Fitz-Hugh-Curtis syndrome is a rare but clinically significant complication of pelvic inflammatory disease. Patients characteristically present with pleuritic right upper quadrant pain secondary to the spread of pelvic inflammatory disease to the liver capsule. Additional clinical manifestations include cervicovaginal discharge, pelvic pain, cervical motion tenderness, and adnexal tenderness. This syndrome primarily affects women in their reproductive years and is classically linked to sexually transmitted infection with Chlamydia trachomatis and Neisseria gonorrhoeae. Long-standing disease may not manifest clinically; thus, diagnosis typically involves a combination of clinical evaluation and imaging modalities. When the diagnosis is not yet clear and complications of pelvic inflammatory disease are present (i.e., hydrosalpinx), diagnostic laparoscopy is indicated for direct visualization. The classic “violin-string” adhesions visualized on laparoscopy connecting the anterior hepatic surface to the abdominal wall are pathognomonic of the disease.

We present an atypical case of Fitz-Hugh-Curtis syndrome with a 26-year-old female who presented with long-standing dysmenorrhea, bilateral hydrosalpinx, and no prior history of sexually transmitted infection or pelvic inflammatory disease. She also lacked the characteristic right upper quadrant pain, which can sometimes be the only clinical manifestation of the disease. The diagnosis of Fitz-Hugh-Curtis syndrome was made based on laparoscopic visualization of extensive “violin-string” adhesions involving the liver, left fallopian tube, uterus, and peritoneum. Laparoscopic adhesiolysis and bilateral salpingectomy was performed, and the patient had an uncomplicated postoperative course.

Fitz-Hugh-Curtis syndrome can pose a diagnostic challenge as it has a spectrum of possible clinical manifestations. As seen in this case, laparoscopy revealed extensive adhesive disease and tubal inflammation yet, the patient did not meet the minimum criteria for pelvic inflammatory disease or complain of right upper quadrant pain at any time during the disease course. Obtaining imaging of the abdomen and pelvis via ultrasound and computed tomography can be particularly valuable in establishing the diagnosis and ruling out other pathology; however, laparoscopy is the gold-standard of diagnosis. Young, sexually active women presenting to the hospital with pelvic pain and bilateral hydrosalpinx should raise high clinical suspicion for Fitz-Hugh-Curtis syndrome, regardless of sexual history or clinical manifestation of perihepatitis. Early diagnosis and treatment with laparoscopy can help patients avoid the pain and suffering that can persist for years, as seen in this case. This case also stresses the importance of treating sexually transmitted infection and pelvic inflammatory disease early on before it progresses to chronic pelvic pain and infertility.