Case report: never stop searching for a diagnosis

L. van der Weele, S.E. Geerlings

Woensdag 20 april 2016

15:10 - 15:20u in Zaal 0.5

Categorie├źn: Parallelsessie

Parallel sessie: Parallelsessie 4: Case reports/research

A 57-year old, obese man was admitted to the emergency room with fever and upper abdominal pain. He had a history of heartburn treated with extremely high dose of proton pomp inhibitors and recently returned from Surinam, where he swam in the Surinam river. He reported epigastric pain associated with fever, nausea and vomiting. He had no symptoms of diarrhea, coughing or arthralgia.

On examination, besides a temperature of 41.50C and abdominal tenderness upon palpation, no other anomalies where found. Laboratory results showed an elevated CRP and creatinin level, with normal leukocytes and without eosinophils. Electrocardiography, urine sediment, chest radiograph and abdominal ultrasound showed no abnormalities.

After admission to the ward, treatment with ceftriaxone was given for a suspected diagnosis of leptospirosis. However, this diagnosis had to be dismissed after negative serology results. In the meanwhile, symptoms of abdominal pain increased and blood cultures became positive for Streptococcus constellatus indicating a gastro-intestinal focus. For that reason a CT-scan of the abdomen was performed, which revealed a liver abscess of 6,8 x 3,2 x 7,7cm in segment 3 and a corpus alienum in close proximity, but outside the stomach with a length of 3.5cm.

After informing the patient of this surprising finding, he reported choking in fish-soup 3 months ago. Since then abdominal pain slowly increased. After drainage of the abscess and laparoscopic removal of a fish bone the patient recovered quickly and was discharged from the hospital. This case history teaches us to look for the original site of bacteremia.