This month’s image is actually a CT scan. Take a look at the video below.
44yo woman presented to the ED. She just got off a plane from St. Vincents. Her chief complaint was fever, altered mental status and abdominal pain. During the course of her ED visit she had the CT scan shown above which helped with the diagnosis.
This case is a fairly complicated one, so I don’t expect you to get it from just the CT scan. Please post in the comments below with your questions about the case. You can ask for lab tests, more history, physical exam findings, perform an intervention or suggest a diagnosis you think is on the differential.
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nchristopher
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21 Comments
Nikita · November 18, 2012 at 10:50 am
Hey Neil, among other things, I feel like I see splenic lesions and I would wonder if there was an embolic source. Given the fever, abdominal pain and altered mental status – my questions would revolve around the consideration of atrial fibrillation and septic emboli such as endocarditis.
My questions:
Does she have a history of afib?
Is there a few murmur on exam?
Any prior or current history of IV drug use?
Niki
nchristopher · November 18, 2012 at 12:11 pm
The pt is altered so she cannot give a detailed hx. Family states she never had any abnormal rhythm. There’s no murmur on exam. As far as the family knows, no hx of IV drug use.
Ian deSouza · November 18, 2012 at 1:18 pm
Yeah NJ! I see splenic lesions. Infarcts, perhaps? The uterus also appears heterogeneous…..myomatous perhaps?
What about a previously undiagnosed hemoglobinopathy leading to splenic infarcts? Maybe had one patient like this in like 2004…
aregan · November 18, 2012 at 3:22 pm
I agree with Nikki that it looks like splenic infarcts with hepatosplenomegaly. Along the same lines, any h/o prosthetic valve? Do we know if she is immunocompetent (can we get an HIV test even though she is altered?) I think some of the AIDs-related illnesses like mycobacteria, CMV and disseminated crypto can look like this. How about infectious mono? Anything to suggest malaria? Can we have a CBC, CMP and peripheral smear
nchristopher · November 18, 2012 at 6:58 pm
Good thought’s guys… The pt does not have and hx of hemoglobinopathy or FH of the same. Also no hx of prosthetic valve. Lets say you can get consent for an HIV test from the family (although you can’t tell them the results). Here are the tests pending:
HIV, CBC, CMP, peripheral smear, anything else?
Ok…. so it’ll take the nurse a couple hours to draw the labs… then the lab will lose the tubes for a few hours and take a couple hours to give you the results… so I’ll post the labs tomorrow.
In the mean time, any other questions?
eabram · November 18, 2012 at 10:06 pm
Thanks, Neil!
For some more history: does she have any known medical conditions? Take any meds? Any fh of lupus or malignancy? Is she vomiting? Diarrhea? Anyone else sick? Hx of dvt?
For exam:
What is her abdominal and her lung exam like? Which part of her abdomen is tender? Is she jaundiced? What are her vitals? Pelvic exam? Rectal?
Ct:In addition to the other findings, she has small pleural effusions. On top of the other great diagnoses suggested, I’m wondering about lupus if this isn’t infectious. I’m also wondering about malignancy. Ascending cholangitis. Vasculitis. Finally, ruptured ectopic is low but present on my list.
I’d like Ana, crp and beta. Urinalysis. Don’t think coags will help.
BB · November 19, 2012 at 9:17 am
Given hepatosplenomegaly with splenic lesion/infarct, AMS, country of origin I am gonna go with ATLL from HTLV infection 🙂
nchristopher · November 20, 2012 at 10:19 am
Here are the labs:
CBC 8 > 7.1/ 21 < 110
Neut 16%, lymph 22%, band 58%, Meta 2%, mono 2%
CMP 133/ 5.3/ 96/ 15/ 118/ 3.54 < 327
Ca 8.8
LFT 6.9/ 3/ 967/ 231/ 55/ 0.9
beta negative
ANA negative
CRP elevated
UA 3+ hgb, 1+ gluc, 2+ prot, nit neg, LE neg, 10-25 rbc, 0-2 WBC
nchristopher · November 20, 2012 at 10:32 am
Also, no malaria parasites.
As far as further hx, no medical problems, no FH of lupus or malignancy, no meds, no hx of DVT.
Vitals 123/60, 117, 35, 101.7
Her exam is normal except for RUQ tenderness and fullness. No jaundice. Rectal exam is normal guiac negative. Pelvic was not done initially.
mritchie · November 21, 2012 at 10:16 am
Can I get a blood gas?
jsa · November 21, 2012 at 11:39 am
I think although rare you have to think ttp. Are there any schistocytes on the smear?
nchristopher · November 21, 2012 at 1:24 pm
ABG 7.50 pCO2 21 pO2 203 S98% HCO3 19.5 – Lactate 5.5
A smear was sent… the hematology tech says they don’t see any schistocytes…
HIV test was negative
nchristopher · November 21, 2012 at 1:27 pm
On another note… the prize will go to the first person who posts the correct SINGLE diagnosis. Many thanks to those that posted a DDx but if you want to be in the running you need to narrow your DDx to one item by Friday. GOOD LUCK!
jsa · November 21, 2012 at 4:05 pm
Any PT, PTT? did a fibrinogen level go off? D-Dimer? DIC??
nchristopher · November 21, 2012 at 5:06 pm
Pt/ptt 9/26/0.9
No d dimer or FIBRINOGEN was done
mritchie · November 22, 2012 at 9:28 am
I am going with systemic histoplasmosis.
She has a respiratory alkalosis, atelectasis vs infiltrate on ct with hepatosplenomegaly, anemia and elevated liver enzymes.
Carl · November 23, 2012 at 12:24 am
This is obviously dengue fever.
mritchie · November 23, 2012 at 12:48 am
Can I get a Lipase? Thought that maybe the head of the pancreas looked off.
nchristopher · November 24, 2012 at 12:44 am
Lipase was normal…
andygrock · November 24, 2012 at 12:43 pm
Great case. Especially during quiet nicu moments with Francis.
Our thoughts: AMS not completely addressed by above work-up. CT/LP? Other missing stuff: pelvic exam done at some point? Assume EKG sinus tach? CXR? EEG study? (20$$$$$).
Multi organ system failure including brain/kidney/spleen/liver/heme. Diff includes above mentioned endocarditis, histo, TTP, dengue, sepsis. To add: leptospirosis, TB/mycobacter, DVT with pfo leading to Arterial thrombi, anti-phospholipid syndrome, malignancy.
My guess leptospirosis, less likely, but hasn’t been mentioned yet.
Francis is voting for endocarditis. Which I think most likely, but, as it has been mentioned, he will not get any reward.
nchristopher · November 27, 2012 at 12:02 am
and the answer is….. see the next post!