show any findings of other intra-abdominal infections, such as cholecystitis, appendicitis, or pyelonephritis. Based on her clinical manifestations and typical CT findings (Fig. 2),14 a diagnosis of Fitz-Hugh-Curtis syndrome was made. Since C. trachomatis is the pathogen most often responsible for the syndrome,7 a single dose oral administration of azithromycin (1.0 g) was empirically initiated immediately after the diagnosis, followed by oral administration of levofloxacin (500 mg/day) for the next 7 days (Fig. 1). Although the cervical bacterial culture and serologic tests for C. trachomatis later proved negative, treatment with the antibiotics decreased her vaginal discharge and ameliorated the right upper abdominal pain, together with improvement of the systemic inflammatory findings (Fig. 1).

Figure 1

Clinical course and the changes in white blood cell count in the peripheral blood (WBC), C-reactive protein level (CRP).

Notes: Although treatment with azithromycin (AZM) followed by levofloxacin (LVFX) decreased the vaginal discharge and improved the systemic inflammatory findings, the low grade fever persisted as did the right lower abdominal pain. However, treatment with ceftriaxone (CTRX), followed by cefditoren pivoxil (CDTR-PI) completely resolved the symptoms, and there were no further signs of recurrence.

Abbreviations: AZM, azithromycin; LVFX, levofloxacin; CTRX, ceftriaxone; CDTR-PI, cefditoren pivoxil; RUQ, right upper quadrant; RLQ, right lower quadrant; WBC, white blood cell count in the peripheral blood; CRP, C-reactive protein.

Figure 2

Computed tomography (CT) scan image on initial presentation.

Note: A computed tomography (CT) image showing hepatomegaly with a hepatic capsular enhancement in the arterial phase (white arrows).

The low grade fever, however, persisted and abdominal pain additionally developed in the right lower quadrant. Since an abdominal CT scan demonstrated an enlarged appendix with wall thickening (Fig. 3), she was additionally diagnosed as appendicitis. Because there were no signs of systemic or peritoneal inflammation, and because the CT scan did not indicate the presence of serious complications, such as purulent ascites, she was not surgically treated. Alternatively, we conservatively managed the patient with intravenous administration of ceftriaxone (1.0 g/day), followed by oral administration of cefditoren pivoxil (300 mg/day) (Fig. 1). After an additional 7 days of treatment with these antibiotics (total 14 days), her symptoms, such as a low grade fever and right lower abdominal pain, had completely disappeared. Afterwards, no recurrence of the symptoms or signs was noted, indicating complete remission of the disease.

Figure 3

CT scan image after 7 days of levofloxacin treatment.

Note: A CT image showing an enlarged appendix with wall thickening (white arrow).

Discussion

In the present case, the cervical culture results were negative for both C. trachomatis and N. gonorrhoeae, although they are the two major pathogens responsible for Fitz-Hugh-Curtis syndrome.6,7 According to previous studies, diverse microorganisms, including anaerobic bacteria and facultative gram negative rods, also cause pelvic inflammatory disease (PID).15 Recently, Woo et al further demonstrated that the organisms other than C. trachomatis and N. gonorrhoeae, such as Trichomonas vaginalis, Ureaplasma urealyticum and Mycoplasma hominis, can cause Fitz-Hugh-Curtis syndrome.16 In our case, however, since the patient’s symptoms were consistent with those typically caused by C. trachomatis or N. gonorrhoeae,17 and since the symptoms responded well to the antibiotic treatment, either or both of the organisms were thought to be responsible for the development of Fitz-Hugh-Curtis syndrome.18 In this context, the negative culture results in our patient may be due to the partial treatment effect by the antibiotics, which were empirically started before sampling the specimen for the culture.

In our case, the diagnosis of appendicitis was additionally made based on the radiological evidence of an enlarged appendix with wall thickening (Fig. 3), which had not been noted in the first abdominal CT scan. Appendicitis is usually caused by the intraluminal overgrowth of enterobacteria, such as Escherichia coli, Peptostreptococcus and Bacteroides fragilis.19,20 However, according to previous reports, the disease can also be caused by exogenous infections with C. trachomatis and N. gonorrhoeae.13,21 In the development of perihepatitis in Fitz-Hugh-Curtis syndrome, these organisms are known to travel intraperitoneally from the genital tract via the paracolic gutters to the liver capsule.3,11 Since the organisms are more preferentially absorbed by the liver capsule than any other intra-abdominal structures,12 peri-hepatitis is considered to be the most frequent intra-abdominal complication of genital tract infections.2,3 In contrast, however, the organisms do not usually affect other intra-abdominal organs,22 although they are located more closely to the genital tract than the liver is. In our case, despite the lack of radiological evidence characteristic to PID, the patient had been suffering from a genital tract infection for the previous 2 weeks, which was sufficient time for the organisms to overgrow within the tract. Since overgrown bacteria can cause inflammation locally in the surrounding organs and increase the fragility of their peritoneal walls,23 it is not surprising that they could penetrate into the adjacent appendix and thus caused appendicitis. Previously, Marbet et al reported two cases of severe peritonitis caused by C. trachomatis in the absence of Fitz-Hugh-Curtis syndrome.24 The cases demonstrated our hypothesis that the organisms can directly extend into the peritoneal cavity from the genital tracts.

Previous studies have demonstrated through in vitro experiments that infections with C. trachomatis and N. gonorrhoeae stimulate the activity of lymphocytes.25,26 Therefore, the involvement of an increased immunological reaction has often been proposed in the pathogenesis of Fitz-Hugh-Curtis syndrome.27 In our case, such increased immunity was also likely to contribute to the pathogenesis of appendicitis, since lymphoid follicular hyperplasia in the appendix can be the main cause of luminal obstruction,28 which might have developed later during treatment with levofloxacin. According to some basic studies, the activity of lymphocytes is closely associated with delayed rectifier K+-channels (Kv1.3) expressed in their plasma membranes.29,30 Recently, we have demonstrated in two patients that non-steroidal anti-inflammatory drugs (NSAIDs), which inhibit the Kv1.3-channels in lymphocytes,31 actually suppressed the hyper-immune response triggered by the virus.32 In the present case, although the patient had complicated with appendicitis, she could be successfully treated with antibiotics alone. However, considering such an immunological involvement in the pathogenesis, the use of selective Kv1.3-channel blockers or NSAIDs could enhance the therapeutic efficacy of the antibiotics, particularly in cases with greater than usual systemic inflammation.

Conclusion

In summary, this is the first report of a patient with Fitz-Hugh-Curtis syndrome complicated by appendicitis. It was conservatively managed with antibiotic treatment alone. Overgrowth of the pathogens within the genital tracts and direct penetration into the appendix was thought to be responsible for the development of appendicitis.