Interesting case

[ac808]

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I have an interesting patient that I would love to hear some comments about.
40y WM who presented with RLQ pain about 2 weeks ago. +N&V but -CT for appendicitis. Despite this an appendectomy revealed a - appendix. Patient still complains of RLQ pain and is unable to eat without vomiting. To make this more interesting, the pt. had just returned home from a trip to the phillipines and taiwan when he first became sick. No uncooked foods or anything like this were eaten. No fever or elevated wbc. Any ideas?? Im thinking mesenteric adenitis but I'm very unsure.

 

[Idiopathic]

Rare in adults....but could follow virus. Leukocytosis is to be expected. Question: what differentiates your case from intestinal blockage?

 

[ac808]

sorry I should have given a better history. The pt. has had, and continues to have bowel mvmts. Negative radiologic studies for any abnormalities and no leukocytosis. The differential did show a slightly increased eosinophil count. I thought about helminths but I am extremely ignorant of differentials when it comes to this subject, so any help would be appreciated.

 

[Idiopathic]

Sure sounds like it could be a tapeworm. The region suggests a liver fluke or fasciolopsis, but pain would be RUQ. Can always examine stool for eggs as these are the only diagnostic criteria, i believe. i would think worms, just from the recent travel history and the eosinophilia.

 

[jpc]

how 'bout yersiniosis?

 

[ac808]

JPC,
thats my current thinking, Im going to stool culture with a CIN differential agar and hopefully get some answers. Thanks for the help!

 

[Idiopathic]

I would be curious to see the outcome...would expect to see more diarrhea than vomiting with enteritis.

 

[Antibiotix]

Can you describe the type and duration of the pain? Any relieving factors? What are his stools like? What other radiological studies were done that were normal apart from the CT? Has an endoscopy been done?
I have my doubts about yersiniosis, and a worm infestation should'nt pose so much of a problem for a diagnosis. Is stool microscopy normal? What antibiotics has he been on? Does he have any history of allergies?

Sorry, lots of questions, no answers (yet!). Interesting case

🙂

 

[pelican]

What's the official path report say about the appendix? Any eosinophilic infiltrations? Other things that can happen on that side of the belly that haven't been mentioned by others are rarer diseases such as eosinophilic gastroenteritis and tiflitis. With EG the appy report might show it. And if I'm remembering my path correctly tiflitis is a neutrophilic infiltration of the ascending colon, though it's usually described in immunocompromised pts (particularly those on chemo).

good luck in sorting it all out.

a

 

[ac808]

Antibiotix,
Pain was constant RLQ 7 out of 10, no relieving factors, stools slightly water. Upper GI was normal, so was triple CT. Stool looks normal, Im not sure what antibiotics and no allergies.

pelican, Path report was completely normal appendix and mesenteric fat, no infiltrates.

Unfortunately the patient has left the hospital, so i am now wondering if he had a factitious disorder. If he did, he probably cost the hospital and county about 15,000. Unfortunate but probable.

 

[Idiopathic]

Its a worm...hell be back 🙂

(always stick to your guns...or in this case, my guns)

Dont you just hate those unresolved mysteries?