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Title : 40 year-old female with fever and right flank pain
Date : June 17, 2010
Contributed by
Ji-Young Rhee, MD
Division of Infectious Diseases, Dankook University, Korea
Patient History
Age/Sex 40 yr old / Female
Chief complaint Fever and right flank pain
Present illness 40 year-old female visited the local clinic for fever and right flank pain for one week. Blood laboratory tests for liver function test, complete blood count, and other chemistry were normal. Urine analysis was normal. Upper endoscopy examination and thyroid function test were normal. However, her symptoms were persisted and somewhat aggravated. She was transferred to tertiary hospital for diagnosis and treatment.
Past medical history She worked as a bar hostess and had no travel history
Physical examination On physical examination, there was severe direct tenderness on right upper quadrant.
Radiologic findings
Hospital course All study excluded the organic causes of hepatobiliary diseases resulting in right upper quadrant pain. She had no vaginal discharge and lower abdominal pain. However, we consult to the gynecologic department to exam the cervix to rule out other cause of right upper quadrant pain. On OBGY exam, she had salphigitis and result of polymerase chain reaction to cervix secretion revealed the infection of Chlamydia trachomatis.

Question - ID Case of the Week ( June 17, 2010 )
What is the most likely diagnosis for RUQ pain ?
Correct Answer
Fitz-Hugh-Curtis syndrome
Fitz-Hugh-Curtis syndrome is a rare complication of pelvic inflammatory disease (PID) named after the two physicians, Fitz-Hugh and Curtis who first reported this condition in 1934 and 1930 respectively. It involves liver capsule inflammation. Fitz-Hugh-Curtis syndrome occurs almost exclusively in women. It is usually caused by gonorrhoea (acute gonococcal perihepatitis) or chlamydia bacteria, which cause a thinning of cervical mucus and allow bacteria from the vagina into the uterus and oviducts, causing infection and inflammation. Occasionally, this inflammation can cause scar tissue to form on Glisson's capsule, a thin layer of connective tissue surrounding the liver. The symptoms are an acute onset, upper right-quadrant abdominal pain and tenderness aggravated by breathing, coughing or movement, and referred to the right shoulder following an episode of PID. Laparoscopy may reveal "violin string" adhesions. The diagnosis is usually made clinically by eliminating other causes of right upper quadrant pain and isolating the pathogen. This can be difficult if salpingitis is absent. Treatment consists of antibiotics directed against N gonorrhoeae and C trachomatis; mechanical lysis of adhesions can be performed laparoscopically if conservative treatment fails.

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