Nontuberculous mycobacterial infection in a clinical presentation of Fitz-Hugh-Curtis syndrome: a case report with multigene diagnostic approach

Abstract

Background: Fitz-Hugh-Curtis syndrome (FHCS) is caused by inflammation of perihepatic capsules associated with pelvic inflammatory disease. In recent years, infections with nontuberculous mycobacteria (NTM) have been increasingly occurring in immunocompromised and immunocompetent patients. However, NTM has never been reported in patients with FHCS. We present the first case of a patient with extrapulmonary NTM infection in a clinical presentation of FHCS.

Case presentation: A 26-year-old Korean woman presented with right upper quadrant and suprapubic pain. She was initially suspected to have FHCS. However, she was refractory to conventional antibiotic therapy. Laparoscopy revealed multiple violin-string adhesions of the parietal peritoneum to the liver and miliary-like nodules on the peritoneal surfaces. Diagnosis of NTM was confirmed by the polymerase chain reaction analysis results of biopsy specimens that showed caseating granulomas with positive acid-fast bacilli. Treatment with anti-NTM medications was initiated, and the patient's symptoms were considerably ameliorated.

Conclusions: An awareness of NTM as potential pathogens, even in previously healthy adults, and efforts to exclude other confounding diseases are important to establish the diagnosis of NTM disease. NTM infection can cause various clinical manifestations, which in the present case, overlapped with the symptoms of perihepatic inflammation seen in FHCS.

Figure 1

Laparoscopic views of the peritoneal cavity revealed the formation of large nodules on the anterior parietal peritoneum, which were completely excised and showed NTM by PCR analysis, multiple membrane and violin-string adhesions of the parietal peritoneum to the liver (A and B), and military-like nodules in the surfaces of the anterior pelvic peritoneum, uterus, and pouch of Douglas (C and D).

Figure 2

Histopathological examination revealed necrotizing granulomatous inflammation (A) with positive acid-fast bacilli on Ziehl-Neelsen staining (B).