Interactive Quiz: Fever and Abdominal Pain
Welcome to Gastroenterology Consultant's latest interactive diagnostic quiz. Over the next few pages, we'll present a case and ask you to make the diagnosis. Along the way, we'll provide details about the case, and at the end, we'll share the patient's diagnosis.
Ready to get started? >>
First, let’s meet the patient…
A 59-year-old woman presented with symptoms that included subjective fevers, myalgias, chills, fatigue, headaches, and sore throat. The patient reported having felt well the day before and that she had gone about her regular routine, even engaging in a vigorous 2-hour workout.
The patient, who was of average weight and height, reported that 3 days prior, she had experienced some watery diarrhea and abdominal pain that had resolved over the course of that day. She denied having fever at the time of the diarrhea, but she noted a decreased appetite that had not returned to normal after the diarrhea and abdominal pain had resolved. During the office visit, she also reported fatigue and dizziness.
The patient’s medical history included hypertension and hyperlipidemia. Her surgical history included a prior hysterectomy and right knee replacement. Her only medications were daily losartan, 25 mg, and aspirin, 81 mg.
On examination, she appeared fatigued with dry mucous membranes but in no acute distress. The patient did have significant tachycardia, but cardiac examination findings were otherwise benign, with no murmurs, rubs, or gallops.
Urinalysis was done in the office, the results of which showed a high level of leukocyte esterase, a moderate level of blood, and no nitrites. Results of a rapid strep test were negative for group A streptococci, and her heart rate increased significantly with positional changes, likely due to dehydration.
Are you correct? >>
Answer: Go to the emergency department
The patient was sent to the emergency department (ED) for a blood draw and likely intravenous hydration. While in the ED, the patient noted that in the last few days she had been having intermittent abdominal pain but denied nausea, emesis, dyspnea, or chest pain and stated the symptoms improved with ibuprofen.
Laboratory test results showed mild hyponatremia with a sodium level of 133 mEq/L and mild leukocytosis with a white blood cell count of 14,000/µL with 84.2% neutrophils (11,800/µL absolute count), and 9.9% lymphocytes. Influenza A and B swab test results were negative.
Are you correct? >>
Answer: Perform a computed tomography
A computed tomography (CT) scan of the abdomen and pelvis with oral and intravenous contrast identified contrast in the base of the appendix but not the tip (Figures). The tip appeared mildly thickened, measuring approximately 6 to 9 mm, with hazy infiltrative change adjacent to it. Numerous clustered subcentimeter lymph nodes in the right lower quadrant also were identified.
Are you correct? >>
Answer: Acute appendicitis
The patient was diagnosed with acute appendicitis.
The patient was seen by the surgical team and taken to the operating room for a laparoscopic appendectomy with lysis of abdominal adhesions (a result of prior surgery). Dense adhesions at the lower anterior abdomen were noted and lysis of these was done. The appendix was visualized and removed.
Are you correct? >>
Answer: A preceding gastrointestinal tract viral illness
The patient described symptoms of fevers, myalgias, and sore throat as her main concerns. The patient did not report abdominal pain during the initial examination, and no tenderness was elicited on the abdominal examination. Her symptoms of tachycardia and orthostatic hypotension led us to an initial diagnosis of viral illness and dehydration.
Viral infections are associated with lymph tissue enlargement resulting from hyperplasia of Peyer patches in the appendix and other lymphoid organs. Viral infections can also cause ulcerations resulting in bacterial infection.
Authors:
Pearl Lui, MD
Stony Brook University Medical Center
Sabina Rebis, MD, MS
Stony Brook University Medical Center
Khaula Tauqeer, MD
Stony Brook University Medical Center
Manal Soliman, MD
Stony Brook University Medical Center
To read the full case report, see:
Lui P, Rebis S, Tauqeer K, Soliman M. Atypical appendicitis preceded by viral illness [published online December 6, 2018]. Gastroenterology Consultant. https://www.consultant360.com/exclusive/gastroenterology/atypical-appendicitis-preceded-viral-illness?page=0.