Occurrence of gonococcal perihepatitis after therapeutic abortion

The patient's boyfriend was examined immediately. He had had a gonococcal infection 1 year earlier, for which he had received treatment. To the editor: We report the occurHe was now asymptomatic. However, rence of the Fitz-Hugh-Curtis synhe had had intercourse recently with drome in a young woman following two women other than our patient. therapeutic abortion. This case is Gram's staining of the urethral swab unusual in that both the patient and showed leukocytes and gram-negative her sexual partner had asymptomatic intracellular diplococci. Culture congenital infections. firmed the presence of N. gonorCase report rhoeae. An 18-year-old woman was admitOur patient was then given penited to hospital 2 days after having cillin intravenously. She responded undergone therapeutic abortion. The rapidly and was discharged after 5 evening before admission sharp right days. upper quadrant abdominal pain developed that radiated to the right Comments scapula and the back of the neck Acute perihepatitis is a rare comwith inspiration. She denied nausea, plication of genital gonorrhea that vomiting, a change in bowel habits, occurs almost exclusively in young fatty food intolerance, dysuria, uri- women. However, two instances have nary frequency and vaginal discharge. been reported in men.1'2 She had no past history of genitouriThe gonococcus may reach the nary infection, and she had had only perihepatic and subphrenic spaces by one sexual partner in the past 2 spreading intraperitoneally from the years. fallopian tubes, retroperitoneally via The patient appeared acutely ill the lymphatics, or through the blood. and had a temperature of 38.3 0C. The most likely route in our patient No abnormalities of the head, neck appears to have been via the fallopian or chest were detected. The abdomen tubes. We suspect that dissemination was not distended and bowel sounds occurred either during or after the were heard. There was marked right therapeutic abortion.3 upper quadrant abdominal tenderThe diagnosis of gonococcal penness, rebound and guarding, and a hepatitis was made clinically. Cholepositive Murphy's sign was elicited. cystitis did not seem likely as there Examination of the pelvis yielded was no past history of symptoms normal results. No skin lesions were suggestive of cholelithiasis, and an present. intravenous cholangiogram revealed The hemoglobin concentration was a normal gallbladder outline. How9.7 g/dL, the leukocyte count 9.9 x ever, the gallbladder may not vis109/L and the total bilirubin con- ualize during the acute stage of centration 29 .mol/L (1.7 mg/dL), gonococcal perihepatitis, and a norwith 7 .mol/L (0.4 mg/dL) conju- mal gallbladder may be seen after the gated. The serum transaminase and inflammation subsides.4 alkaline phosphatase concentrations It is of particular interest that both were normal. At the time of admis- our patient and her sexual partner sion a chest roentgenogram, an ab- had no symptoms of genitourinary dominal series of roentgenograms and infection. Although asymptomatic an intravenous cholangiogram showed gonococcal infections in women are no abnormalities. well known, recent reports also stress The possibility of gonococcal pen- the importance of asymptomatic gonhepatitis was considered. Gram's orrhea in men.5 Asymptomatic instaining of the endocervical secretions dividuals with gonorrhea may be revealed gram-negative intracellular highly susceptible to disseminated indiplococci, and Neisseria gonorrhoeae fection.6 was cultured. Cultures of blood and Since gonorrhea is currently epiof throat, urethral and rectal swabs demic, it is advisable to screen all revealed no pathogens. women at risk. The Fitz-Hugh-Curtis 408 CMA JOURNAL/FEBRUARY 17, 1979/VOL. 120

syndrome should be included in the differential diagnosis of right upper quadrant abdominal pain. DAVID PORTNOY, MD JOSEPH PORTNOY, MD, FRCP[C] JACK MENDELSON, MD, FRCP[C] Department of microbiology and infectious diseases Jewish General Hospital Montreal, PQ

References 1. KIMBALL MW, KNEE S: Gonococcal perihepatitis in a male. The Fitz-HughCurtis syndrome. N Engi J Med 282: 1082, 1970 2. FRANCIs TJ, OSOBA AG: Gonococcal hepatitis (Fitz-Hugh Curtis syndrome) in a male patient. Br J Vener Dis 48: 187, 1972 3. STEINBERG CR, BERKOWITZ RL, MERKATZ IR, et al: Fever and bacteremia associated with hypertonic saline abor-

tion. Obstet Gynecol 39: 673, 1972 4. STANLEY MM: Gonococcic peritonitis of upper part of abdomen in young women (phrenic reaction, or subcostal syndrome of Stajano; Fitz-Hugh-Curtis syndrome); report of cases of 3 patients treated successfully with penicillin and summary of literature. Arch intern Med 78: 1, 1946 5. PORTNOY J, MENDELSON J, CLECNER

B, et al: Asymptomatic gonorrhea in the male. Can Med Assoc J 110: 169, 1974 6. HOLMES KK, COUNTS GW, BEATY

HN: Disseminated gonococcal infection. Ann intern Med 74: 979, 1971

Gun control To the editor: The letter from James Hayes (Can Med Assoc 1 119: 1386, 1978) is welcome, for as coordinator of the working group on gun control he speaks with concern and authority. As a member of the solicitor general's office he is primarily concerned with the law, and it is in this area that physicians who are equally concerned have discovered problems. Mr. Hayes can take it for granted that all physicians deplore the proliferation and irresponsible use of firearms. The tragedies affect patients; therefore, physicians have first-hand experience with these tragedies, whereas the general public and even lawyers do not. One may legitimately ask why there appears to be such a conflict between the law and the medical profession, both of which are equally well intentioned. It is obvious that the amendment to the Criminal Code relative to gun control was made

(amoxicillin) AMOXIL' (amoxicillin)... A new generation broad-spectrum penicillin. INDICATIONS: Infections due to susceptible strains of the following microorganisms: Gram-negative-H. influenzae, E. coli, R mirabilis and N'gonorrhoeae. Gram-positive-Streptococci, D.pneumoniae and penicillin-sensitive staphylococci. In emergency cases where the causative organism is not yet identified, therapy may be initiated with AMOXIL on the basis of clinical jud g ment while awaiting the results of bacteriologic studies. DOSAGE AND ADMINISTRATION: Infections of the ear, nose and throat due to streptococci, pneumococci, and penicillin-sensitive staphylococci; infections *of the upper respiratory tract due to H. influenzae; in fections of the genitourinary tract due to E. coil, R mirabilis, and S. faecalis; infections of the skin and soft tissues due to streptococci, penicillin-sensitive staphylodocci and E. coli: Usual Dese: Adults-250 mg every 8 hours. Children-25 mg/kg/day in divided doses every 8 hours. This dosage should not exceed the recommended adult dosage. In severe infections or infections caused by less sensitive organisms: 500 mg every 8 hours for adults, and 50 mg/kg/day in divided doses every 8 hours for children. Infections of the lower respiratory tract due to streptococci, pneumococci, penicillin-sensitive staphylococci and H. influenzae: Usual Dese: Adults-500 mg every 8 hours. Children-SO mg/kg/day in divided doses every 8 hours. This dosage should not exceed the recommended adult dosage. Urethritis due to N. gonorrhoeae: 3 g as a single oral dose. Patients with gonorrhea, with a suspected lesion of syphilis, should have darkfield examinations before receiving AMOXIL, and monthly serologic tests for a minimum of four months. For chronic urinary tract infections, frequent bacteriologic and clinical appraisals are necessary. Smaller doses than those recommended above should net be used. Stubborn infections may require several weeks' treatment, sometimes at higher doses than recommended above. Concurrent bacteriologic sensitivity monitoring is recommended. Continued clinical and/or bacteriologic follow-up for several months after cessation of therapy may be required. Treatment should continue for 48 to 72 hours beyond the time patient becomes asymptomatic or bacterial eradication is obtained. At least 10 days' treatment is recommended for infections caused by beta-hemolytic streptococci to prevent acute rheumatic fever or glomerulonephritis. CONTRAINDICATION: In patients with a history of allergy to the .enicHiins or the cephalosporins- PRECAUriodic assessment of renal, hepatic, and hematopoietic function should be made during prolonged AMOXIL therapy. AMOXIL is excreted mostly by the kidney. The dosage administered to patients with renal impairment should be reduced proportionately to the degree of loss of renal function. The possibility of superinfections with mycotic or bacterial organisms should be kept in mind during therapy. If superinfections occur (usually involving Aero bacter, Pseudomonas or Candida), the drug should be discontinued and aproriatethera Instituted. ADVERSE REACIONS. As with other penicillins, presumably the most common untoward reactions will be related to sensitivity phenomena, similar to those observed with ampicillin. They are more likely to occur in individuals who have previously demonstrated hypersensitivity to penicillins and in those with a history of allergy, asthma, hay fever or urticaria. (See Product Monograph which is available on request).SUPPLI ED: AMOXIL-250 Capsules (250 mg amoxicillin) in bottles of 100 and 500. AMOXIL-500 Capsules (500 mg amoxicillin) in bottles of 100. AMOXIL-l2sSuspension(125mg amoxicillin per 5 ml) in bottles of 75, 100 and 150 ml. AMOXIL-250 Suspension (250 mg amoxicillin per 5 ml) in bottles of 75, 100 and 150 ml. AMOXIL Pediatric Drops (50mg amoxicillin per ml) in bottles of 15 ml. AYERST LABORATORIES

Division of Ayerst, McKenna & Harrison Limited Montreal, Canada Made In Canada by arrangement with Reg'd BEECHAM INC.

without consultation with the leaders of the medical profession. Unfortunately, the law therefore regards the problem entirely as a matter of legal enforcement. However, Mr. Hayes admits that the amendments are not a total answer, and states that physicians, psychiatrists and other citizens should play their part. As a psychiatrist I am very concerned about the increasing rate of suicide by firearms. In Canada approximately 1500 persons a year commit suicide by using firearms. This figure now exceeds the number of suicides committed by other methods. Since not less than 10% of suicides are associated with homicide, the problem is even greater. The irresponsible use of firearms by temporarily irresponsible people is more frequent than the use of firearms in the furtherance of crime, although I am not playing this side down. That the Canadian Medical Association and the Canadian Psychiatric Association were not consulted was a grave mistake and one that has probably prevented the law from being as effective as it might have been. Since this law does not compel physicians to provide information on their patients, gun control has a lower priority than infectious disease, handicapped drivers, colourblind signalmen and epileptic airtraffic controllers. The gun clubs in the United Kingdom exercise considerable responsibility for their members, and rightly so, for they do not wish them to kill each other or themselves. However, the gun clubs in Canada have not developed the facilities to exercise this supervision. If it were mandatory for them to do so and the facilities were then a condition for registration, an important advance would be made. Doctors could then advise depressed patients or their families to give weapons and ammunition to the gun clubs until the danger was over. This measure would not require action from law officials, and would therefore be more likely to gain the support of the public, the medical profession and the gun clubs. This measure, if effectively pursued, would make a tremendous impact on the problem.

The other measures in the amendments of the gun control law could then include the mandatory taking of responsibility by the physician, for it would be apparent that the law is sensible and likely to be effective. The very few instances where the physician must invoke the law would not be seen as futile as they now appear to be. I have found my discussions with Mr. Hayes and his colleagues most helpful; I am sure that formal talks between the leaders of the medical profession, the gun clubs and the government are the next step. A more satisfactory amendment is what is needed. M. SiM, MD (EDIN), FRCP (ED), FRC PSYCH, FRCP[C] Professor of psychiatry Faculty of medicine University of Ottawa Consultant psychiatrist Royal Ottawa and Ottawa General hospitals

Ottawa, Oat.

Breast feeding: shared experience between husband and wife To the editor: The La Leche League does allow fathers to attend meetings, contrary to Paul M. Gelpke's contention in his letter entitled "Rediscovery of breast feeding" (Can Med Assoc J 119: 1170, 1978). Whenever more than one group of the La Leche League meets locally, one of them may be for couples. In this instance women have the option of attending a meeting either for women only or for a mixed group. Our primary concern is the nursing mother. We recognize that in this culture some women are so inhibited that they find it difficult to touch their breasts to express milk when necessary, and they may feel more secure in the company of women, especially if they are breast feeding for the first time. Thus, for cultural reasons, when there is only one group meeting it is our policy to reserve it for women. Even then such groups frequently hold special meetings for fathers only or for couples. MARGARET BENNET-ALDER

Coordinating director

La Leche League in Canada 490 Briar Hill Ave. Toronto, Ont.

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