Hepatic pseudolesion as an unusual presentation of Fitz-Hugh-Curtis syndrome

Abstract

Fitz-Hugh-Curtis Syndrome is a rare disorder manifesting as a complication associated with Pelvic Inflammatory Disease. The initial presentation generally consists of concomitant right upper quadrant and lower abdominal pain. This syndrome is characterized by inflammation of the peritoneum with the involvement of hepatic capsule and the tissues surrounding the liver. Intrahepatic involvement is rare and not yet well investigated. An accurate interpretation of Computed Tomography and Magnetic Resonance Imaging findings is missing in the literature. This report presents a case of Fitz-Hugh-Curtis Syndrome in which Computed Tomography and Magnetic Resonance Imaging showed a region of heterogeneously decreased enhancement and abnormal signal intensity within the liver mimicking a lesion.

Keywords: Computed Tomography; Fitz-Hugh-Curtis Syndrome; Hepatic Pseudolesion; Liver; Magnetic Resonance Imaging; Neoplastic Mimics.

Fig. 1

Contrast-enhanced abdominal CT on admission. (A) Axial contrast-enhanced CT scan in arterial phase shows thickening of the liver capsule associated with conspicuous increased perihepatic enhancement, suggesting perihepatitis compatible with Fitz-Hugh-Curtis Syndrome. (B) Axial contrast-enhanced CT image obtained at the level of the pelvis during portal-venous phase demonstrates free fluid within the pouch of Douglas with thickening and enhancement along the peritoneum and the peritoneal coverings of the uterus, suggesting the presence of an infectious-inflammatory process. Moreover, the right adnexal region appears swollen and inhomogeneous with surrounding inflammatory stranding, fallopian tube is more conspicuous due to wall thickening and enhancement, and uterine border is slightly indistinct: all common CT imaging features of PID.

Fig. 2

Contrast-enhanced abdominal CT on admission through the liver dome. (A) Axial contrast-enhanced CT image obtained at the level of the liver dome during arterial phase shows a large lesion seen as a region of heterogeneously decreased enhancement relative to the rest of the liver. (B) Axial contrast-enhanced CT image obtained during portal-venous phase reveals the presence of hypoattenuating linear areas along segmental branches of left portal vein in the exact same location where the lesion was observed, suspicious for thrombosis.

Fig. 3

MRI of the liver performed three days after CT. (A) Axial T2-weighted sequence with fat suppression demonstrates an ill-defined area of increased parenchymal signal intensity around the portal system in the same position where the liver lesion was observed on CT, compatible with inflammatory changes. Peri-hepatic and peri-splenic free fluid is also present. (B) Coronal T2-weighted sequence with fat suppression confirming the findings.

Fig. 4

Contrast-enhanced MRI of the liver after completion of therapy. (A) Axial T2-weighted sequence with fat suppression shows disappearance of the parenchymal alteration of the liver and free intraperitoneal fluid. (B) Axial plane post-contrast T1-weighted image through the liver dome shows how the hepatic parenchymal alteration completely resolved on follow-up MRI after doxycycline treatment.