JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
CLINICAL CASE OF THE MONTH Abdominal Pain in a 39-year-old Man with Recent International Travel
Walter Liszewski, MD, Seema Walvekar, MD, Fred A. Lopez, MD
CASE PRESENTATION
Additionally, total serum creatinine kinase, lipase, and lactic acid were all within normal limits. The patient’s HIV and acute hepatitis tests were non-reactive. An abdominal ultrasound revealed an approximately 5 X 4 X 3 cm lobulated echogenic hepatic mass in the right hepatic lobe; the liver was enlarged at 21 cm in length. No biliary duct obstruction or dilation was observed. The mass was further characterized with a triple-phase MRI which showed a 5.8 X 5.7 cm mass with central necrosis and adjacent edema (figure 1).
A 39-year-old man presented to the emergency department with a five-day history of right upper quadrant pain, nausea, subjective fevers, fatigue, decreased appetite, myalgias, and pain with deep inspiration. The patient denied any vomiting, constipation, diarrhea, cough, or shortness of breath. Although the patient’s symptoms had improved since their onset, the patient was concerned about his ongoing abdominal pain. The patient denied a history of intravenous drug use. He worked as a bartender, and he admitted to numerous recent sick contacts. The patient also admitted to distant travel to rural Ecuador as a teenager, andmore recently, he spent threemonths in Northern India four months before presentation. Before going to India, the patient attended a travel clinical where he received prescriptions for malaria prophylaxis and azithromycin should he develop severe diarrhea. He also received instructions on food safety in developing countries. The patient stated that he completed his entire course of malaria prophylaxis, and although he only consumed cooked foods and bottled water, he had several episodes of diarrhea during his travels. For the first episode of diarrhea, the patient took his pre-prescribed course of azithromycin, but for subsequent episodes, he obtained unknown antibiotics from local pharmacies. The patient denied any episodes of hematochezia, and he denied noticing worms in his stool. At the time of presentation, the patient had a pulse of 88/ minute, temperature of 98.6 °F, respiratory rate of 21/minute, and blood pressure of 105/64 mmHg. Abdominal exam revealed normoactive bowel sounds and pain with palpation and percussion of the right upper quadrant without rebound or guarding. Murphy’s sign and splenomegaly were not appreciated. The lungs were clear to auscultation. The patient’s white cell blood count was 17,900 cells/uL (normal range 4,500- 11,000 cells/uL) with a normal differential. The patient was mildly hyponatremic at 132 mmol/L (normal range135-146) and hypokalemic at 3.5 mmol/L (normal range 3.6-5.0). Total protein was elevated at 8.9 g/dL (normal range 3.6-5.2), with a normal albumin at 4.2 g/dL (normal range 3.4-5.0 g/dL). Total bilirubin was elevated at 1.5 mg/dL (normal range <1.3 mg/ dL) as was alkaline phosphatase at 135 units/L (normal range 20-120 units/L); both AST and ALT were within normal limits.
Figure 1. Coronal image of a triple-phase MRI with contrast of the abdomen. Arrow points to a large, walled mass with a central hypodensity in the liver that was subsequently identified as an amoebic abscess.
The patient initially received piperacillin-tazobactam for a possible bacterial hepatic abscess. However, given his recent travel history, the possibility of a parasitic abscess could not be excluded. The patient’s abdominal pain did not improve with piperacillin-tazobactam, and on the second hospital day the abscess was drained percutaneously. The abscess drained a purulent, dark-brown material, and the Gram stain was negative for any organisms. Following the Gram stain, the patient was started on metronidazole for a presumed amoebic abscess. Withinadayof draining the abscess and initiatingmetronidazole, the patient’s abdominal pain began to resolve. The patient was
106 J La State Med Soc VOL 169 JULY/AUGUST 2017
Made with FlippingBook Digital Publishing Software