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

Occurrence of gonococcal perihepatitis after therapeutic abortion.

A case history of an 18-year-old woman admitted 2 days after undergoing a therapeutic abortion with acute abdominal pain is reported. The patient deni...
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