Hot Seat #170: 11yo with Left Abdominal Pain

Posted on: April 19, 2021, by :

Case by Chris Kovaleski, MD. Inova Children’s

HPI: 8 year-old girl, otherwise healthy, presents with abdominal pain and emesis. The patient had abdominal pain starting three days ago, localized to her left side and associated with two episodes of non-bloody, non-bilious emesis. Otherwise denies fevers, diarrhea, urinary symptoms. She went to an outside urgent care where she was found to have a white blood cell count of 28 and is referred here for further care.

ROS: Decreased appetite, but otherwise denies constipation, sick contacts, cough or congestion. As above, no diarrhea, no dysuria, no urinary frequency.

Exam: Vitals: T-36.9, HR-126, RR-22. BP 117/69, SaO2: 100%RA

GEN: Uncomfortable-appearing

Pulm: Chest with mildly decreased aeration at bases, no wheezes, rhonci

CV: No murmurs, gallops

Abd/left flank with mild diffuse tenderness, guarding LUQ; TTP to L costal margin

Labs/Rad:

WBC: 30.0 (neutrophil predominance), Hemoglobin:13.9, Platelets:277, MCV: 82

Na; 133, K; 4.8, Cl: 96, CO2: 20, BUN: 9, Cr: 0.6, Glu: 96

AST 21 ALT 13 Lipase 4 Total Bili 0.4

CXR with no evidence of acute disease, UA pending collection

She develops a fever to 101 during the course of her evaluation. HR 122. BP 124/71. RR 26. Urine still pending collection.

Urine is obtained and she receives empiric ceftriaxone. UA notable for Large (>160) ketones but negative for leukocyte esterase, nitrites, or WBC. CT abd/pelvis with IV/PO contrast obtained and notable for prominent diffusely hypoenhancing spleen with nonopacification of the splenic vessels at the hilum, concerning for splenic artery thrombosis of uncertain etiology. Further history obtained from family notable for no sickle cell disease or clotting disorders.

Discussed with pediatric surgeon. No role for emergent surgical intervention. Peds hem-onc with no recommendations for specific laboratory/imaging/management at this time. Given involvement of both splenic vessels, the radiologist is asked to comment further on possibility of torsion-process — per discussion, there are no overt signs of torsion/twisting but could be considered to have indirect features of splenic torsion.

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Brian Lee
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