Four of the nine women with signs of chlamydial infections

Of these 11 women with perihepatitis or diffuse peritonitis, nine had excellent serological evidence of acute recent chlamydial infections. Five of the patients had no evidenceof gonococcal infection. The age, sexual activity, symptoms, and the laparoscopic findings typical of Fitz-Hugh-Curtis syndrome in three of the women suggested that a genital tract infection may have spread to the peritoneum. Chlamydiae, increasingly found to be responsible for various non-gonococcal sexually transmitted diseases in men. and women, are plausible candidates for this type of infection. Five women in our series had evidence of past or current gonococcal infection. Local genital tract infections with more than one agent are frequent,9 and the invading organisms are not necessarily identical with those cultivated from the cervical mucosa. Unless agents are cultured directly from the inflamed peritoneum, it is impossible in such cases to determine whether the peritonitis may have been due to one or the other agent or both. Nevertheless, the extremely high C trachomatis antibody titres in many ofour patients was suggestive of an aetiological association. Only two of our 1L patients with peritonitis had. signs of salpingitis on gynaecological examination. If the assumption that our patients had genitally acquired infections is correct, probably the infectious agent ascending from the cervical canal often reaches the peritoneum without causing salpingitis. Equally, perihepatitis does not seem to be an invariable feature of the disease. Two patients (cases 1 and 4), both of whom had very high titres to chlamydiae, had neither salpingitis nor perihepatitis. These two cases show that evidence for genitally transmitted infections should be sought in all women with apparent "spontaneous" peritonitis. Four of the nine women with signs of chlamydial infections were not treated with tetracycline but with antibiotics not thought to be active against chlamydiae (two with ampicillin, two with spectinomycin), yet their disease subsided within one to two weeks. Nevertheless, one patient (case 2) continued to be ill for weeks when taking ampicillin alone, but rapidly improved after receiving tetracycline. Hence chlamydial peritonitis may follow a benign course, but tetracyclines can accelerate recovery. In sexually active women with various partners multiple C trachomatis antibody types may be found. Studies on monkeys'0 and experience with patients attending venereal-disease clinics showed that the original infecting type was often recalled after infection with a new type, and in the screening microimmunofluorescence test or with IgG conjugate the highest antibody titre was found against a previous immunotype rather than the current infecting type.7 If the organism cannot be isolated the use of the IgM conjugate helps to determine the current infecting type when multiple antibody types are present. Thus in three of our patients (cases 5, 6, and 8) the antibody type measured with IgM conjugate was probably the current infecting type. We hope that our report will encourage clinicians and microbiologists to look for direct evidence of chlamydial infections in similar cases by culturing the agents from the inflamed sites.