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Culture-proved Fitz-Hugh-Curtis syndrome
106
Communications
in brief
Culture-proved Fitz-Hugh-Curtis syndrome STEPHEN
J.
MICHAEL
G.
KORNFELD,
formed. However,
No blood or peritoneal fluid was obtained initially. lavage with 200 ml of nonbacteriostatic sterile saline solution yielded the return of a yellow, cloudy Huid. The ccl1 cnunl of the fluid revealed no red cells and 1,230 white (ells per milliliter with a differential cell count of 100% pol\mor-
M.D.
WORTHINGTON.
phonuclear
M.D.
Department of infectious Disease, Tufts-New England Medical Center, Boston, Massachusetts, and Department of Medicine, St. Elizabeth’s Hospital, Brighton, Massachusetts AN CNCOMMON SEQUELA ofgenitourinary gonococcal infections which is seen almost exclusively in women is the Fitz-Hugh-Curtis syndrome. Although the syndrome was first described in 1919, and many cases have been reported since, the proposed etiologic agent, Neisseriu gonorrhoeae, has never been isolated in cultures from the peritoneal cavity.’ This lack of culture-proved cases has led some investigators’ to speculate that other organisms may be partly or wholly responsible for this syndrome, and others’ to doubt that the gonococcus directly traverses the peritoneal cavity en route to the liver. In this article, we present the first report of a patient with the Fitz-Hugh-Curtis syndrome in whom N. gonorrhoeae was isolated from both endocervical and peritoneal cultures, and we also emphasize that this syndrome may occur after abdominal trauma and mimic an acute surgical emergency.
A N-year-old woman was admitted to St. Elizabeth’s Hospital with a l-day history of severe pain in the right upper quadrant of the abdomen, associated with pleuritic pain in the right lower side of the chest and in the right shoulder. subsequent to abdominal trauma that was secondary to physical abuse. On admission, the patient was in acute distress because of abdominal pain. The physical examination disclosed a blood pressure of 90/70 mm Hg without postural changes, a pulse rate of 120, and a temperature of 101.2” F orally. The chest and cardiovascular systems exhibited no abnormalities. Examination of the abdomen revealed a lack of bowel sounds, a diffusely tender abdomen with exquisite tenderness in the right upper quadrant associated with localized voluntary guarding, and rebound tenderness in this area. Findings on examination of the pelvis included a mildly tender cervix with a white discharge at the cervical OS. Initial laboratory data showed a hematocrit of 29% and white blood cell count of 6,000. Electrolytes, blood urea nitrogen, and amylase were normal. Liver function tests exhibited mild abnormalities with an alkaline phosphatasc of 238 IU per liter, a serum glutamic pyruvic transaminase of 34 IU per liter, and a serum glutamic oxaloacetic transaminase of 78 IU per liter. Roentgenograms of the chest, ribs, and abdomen were unremarkable. Because of the clinical presentation of an acute condition in the abdomen, associated with a recent history of abdominal trauma and a low hematocrit, an abdominal tap was perReprint requests: ment of Medicine, sachusetts 02135.
Michael G. Worthington, St. Elizabeth’s Hospital.
0002-9378/81/010106+02$00.20/0
M.D., DepartBrighton, Mas-
1981 The C. V. Mosby
Co.
la-
Clearly, this patient was auttering Irotn tllc FitcHugh-Curtis syndrome. The symptom complex. corlsisting of the acute onset 01’ severe pleuritic- pain in the right upper quadrant of the abdomen. with radiation to the right shoulder and around to the back. in a patient with genitourinary gonorrhea, was svnom II~OIIS with the classic clinical descriptions of the tlisease. Of interest is the fact that this case occurred after abdominal trauma and mimicked an acute surgical condition in the abdomen. Since the original description of the FitL-Hugh-Curtis syndrome, investigators have pondered the route of. spread of the gonococcus from the genitourinar!, s\ stem to Glisson’s capsule. Initially, the mechanism of spread was thought to be a direct one from a genitourinary focus through the fallopian tubes and via the peritoneal cavity to the liver. However, despite a multitude of case reports which have documented the existence of the clinical syndrome and its association with genitourinary
gonococcal
intections.
the
gonococcus
has never been retrieved from peritoneal cultures.’ In light of this. and the fact that two cases ofperihepatitis have been documented in male patients,’ mechanisms of spread to the liver capsule other than b!. direct extension from the fallopian tubes have been h\pothesized.’ Similarly, other invcsrigators have presented evidence which suggests that (Jhlamydia trachomatb ma) be involved in the pathogenesis ofmany, and perhaps most, cases of this syndrome. In summary, this case clearly demonsrrates that the Fitz-Hugh-Curtis syndrome may be caused solely by an ascending gonococcal infection in female patients, and it substantiates earlier theories that the gonococcus is the etiologic agent in this syndrome and that it reaches the liver capsule by direct spread across the peritoneal cavity.
Lavage
of the
peritoneal
cavity
with
saline
solu-
tion, as performed in this patient, ma) increase the yield of positive peritoneal cultures in cases of this syndrome, particularly if the material obtained is cultivated
0
leukocytes. Cervical discharge and peritoneal
vage were cultured on chocolate agar. sheep blood agal, EMB agar, and m thloglycollate broth. With evidence of peritoniris, therapy with clindamycin and gentamicin was begun On the second hospital day, reports on the cultures indicated that both peritoneal and endocervical cultures were gro\c ing .\. gonorrhorae, confirmed by cysteine rryptic agar rltgars. (:ultures of urine and blood were negative. No than-gc in rhr patient’s clinical status had occurred since the time of admission. Intravenous ampicillin was added to the patienr’\ r-cgimen. The patient showed remarkable improvement and uar tree of symptoms after 6 davs of ampicillin rhea ,tp.‘.
on appropriate
media.
Obviously.
if’ unnecessary
Communications in brief
surgical procedures are to be avoided, it is essential that physicians be aware of the ability of this syndrome to mimic at1 acute condition in the abdomen, particularly after- trauma.
Table I. Comparison of daily fetal movement (DFMR) and the nonstress test (NST)
.4dequate
Reactive (224) J. W., Wang,
Ch/r~,myrliatrachomnti\ 2.
S. P., Munzinger,
J., et al.:
as possible cause of peritonitis
perih&patitis in young women. Francis, T. I.. and Osoba, (k&-Hugh Curtis syndrome) Vener. Dis. 48:187. 1972.
Br. Med.
J. 1:1022,
and
a male
patient,
Br.
J.
Correlation of daily fetal movements and the nonstress test as tools for assessment of fetal welfare JAMES A. O’LEARY, M.D. GEORGE (:. ANDRINOPOULOS,
M.D.
Drpartm~nt qf Obstetrics and Gynerolo~, .4lnbamrr, Mobile, .4labnmn
Uniwrsity
of South
I‘HE ASSOCIATION of acceleration of the fetal heart rate with fetal movements (the nonstress test) and the presence of daily fetal movements have been shown to be helpful in assessing antenatal fetal welfare.‘, * Both tests have their greatest accuracy in predicting a healthy fetus. The limitations are their reduced accuracy in identifying a compromised fetus. This prospective study was designed to evaluate the relationship of two fetal biophysical variables, the nonstress test (NST) and the daily fetal movement record (DFMR), and to compare the accuracy of combining rhe two in predicting antenatal fetal welfare and not intrapartum or postpartum complications. .4 f-year prospective study of 237 high-risk prenatal patients was performed. All patients volunteered for the study after a careful explanation of the protocol. The women were provided a form on which to record, three times each day for 30 minutes, daily fetal movements. They were instructed to lie down in a comfortable position fcrr three uninterrupted periods. Movements were recorded in the morning, afternoon, and evening. ‘The results were collected each week, and a new form was provided. Reduced fetal movements were defined as less than 0 to 5 movements per 30 minutes frrr each of the three periods (a modification of the Sadovsky-Yaffe method).’ If there were reduced fetal movements, the patients were instructed to notify a member of the perinatal team.
Reprint requests: James A. O’Leary, M.D.. State University of New York at Buffalo, Maternity Hospital, 140 Hodge Ave., Buffalo,
New
York
0002-9378/X1/010107+02$00.20/0
*No
statistical
1981
The
C. V. Mosby
Co.
41 (95.5%) 2 (4..5%)* 43 (18.1%)
significance.
A nonstress test was performed* at each visit. Testing was usually begun at 32 weeks and repeated at weekly intervals unless changes in the status of the mother and the fetus dictated that the pregnancy should be interrupted. To be included in the present analysis, all patients had to have had their last tracing within 1 week of delivery. A reactive NST was defined according to Rochard and associates.‘. The number of DFMRs varied from as few as 7 days to as many as 35 days. The 237 patients had 44 1 NSTs. For purposes of analysis. only the last NST and DFMR performed within 7 days of delivery were considered. Since antenatal fetal surveillance techniques do not necessarily predict intrapartum problems, these were not considered in a comparison of the two modalities. There were no antenatal fetal losses. Overall, fetal movements were adequate in 8 1.9% of observations, and the NST was reactive in 94.5% of these patients. Fetal movements were adequate in 94.3% of the women with a reactive NST and were adequate in 95.5% with a nonreactive NST. Conversely, fetal movements were reduced in 5.7% of the patients with a reactive NST and were reduced in 4.5% of the patients with a nonreactive NST (Table I). Statistical analysis of these results showed that the presence of daily fetal movements was not very sensitive nor specific for the detection of antenatal fetal jeopardy when the two groups were compared. Statistical analysis indicated that the NST and DFMR were not related (xf = 0.01; p > 0.90). The frequency of a nonreactive NST is essentially the same whether fetal movements are adequate or reduced. Statistical significance was examined by means of Fisher’s exact probability test. The observations were well below levels of significance. Thus, the accuracy of the DFMR in predicting uteroplacental insufficiency is negligible. In this prospective study, we have measured two variables in the same patient and noticed remarkable dissimilarities between the two in the predictive accuracy of the DFMR. Thus, it is apparent that the combination of these two modalities offers very little help to the clinician. *Brattle Instrument
14222. 0
183 (94.3%) 11 (5.7%)” 194 (81.9%)
(13)
1978.
A. 0.: Gonococcal hepatitis in
Nonreactive
Reduced I
I
1. Muller-Schoop.
record
DFMR NST
REFERENCES
107
Corporation.
Communications
in brief
Culture-proved Fitz-Hugh-Curtis syndrome STEPHEN
J.
MICHAEL
G.
KORNFELD,
formed. However,
No blood or peritoneal fluid was obtained initially. lavage with 200 ml of nonbacteriostatic sterile saline solution yielded the return of a yellow, cloudy Huid. The ccl1 cnunl of the fluid revealed no red cells and 1,230 white (ells per milliliter with a differential cell count of 100% pol\mor-
M.D.
WORTHINGTON.
phonuclear
M.D.
Department of infectious Disease, Tufts-New England Medical Center, Boston, Massachusetts, and Department of Medicine, St. Elizabeth’s Hospital, Brighton, Massachusetts AN CNCOMMON SEQUELA ofgenitourinary gonococcal infections which is seen almost exclusively in women is the Fitz-Hugh-Curtis syndrome. Although the syndrome was first described in 1919, and many cases have been reported since, the proposed etiologic agent, Neisseriu gonorrhoeae, has never been isolated in cultures from the peritoneal cavity.’ This lack of culture-proved cases has led some investigators’ to speculate that other organisms may be partly or wholly responsible for this syndrome, and others’ to doubt that the gonococcus directly traverses the peritoneal cavity en route to the liver. In this article, we present the first report of a patient with the Fitz-Hugh-Curtis syndrome in whom N. gonorrhoeae was isolated from both endocervical and peritoneal cultures, and we also emphasize that this syndrome may occur after abdominal trauma and mimic an acute surgical emergency.
A N-year-old woman was admitted to St. Elizabeth’s Hospital with a l-day history of severe pain in the right upper quadrant of the abdomen, associated with pleuritic pain in the right lower side of the chest and in the right shoulder. subsequent to abdominal trauma that was secondary to physical abuse. On admission, the patient was in acute distress because of abdominal pain. The physical examination disclosed a blood pressure of 90/70 mm Hg without postural changes, a pulse rate of 120, and a temperature of 101.2” F orally. The chest and cardiovascular systems exhibited no abnormalities. Examination of the abdomen revealed a lack of bowel sounds, a diffusely tender abdomen with exquisite tenderness in the right upper quadrant associated with localized voluntary guarding, and rebound tenderness in this area. Findings on examination of the pelvis included a mildly tender cervix with a white discharge at the cervical OS. Initial laboratory data showed a hematocrit of 29% and white blood cell count of 6,000. Electrolytes, blood urea nitrogen, and amylase were normal. Liver function tests exhibited mild abnormalities with an alkaline phosphatasc of 238 IU per liter, a serum glutamic pyruvic transaminase of 34 IU per liter, and a serum glutamic oxaloacetic transaminase of 78 IU per liter. Roentgenograms of the chest, ribs, and abdomen were unremarkable. Because of the clinical presentation of an acute condition in the abdomen, associated with a recent history of abdominal trauma and a low hematocrit, an abdominal tap was perReprint requests: ment of Medicine, sachusetts 02135.
Michael G. Worthington, St. Elizabeth’s Hospital.
0002-9378/81/010106+02$00.20/0
M.D., DepartBrighton, Mas-
1981 The C. V. Mosby
Co.
la-
Clearly, this patient was auttering Irotn tllc FitcHugh-Curtis syndrome. The symptom complex. corlsisting of the acute onset 01’ severe pleuritic- pain in the right upper quadrant of the abdomen. with radiation to the right shoulder and around to the back. in a patient with genitourinary gonorrhea, was svnom II~OIIS with the classic clinical descriptions of the tlisease. Of interest is the fact that this case occurred after abdominal trauma and mimicked an acute surgical condition in the abdomen. Since the original description of the FitL-Hugh-Curtis syndrome, investigators have pondered the route of. spread of the gonococcus from the genitourinar!, s\ stem to Glisson’s capsule. Initially, the mechanism of spread was thought to be a direct one from a genitourinary focus through the fallopian tubes and via the peritoneal cavity to the liver. However, despite a multitude of case reports which have documented the existence of the clinical syndrome and its association with genitourinary
gonococcal
intections.
the
gonococcus
has never been retrieved from peritoneal cultures.’ In light of this. and the fact that two cases ofperihepatitis have been documented in male patients,’ mechanisms of spread to the liver capsule other than b!. direct extension from the fallopian tubes have been h\pothesized.’ Similarly, other invcsrigators have presented evidence which suggests that (Jhlamydia trachomatb ma) be involved in the pathogenesis ofmany, and perhaps most, cases of this syndrome. In summary, this case clearly demonsrrates that the Fitz-Hugh-Curtis syndrome may be caused solely by an ascending gonococcal infection in female patients, and it substantiates earlier theories that the gonococcus is the etiologic agent in this syndrome and that it reaches the liver capsule by direct spread across the peritoneal cavity.
Lavage
of the
peritoneal
cavity
with
saline
solu-
tion, as performed in this patient, ma) increase the yield of positive peritoneal cultures in cases of this syndrome, particularly if the material obtained is cultivated
0
leukocytes. Cervical discharge and peritoneal
vage were cultured on chocolate agar. sheep blood agal, EMB agar, and m thloglycollate broth. With evidence of peritoniris, therapy with clindamycin and gentamicin was begun On the second hospital day, reports on the cultures indicated that both peritoneal and endocervical cultures were gro\c ing .\. gonorrhorae, confirmed by cysteine rryptic agar rltgars. (:ultures of urine and blood were negative. No than-gc in rhr patient’s clinical status had occurred since the time of admission. Intravenous ampicillin was added to the patienr’\ r-cgimen. The patient showed remarkable improvement and uar tree of symptoms after 6 davs of ampicillin rhea ,tp.‘.
on appropriate
media.
Obviously.
if’ unnecessary
Communications in brief
surgical procedures are to be avoided, it is essential that physicians be aware of the ability of this syndrome to mimic at1 acute condition in the abdomen, particularly after- trauma.
Table I. Comparison of daily fetal movement (DFMR) and the nonstress test (NST)
.4dequate
Reactive (224) J. W., Wang,
Ch/r~,myrliatrachomnti\ 2.
S. P., Munzinger,
J., et al.:
as possible cause of peritonitis
perih&patitis in young women. Francis, T. I.. and Osoba, (k&-Hugh Curtis syndrome) Vener. Dis. 48:187. 1972.
Br. Med.
J. 1:1022,
and
a male
patient,
Br.
J.
Correlation of daily fetal movements and the nonstress test as tools for assessment of fetal welfare JAMES A. O’LEARY, M.D. GEORGE (:. ANDRINOPOULOS,
M.D.
Drpartm~nt qf Obstetrics and Gynerolo~, .4lnbamrr, Mobile, .4labnmn
Uniwrsity
of South
I‘HE ASSOCIATION of acceleration of the fetal heart rate with fetal movements (the nonstress test) and the presence of daily fetal movements have been shown to be helpful in assessing antenatal fetal welfare.‘, * Both tests have their greatest accuracy in predicting a healthy fetus. The limitations are their reduced accuracy in identifying a compromised fetus. This prospective study was designed to evaluate the relationship of two fetal biophysical variables, the nonstress test (NST) and the daily fetal movement record (DFMR), and to compare the accuracy of combining rhe two in predicting antenatal fetal welfare and not intrapartum or postpartum complications. .4 f-year prospective study of 237 high-risk prenatal patients was performed. All patients volunteered for the study after a careful explanation of the protocol. The women were provided a form on which to record, three times each day for 30 minutes, daily fetal movements. They were instructed to lie down in a comfortable position fcrr three uninterrupted periods. Movements were recorded in the morning, afternoon, and evening. ‘The results were collected each week, and a new form was provided. Reduced fetal movements were defined as less than 0 to 5 movements per 30 minutes frrr each of the three periods (a modification of the Sadovsky-Yaffe method).’ If there were reduced fetal movements, the patients were instructed to notify a member of the perinatal team.
Reprint requests: James A. O’Leary, M.D.. State University of New York at Buffalo, Maternity Hospital, 140 Hodge Ave., Buffalo,
New
York
0002-9378/X1/010107+02$00.20/0
*No
statistical
1981
The
C. V. Mosby
Co.
41 (95.5%) 2 (4..5%)* 43 (18.1%)
significance.
A nonstress test was performed* at each visit. Testing was usually begun at 32 weeks and repeated at weekly intervals unless changes in the status of the mother and the fetus dictated that the pregnancy should be interrupted. To be included in the present analysis, all patients had to have had their last tracing within 1 week of delivery. A reactive NST was defined according to Rochard and associates.‘. The number of DFMRs varied from as few as 7 days to as many as 35 days. The 237 patients had 44 1 NSTs. For purposes of analysis. only the last NST and DFMR performed within 7 days of delivery were considered. Since antenatal fetal surveillance techniques do not necessarily predict intrapartum problems, these were not considered in a comparison of the two modalities. There were no antenatal fetal losses. Overall, fetal movements were adequate in 8 1.9% of observations, and the NST was reactive in 94.5% of these patients. Fetal movements were adequate in 94.3% of the women with a reactive NST and were adequate in 95.5% with a nonreactive NST. Conversely, fetal movements were reduced in 5.7% of the patients with a reactive NST and were reduced in 4.5% of the patients with a nonreactive NST (Table I). Statistical analysis of these results showed that the presence of daily fetal movements was not very sensitive nor specific for the detection of antenatal fetal jeopardy when the two groups were compared. Statistical analysis indicated that the NST and DFMR were not related (xf = 0.01; p > 0.90). The frequency of a nonreactive NST is essentially the same whether fetal movements are adequate or reduced. Statistical significance was examined by means of Fisher’s exact probability test. The observations were well below levels of significance. Thus, the accuracy of the DFMR in predicting uteroplacental insufficiency is negligible. In this prospective study, we have measured two variables in the same patient and noticed remarkable dissimilarities between the two in the predictive accuracy of the DFMR. Thus, it is apparent that the combination of these two modalities offers very little help to the clinician. *Brattle Instrument
14222. 0
183 (94.3%) 11 (5.7%)” 194 (81.9%)
(13)
1978.
A. 0.: Gonococcal hepatitis in
Nonreactive
Reduced I
I
1. Muller-Schoop.
record
DFMR NST
REFERENCES
107
Corporation.