5/25/16 Chief Complaint Fever and abdominal pain UCSF CME - - PDF document

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5/25/16 Chief Complaint Fever and abdominal pain UCSF CME - - PDF document

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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

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5/25/16 1

UCSF CME Clinical Problem Solving

May 25, 2016

Chief Complaint

  • Fever and abdominal pain

2

History of Present Illness

  • 49M presents with 3 weeks of abdominal pain

and fever

– 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

  • r sick contacts

– ROS otherwise negative, except 30 lb weight loss

  • ver the past few weeks

3

Past Medical History

  • No known medical problems
  • Appendectomy 10 years ago

4

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Medications and Allergies

  • No medications
  • NKDA

5

Social History

  • Originally from Philippines, came to US one

year ago

  • 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

6

Family History

  • Noncontributory

7

UCSF CME Clinical Problem Solving

May 25, 2016

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Physical Exam

  • VS: 38.2, 110, 129/88, 16, 99%RA
  • General: uncomfortable, ill-appearing

gentleman lying in bed

  • HEENT: PERRL, pale conjunctiva without icterus, no LAD
  • CV: tachycardic, regular, no m/r/g, no JVD
  • Pulm: decreased breath sounds at R lung base, left lung

clear

  • Abd: soft, nondistended,

moderate TTP over epigastrium with indurated mass, approximately 8x5cm without overlying erythema or fluctuance, no organomegaly, negative murphy’s sign, no CVAT, normoactive bowel sounds

  • Ext: no edema, 2+ distal pulses
  • Skin: warm and dry without rashes or lesions
  • Neuro: AOx3, no gross deficits

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Labs

10

181 128 4.2 93 27 0.55 1 1 0.7 32 48 349

  • Ca 8.0
  • Albumin 3.7
  • Total protein 8.6
  • Lipase 53 (nl)

13.6 16.8 360 39 Diff: 88 PMNs

  • INR 1.4
  • Trop neg
  • UA unremarkable
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UCSF CME Clinical Problem Solving

May 25, 2016

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 collection in the anterior abdominal wall musculature

  • Gas within gallbladder and CBD
  • Right pleural effusion and retroperitoneal

lymphadenopathy also present

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UCSF CME Clinical Problem Solving

May 25, 2016

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Hospital course

  • Blood cultures sent
  • Started on ceftriaxone and metronidazole
  • IR consulted and drained 175ml of foul smelling

fluid

– Gram stain showed many GPCs in pairs and many GNRs – the GPCs later speciated to Strep viridans, and the GNRs were medium-sized with final speciation still pending

21

Hospital course

  • 5 days after admission, he continued to spike

intermittent fevers and abdominal pain began to increase

– BCx NGTD, repeat cultures pending – Repeat imaging showed resolution of drained abscess, but other abscesses remained, with increased gas in the biliary system

  • Switched to ertapenem, GI consulted

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UCSF CME Clinical Problem Solving

May 25, 2016

Hospital course

  • ERCP and MRCP: multiple cystic ectasias in

most peripheral intrahepatic ducts with associated dilation

  • Sphincterotomy was performed with good

drainage

  • Initial cultures from abscess further speciated

to show beta hemolytic strep and moderate anaerobic gram negative cocci and gram negative rods (not B. fragilis) in addition to strep viridans

  • Stool cultures and O+P returned negative
  • Fluid from gallbladder sample showed negative

gram stain

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UCSF CME Clinical Problem Solving

May 25, 2016

Hospital course

  • A second drain was placed by IR, but he

continued to spike fevers to 39

  • A diagnostic procedure was performed…

28

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Diagnosis…

  • A. Clonorchis sinensis
  • B. Caroli Disease
  • C. Candidal liver abscess
  • D. Amebiasis
  • E. Hepatocellular carcinoma
  • F. Tuberculosis
  • G. Echinococcus (hydatid cyst)

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  • General surgery was consulted due to

concern for inadequate source control

  • Went to OR for partial hepatectomy and

cholecystectomy, though the infection coul d not be fully resected

30

Pathology showed…

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UCSF CME Clinical Problem Solving

May 25, 2016

Conclusion

  • Sputum AFB culture and smear were sent

and returned negative

  • TB PCR from hepatic sample returned

positive – Diagnosed with infiltrative TB cholangiopathy, which likely led to liver abscess formation – Started on RIPE

34

Conclusion

  • Fevers resolved and abdominal pain improved
  • 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

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FINAL DIAGNOSIS Infiltrative TB cholangiopathy

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UCSF CME Clinical Problem Solving

May 25, 2016