What is the recommended treatment for Gonococcal perihepatitis (Fitz-Hugh-Curtis syndrome)?

Treatment of Gonococcal Perihepatitis (Fitz-Hugh-Curtis Syndrome)

Treat gonococcal perihepatitis with ceftriaxone 1 g IM or IV every 24 hours for 24-48 hours until clinical improvement, then switch to oral therapy to complete at least 7 days total treatment, plus concurrent treatment for Chlamydia trachomatis. 1

Initial Parenteral Therapy

• Hospitalization is recommended for initial therapy, particularly for patients with uncertain diagnosis, compliance concerns, or complicated presentations 1, 2
• Start with ceftriaxone 1 g IM or IV every 24 hours as the first-line regimen 1, 2
• Continue parenteral therapy for 24-48 hours after clinical improvement begins before transitioning to oral therapy 1, 2

Alternative Parenteral Regimens (if ceftriaxone unavailable)

• Cefotaxime 1 g IV every 8 hours 1
• Ceftizoxime 1 g IV every 8 hours 1
• Spectinomycin 2 g IM every 12 hours (for β-lactam allergy) 1

Important caveat: Quinolones (ciprofloxacin, ofloxacin, levofloxacin) should NOT be used due to widespread resistance, despite being listed in older guidelines 1, 3

Transition to Oral Therapy

After 24-48 hours of clinical improvement with parenteral therapy, switch to one of the following oral regimens to complete at least 7 days total antimicrobial therapy: 1, 2

• Cefixime 400 mg orally twice daily (preferred oral option) 1, 2
• Ciprofloxacin 500 mg orally twice daily (only if local resistance patterns permit) 1
• Ofloxacin 400 mg orally twice daily (only if local resistance patterns permit) 1

Mandatory Concurrent Chlamydia Treatment

All patients with gonococcal perihepatitis must receive presumptive treatment for Chlamydia trachomatis unless appropriate testing definitively excludes coinfection: 1, 2, 4

• Azithromycin 1 g orally as a single dose (preferred) 1, 5, 4
• OR Doxycycline 100 mg orally twice daily for 7 days 1, 5, 4

The rationale is that Chlamydia trachomatis is a co-pathogen in Fitz-Hugh-Curtis syndrome and coinfection rates are 40-50% in gonococcal infections 5, 6

Clinical Context and Diagnosis

Gonococcal perihepatitis presents as severe right upper quadrant pain that is sharp, pleuritic, and most intense at the right lower rib margin, frequently mimicking acute cholecystitis or pleurisy 6, 7. The condition is a complication of disseminated gonococcal infection (DGI) that occasionally involves perihepatitis 1. While historically described primarily in women with pelvic inflammatory disease, it can occur in men as well 7.

Special Populations

Pregnancy

• Use ceftriaxone 1 g IM or IV every 24 hours (same as non-pregnant patients) 1, 4
• Never use quinolones or tetracyclines in pregnancy 1, 4
• For Chlamydia coverage, use azithromycin 1 g orally (doxycycline is contraindicated) 1, 5

Severe Cephalosporin Allergy

• Use spectinomycin 2 g IM every 12 hours for 24-48 hours, then transition to oral therapy if possible 1, 4

Partner Management

All sexual partners from the preceding 60 days must be evaluated and treated with the same dual therapy regimen for gonorrhea and chlamydia: 1, 2, 5

• Ceftriaxone 250-500 mg IM single dose PLUS azithromycin 1 g orally single dose 5
• Patients should avoid sexual intercourse until therapy is completed and both patient and partners are asymptomatic 1, 5

Monitoring and Follow-Up

• Examine patients for clinical evidence of endocarditis and meningitis at presentation, as these require prolonged therapy (10-14 days for meningitis, at least 4 weeks for endocarditis) 1, 2, 4
• Test-of-cure is not routinely required for patients who respond appropriately to recommended therapy 1, 2
• Retest approximately 3 months after treatment due to high reinfection risk (not for treatment failure assessment) 1, 5
• If symptoms persist after treatment, obtain cultures with antimicrobial susceptibility testing and consult infectious disease specialists 1, 2

Critical Pitfalls to Avoid

• Do not use azithromycin monotherapy for gonorrhea (only 93% cure rate and promotes resistance) 1, 5
• Do not use quinolones given widespread resistance patterns 1, 3
• Do not omit Chlamydia coverage - coinfection is extremely common and both pathogens contribute to perihepatitis 1, 6
• Do not use spectinomycin for pharyngeal gonorrhea if present (only 52% efficacy) 1, 5
• Do not discharge patients prematurely - hospitalization for initial 24-48 hours ensures compliance and allows monitoring for complications 1, 2