5/25/16 Chief Complaint • Fever and abdominal pain UCSF CME Clinical Problem Solving May 25, 2016 2 History of Present Illness Past Medical History • 49M presents with 3 weeks of abdominal pain • No known medical problems and fever • Appendectomy 10 years ago – Was in usual state of good health until 3 weeks ago, when he developed a “high fever” at home – Went to ED, sent home with diagnosis of mild respiratory infection – The following day, developed sharp, mid-epigastric abdominal pain – Continued intermittent fevers up to 102 with chills, anorexia, fatigue, and emesis – No diarrhea, urinary symptoms, melena, hematochezia or sick contacts – ROS otherwise negative, except 30 lb weight loss over the past few weeks 3 4 1
5/25/16 Medications and Allergies Social History • No medications • Originally from Philippines, came to US one year ago • NKDA • Works as an IHSS worker – Previously worked in Qatar and Oman 10 years ago as an electrical engineer • Lives with wife and 5 children • Denies alcohol, tobacco, or drug use • No travel since moving to the US 5 6 Family History • Noncontributory UCSF CME Clinical Problem Solving May 25, 2016 7 2
5/25/16 Physical Exam Labs • VS: 38.2, 110, 129/88, 16, 99%RA 128 93 1 1 13.6 • General: uncomfortable, ill-appearing gentleman lying in bed 181 16.8 360 4.2 27 0.55 39 • HEENT: PERRL, pale conjunctiva without icterus, no LAD • CV: tachycardic, regular, no m/r/g, no JVD Diff: 88 PMNs • Pulm: decreased breath sounds at R lung base, left lung clear • Ca 8.0 • INR 1.4 0.7 • Abd: soft, nondistended, moderate TTP over epigastrium • Albumin 3.7 • Trop neg with indurated mass, approximately 8x5cm without overlying 32 48 • Total protein 8.6 erythema or fluctuance, no organomegaly, negative murphy’s • UA unremarkable 349 sign, no CVAT, normoactive bowel sounds • Lipase 53 (nl) • Ext: no edema, 2+ distal pulses • Skin: warm and dry without rashes or lesions • Neuro: AOx3, no gross deficits 9 10 3
5/25/16 CT abdomen/pelvis: radiology read • Multiple ill-defined rim-enhancing fluid collections replacing nearly the entire left hepatic lobe, largest 8.4 x 5.8 x 8.6cm • Extends beyond the liver capsule through the anterior abdominal wall with a large enhancing fluid UCSF CME collection in the anterior abdominal wall musculature Clinical Problem • Gas within gallbladder and CBD Solving • Right pleural effusion and retroperitoneal lymphadenopathy also present May 25, 2016 14 4
5/25/16 UCSF CME Clinical Problem Solving May 25, 2016 5
5/25/16 Hospital course Hospital course • Blood cultures sent • 5 days after admission, he continued to spike intermittent fevers and abdominal pain began to • Started on ceftriaxone and metronidazole increase • IR consulted and drained 175ml of foul smelling – BCx NGTD, repeat cultures pending fluid – Repeat imaging showed resolution of drained – Gram stain showed many GPCs in pairs and many abscess, but other abscesses remained, with GNRs – the GPCs later speciated to Strep viridans, increased gas in the biliary system and the GNRs were medium-sized with final • Switched to ertapenem, GI consulted speciation still pending 21 22 Hospital course • ERCP and MRCP: multiple cystic ectasias in most peripheral intrahepatic ducts with associated dilation • Sphincterotomy was performed with good drainage UCSF CME • Initial cultures from abscess further speciated Clinical Problem to show beta hemolytic strep and moderate Solving anaerobic gram negative cocci and gram negative rods (not B. fragilis) in addition to strep viridans May 25, 2016 • Stool cultures and O+P returned negative • Fluid from gallbladder sample showed negative gram stain 24 6
5/25/16 Hospital course • A second drain was placed by IR, but he continued to spike fevers to 39 • A diagnostic procedure was performed… UCSF CME Clinical Problem Solving May 25, 2016 28 7
5/25/16 Diagnosis… A. Clonorchis sinensis • General surgery was consulted due to B. Caroli Disease concern for inadequate source control C. Candidal liver abscess • Went to OR for partial hepatectomy and cholecystectomy, though the infection coul d D. Amebiasis not be fully resected E. Hepatocellular carcinoma F. Tuberculosis Pathology showed… G. Echinococcus (hydatid cyst) 29 30 8
5/25/16 Conclusion • Sputum AFB culture and smear were sent and returned negative • TB PCR from hepatic sample returned positive UCSF CME – Diagnosed with infiltrative TB Clinical Problem cholangiopathy, which likely led to liver abscess formation Solving – Started on RIPE May 25, 2016 34 Conclusion FINAL DIAGNOSIS • Fevers resolved and abdominal pain improved Infiltrative TB cholangiopathy • Discharged home 9 days later • Seen in DPH TB clinic with plan to continue treatment for 9 months – 2 months of RIPE – 7 months of rifampin/INH • Several weeks later, sensitivities showed resistance to INH, so regimen was modified to rifampin/ethambutol/pyrazinamide • At his most recent TB clinic follow-up, he was experiencing some nausea, but overall tolerating RIPE treatment well, and abdominal pain has resolved 35 36 9
5/25/16 UCSF CME Clinical Problem Solving May 25, 2016 10
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