Een gynaecologische oorzaak van bovenbuikpijn

Het Fitz-Hugh-Curtis-syndroom
Klinische les
03-05-2016
Eva A.M. Hesius, Bram Kok en E.J.M. (Vera) Mattijssen

A gynaecological cause of upper abdominal pain: Fitz-Hugh-Curtis syndrome

This supplementary information is presented as submitted by the corresponding author. It has not been copy-edited by NTvG.

Introduction

A 19-year old woman was admitted to our hospital because of unexplained pain in the upper abdomen. Due to an incomplete differential diagnosis we initially overlooked the possibility of a gynaecological disease to explain her symptoms. To increase awareness of the importance of a complete differential diagnosis we present this clinical lesson about the Fitz Hugh Curtis syndrome.

Case description

The patient was a 19-year old woman who complained about fever and pain in the right upper abdomen that worsened on inspiration. She had been treated with antibiotics for a urinary tract infection since 3 days. Her medical history noted an unplanned yet uncomplicated pregnancy. She had given birth to a healthy child 7 weeks before.

On examination we found a sub febrile temperature and right loin pain. Laboratory results showed a raised CRP (118 mmol/L). The urinalysis and X-ray of the chest showed normal results.

Our differential diagnosis included pyelonephritis, pulmonary embolism, pneumonia causing pleural pain, a gastro intestinal cause (cholangitis, cholecystitis) and subphrenic abscess.

The patient was treated with cefuroxime intravenously after taking blood and urinary cultures. Pulmonary embolism was excluded by means of a CT angiography. An ultrasound of the abdomen showed normal liver and kidneys, and an enlarged right ovary. The consulted gynaecologist attributed the enlargement most likely to a cyst not explaining the illness of the patient. A vaginal culture was taken just in case.

However, after a few days the vaginal PCR on Chlamydia was positive. This made us aware of the possibility of the Fitz Hugh Curtis syndrome. This syndrome is a complication of a pelvic inflammatory disease caused by a bacterial infection with most often either Gonococcal or Chlamydia species. Untreated, this syndrome might result in infertility or subfertility due to adhesions inside the ovary tubes.

The patient was treated with doxycycline and recovered quickly. Her baby did not have a conjunctivitis neonatorum as can be seen with Chlamydia infection of the newborn.

Conclusion

As a result of ignoring a possible gynaecological cause in this patient, the time to diagnosis and treatment was delayed. A Fitz Hugh Curtis syndrome should have been suspected because the patient was young and sexually active and should have prompted us to perform an SOA screening earlier. Left untreated this disease might result in infertility and complication in the newborn.

This report increased our awareness on the importance of a broad differential diagnosis. We all must keep an open mind every time a patient is admitted to prevent ourselves from narrowing our clinical views.