I came across this fun case but i'm not 100% certain what she has .... does anyone want to share ideas?
A 29-year-old woman was admitted to the hospital because of fever and increasing abdominal pain.
The patient had spastic quadriplegia due to cerebral palsy but had been in her usual state of health until approximately 2 weeks before admission, when intermittent fevers, with temperatures up to 37.7°C, developed. One day before admission, pain in the left flank and left lower quadrant developed, and she noted foul-smelling urine. During the night before admission, the oral temperature rose to 39.1°C, associated with nausea and pain in the chest, both legs, and the abdomen, which radiated to the back, both flanks, and the midscapular region. She took ibuprofen, and her parents brought her to the emergency department at this hospital in the early afternoon.
The patient rated the pain at 8 on a scale of 1 to 10, with 10 indicating the most severe pain. She had cerebral palsy with spastic quadriplegia, obesity, iron-deficiency anemia, polycystic ovary syndrome with irregular menses, recurrent urinary tract infections, and nephrolithiasis. A ureteral stent had been placed temporarily 10 years earlier because of an obstructing stone in the left ureter. She drank alcohol socially and did not smoke or use illicit drugs. She lived with her parents and a sibling in an urban area, and she had recently broken up with her boyfriend. She used a wheelchair and required assistance cutting food. She followed a low-oxalate diet. She reported no contact with sick persons and no exposure to ticks, and she was not sexually active. Her father and paternal grandfather had diabetes mellitus, her father had reactive arthritis (formerly known as Reiter's syndrome), one grandfather had relapsing polychondritis, and two grandparents had coronary artery disease.😛>😛>
On examination, the patient, who was in a wheelchair, was alert and communicative. The temperature was 37.5°C, the blood pressure 119/63 mm Hg, the pulse 108 beats per minute, and the oxygen saturation 96% while she was breathing ambient air. There was mild tenderness of the sternum, which was reproduced with deep inspirations, and tenderness of the left costovertebral angle. The abdomen was soft and tender to palpation on the left side, with the most severe tenderness in the left lower quadrant; there was no rebound or guarding. Radial pulses were 2+. The remainder of the examination was consistent with spastic quadriplegia.😛>😛>
The platelet count and levels of serum electrolytes, glucose, calcium, phosphorus, magnesium, total protein, albumin, globulin, amylase, and lipase were normal, as were tests of renal function; other test results are shown in Table 1
Review of the peripheral-blood smear revealed anisocytosis (2+), polychromatocytosis (1+), hypochromatocytosis (2+), and microcytosis (3+). Urinalysis revealed clear amber urine with a specific gravity of 1.025, a pH of 6.0, 2+ bilirubin, 1+ protein, and trace amounts of ketones and urobilinogen; a culture was sterile.
While the patient was in the emergency department, narcotic analgesia was administered intravenously, and her pain decreased to a score of 7 out of 10. Eight hours after arrival, the patient vomited once; ondansetron was administered. Computed tomography (CT) of the abdomen was performed after the oral and intravenous administration of contrast material, but it was complicated by extravasation of the contrast material at the intravenous site in the right arm. The study showed malrotation of the left extrarenal pelvis, multiple cortical defects in the left kidney that were consistent with scarring, and a urinary catheter in the urethra. The spleen was mildly enlarged (14.8 cm in the craniocaudal dimension; upper limit of the normal range, 12 to 13). There were prominent periportal, mesenteric, inguinal, and retroperitoneal lymph nodes, up to 1.4 cm in diameter, with trace free fluid in the pelvis. The patient was admitted to the hospital early the next morning.
On the day of admission, the temperature was 38.1°C. The pain (rated as 8 out of 10) persisted, and narcotic analgesia was administered intravenously. Nausea and vomiting recurred but lessened after the administration of prochlorperazine. Treatment with dalteparin sodium was begun. A repeat culture of the urine grew rare mixed bacteria. The chest radiograph showed low lung volumes and no opacities that were suggestive of pneumonia. The next day, ultrasonography of the kidneys and the venous system of the lower extremities was normal, with no evidence of hydronephrosis or deep venous thrombosis.
During the third, fourth, and fifth hospital days, the serum iron-binding capacity and levels of iron, ferritin, folate, and vitamin B12 were normal; other laboratory-test results are shown in Table 1. On the third day, the temperature rose to 38.5°C. Urinalysis revealed leukocytes (>100 white cells per high-power field), and a urine culture grew Proteus mirabilis and Escherichia coli; blood cultures remained sterile. Ciprofloxacin was administered. The next day, a cherry-red rash developed on the patient's feet and resolved spontaneously after several hours. Ultrasonography of the abdomen was normal. Low-grade fevers occurred intermittently thereafter, and severe abdominal pain (8 out of 10) persisted; it was greatest in the left upper quadrant, with radiation to the left flank, and was associated with nausea and intermittent vomiting.
On the fifth day, testing for antibodies to Borrelia burgdorferi, cytomegalovirus (CMV), and hepatitis B and C viruses was negative, as were tests for antinuclear antibody, CMV antigenemia, and heterophile antibody; other test results are shown in Table 1. A CT scan of the abdomen, after the intravenous administration of contrast material, showed persistent mild splenomegaly with peripheral wedge-shaped areas of hypoattenuation that were consistent with infarcts; other findings were unchanged from the CT performed on admission.
Tests for malaria and antibodies to the human immunodeficiency virus (HIV) and heparin–platelet factor 4 were negative, as were nucleic acid testing for ehrlichia, Coombs' direct antibody test, cold-agglutinin screening, and testing for lupus anticoagulant; hemoglobin electrophoresis and levels of fibrinogen, homocysteine, lipoprotein(a), β2-glycoprotein I, antithrombin III, and protein C (functional) were normal. Other test results are shown in Table 1. Blood cultures remained sterile. Transthoracic echocardiography was normal, with no evidence of valvular vegetations.
On the 10th day, diagnostic test results were received..<o></o>.
A 29-year-old woman was admitted to the hospital because of fever and increasing abdominal pain.
The patient had spastic quadriplegia due to cerebral palsy but had been in her usual state of health until approximately 2 weeks before admission, when intermittent fevers, with temperatures up to 37.7°C, developed. One day before admission, pain in the left flank and left lower quadrant developed, and she noted foul-smelling urine. During the night before admission, the oral temperature rose to 39.1°C, associated with nausea and pain in the chest, both legs, and the abdomen, which radiated to the back, both flanks, and the midscapular region. She took ibuprofen, and her parents brought her to the emergency department at this hospital in the early afternoon.
The patient rated the pain at 8 on a scale of 1 to 10, with 10 indicating the most severe pain. She had cerebral palsy with spastic quadriplegia, obesity, iron-deficiency anemia, polycystic ovary syndrome with irregular menses, recurrent urinary tract infections, and nephrolithiasis. A ureteral stent had been placed temporarily 10 years earlier because of an obstructing stone in the left ureter. She drank alcohol socially and did not smoke or use illicit drugs. She lived with her parents and a sibling in an urban area, and she had recently broken up with her boyfriend. She used a wheelchair and required assistance cutting food. She followed a low-oxalate diet. She reported no contact with sick persons and no exposure to ticks, and she was not sexually active. Her father and paternal grandfather had diabetes mellitus, her father had reactive arthritis (formerly known as Reiter's syndrome), one grandfather had relapsing polychondritis, and two grandparents had coronary artery disease.😛>😛>
On examination, the patient, who was in a wheelchair, was alert and communicative. The temperature was 37.5°C, the blood pressure 119/63 mm Hg, the pulse 108 beats per minute, and the oxygen saturation 96% while she was breathing ambient air. There was mild tenderness of the sternum, which was reproduced with deep inspirations, and tenderness of the left costovertebral angle. The abdomen was soft and tender to palpation on the left side, with the most severe tenderness in the left lower quadrant; there was no rebound or guarding. Radial pulses were 2+. The remainder of the examination was consistent with spastic quadriplegia.😛>😛>
The platelet count and levels of serum electrolytes, glucose, calcium, phosphorus, magnesium, total protein, albumin, globulin, amylase, and lipase were normal, as were tests of renal function; other test results are shown in Table 1
Review of the peripheral-blood smear revealed anisocytosis (2+), polychromatocytosis (1+), hypochromatocytosis (2+), and microcytosis (3+). Urinalysis revealed clear amber urine with a specific gravity of 1.025, a pH of 6.0, 2+ bilirubin, 1+ protein, and trace amounts of ketones and urobilinogen; a culture was sterile.
While the patient was in the emergency department, narcotic analgesia was administered intravenously, and her pain decreased to a score of 7 out of 10. Eight hours after arrival, the patient vomited once; ondansetron was administered. Computed tomography (CT) of the abdomen was performed after the oral and intravenous administration of contrast material, but it was complicated by extravasation of the contrast material at the intravenous site in the right arm. The study showed malrotation of the left extrarenal pelvis, multiple cortical defects in the left kidney that were consistent with scarring, and a urinary catheter in the urethra. The spleen was mildly enlarged (14.8 cm in the craniocaudal dimension; upper limit of the normal range, 12 to 13). There were prominent periportal, mesenteric, inguinal, and retroperitoneal lymph nodes, up to 1.4 cm in diameter, with trace free fluid in the pelvis. The patient was admitted to the hospital early the next morning.
On the day of admission, the temperature was 38.1°C. The pain (rated as 8 out of 10) persisted, and narcotic analgesia was administered intravenously. Nausea and vomiting recurred but lessened after the administration of prochlorperazine. Treatment with dalteparin sodium was begun. A repeat culture of the urine grew rare mixed bacteria. The chest radiograph showed low lung volumes and no opacities that were suggestive of pneumonia. The next day, ultrasonography of the kidneys and the venous system of the lower extremities was normal, with no evidence of hydronephrosis or deep venous thrombosis.
During the third, fourth, and fifth hospital days, the serum iron-binding capacity and levels of iron, ferritin, folate, and vitamin B12 were normal; other laboratory-test results are shown in Table 1. On the third day, the temperature rose to 38.5°C. Urinalysis revealed leukocytes (>100 white cells per high-power field), and a urine culture grew Proteus mirabilis and Escherichia coli; blood cultures remained sterile. Ciprofloxacin was administered. The next day, a cherry-red rash developed on the patient's feet and resolved spontaneously after several hours. Ultrasonography of the abdomen was normal. Low-grade fevers occurred intermittently thereafter, and severe abdominal pain (8 out of 10) persisted; it was greatest in the left upper quadrant, with radiation to the left flank, and was associated with nausea and intermittent vomiting.
On the fifth day, testing for antibodies to Borrelia burgdorferi, cytomegalovirus (CMV), and hepatitis B and C viruses was negative, as were tests for antinuclear antibody, CMV antigenemia, and heterophile antibody; other test results are shown in Table 1. A CT scan of the abdomen, after the intravenous administration of contrast material, showed persistent mild splenomegaly with peripheral wedge-shaped areas of hypoattenuation that were consistent with infarcts; other findings were unchanged from the CT performed on admission.
Tests for malaria and antibodies to the human immunodeficiency virus (HIV) and heparin–platelet factor 4 were negative, as were nucleic acid testing for ehrlichia, Coombs' direct antibody test, cold-agglutinin screening, and testing for lupus anticoagulant; hemoglobin electrophoresis and levels of fibrinogen, homocysteine, lipoprotein(a), β2-glycoprotein I, antithrombin III, and protein C (functional) were normal. Other test results are shown in Table 1. Blood cultures remained sterile. Transthoracic echocardiography was normal, with no evidence of valvular vegetations.
On the 10th day, diagnostic test results were received..<o></o>.
