A 29 y.o. woman presents with RUQ pain and a WBC of 12.
What do you notice on her CT?
Our patient had Fitzhugh-Curtis syndrome which is subcapsular inflammation of the liver from PID. The disease was named after the two physicians , Thomas Fitz-Hugh and Arthur Curtis who first reported the condition in 1934 and 1930. Because of negative subdiaphragmatic pressure infected material or malignant cells are drawn toward the subcapsular area causing the infiltrate seen on CT.
another example of subcapsular inflammation of the liver and an ovarian cyst with PID
DISEASES AFFECTING THE LIVER CAPSULE
1. Infectious and inflammatory- Fitz-Hugh-Curtis
2. Parasitic diseases- amebiasis, hydatid disease, schistosomiasis. Parasites migrate through the peritoneum and perforate the liver; causing leions at the subcapsular region initially.
subcapsular inflammation leading to calcification in schistosomiasis
1. Infiltrative diseases- lymphoma can infiltrate the subcapsular region of the liver cemtrally.
2. Malignancy- can affect the subcapsular regions of the liver.
3. Extramedullary hematopoiesis – can occur in the subcapsular liver area when bone marrow is inadequate for cell production as in myelofibrosis and leukemia.
extramedullary hematopoesis along the portal subcapsular liver
This brings us to the diagnosis of PID.
5% of women report being treated for PID in their lifetime. There are significant health disparities associated with PID with black women having 2-3 times higher rates.
While laboratory tests may help confirm the diagnosis NAAT negative results do not exclude the diagnosis. (We do not test for an important cause: Mycoplasma genitalium ) GC is frequently negative in later stages of PID. An ultrasound or CT without findings of PID does not exclude the diagnosis.and fewer than 50% of women with acute PID have an elevated WBC.
PID is a CLINICAL DIAGNOSIS. It requires a pelvic exam. With the availability of urine tests for gonorrhea and chlamydia; it has been noted that fewer pelvic exams are being performed in women with lower abdominal pain. This enables a misdiagnosis of UTI in patients with PID.
The risk of undiagnosed PID is infertility in 10-50% of females, chronic pelvic pain in 25% and ectopic pregnancy in 15-60%
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