Case by Ilana Lavina MD, CNMC PEM Fellow

A previously healthy 17-year-old female is presenting with 3 months of abdominal pain, distension and anemia. She is being referred in by an outpatient GI at another institution. The patient reports that she had been in her usual state of health until 3 months ago when she noticed a decrease in appetite associated with abdominal pain that was exacerbated with eating.

First, she saw her PCP and was diagnosed with constipation and gastritis, but neither stool softeners nor anti-reflux medications improved her symptoms. She gradually noticed abdominal distension, ongoing weight loss, and was referred to an OSH GI. She reports that she had multiple tests including a CT scan and “testing of the fluid from the abdomen” but was not told of any results. She returned to her GI doctor today and had repeat labs which demonstrated a significant drop in hemoglobin from ~10.8 to around 8 over the last month. She was also noted to have interval weight loss of about 50 pounds over 3 months.

VS: T 36.5 C Pulse 118 bpm Respiratory Rate 18 br/min  BP 115/74 mmHg SpO2 100 %

General:  Alert.  appropriate for age.  cooperative.  

Skin:  Pale

Head:  Normocephalic.  atraumatic.  

Neck:  Trachea midline.  no tenderness.  no lymphadenopathy.  

Eye:  Pupils are equal, round and reactive to light.  extraocular movements are intact.  normal conjunctiva.  no discharge.  no jaundice.  vision grossly normal.  

Ears, nose, mouth and throat:  No pharyngeal erythema or exudate.  Dentition intact.   dry mucous membranes.  

Cardiovascular:  No murmur.  Normal peripheral perfusion.  Extremity pulses equal.  tachycardic.  

Respiratory:  Lungs are clear to auscultation.  respirations are non-labored.  breath sounds are equal.  

Chest wall:  No tenderness.  No deformity.  

Back:  Normal alignment.  no step-offs.  

Musculoskeletal:  Normal ROM.  normal strength.  no tenderness.  no swelling or edema.  no deformity.  moves all extremities.  

Gastrointestinal:  Normal bowel sounds.  + Distension, Mild abdominal TTP on the left side.  Firm but compressible. +Fluid shift.  

Neurological:  Alert.  No focal neurological deficit observed.  CN II-XII intact.  normal speech observed.  developmentally normal.  

Lymphatics:  No lymphadenopathy

Psychiatric:  Cooperative.  appropriate mood & affect

AXR reveals a non-obstructive bowel gas pattern with no free air, small amount of stool, and excess small bowel gas with air-fluid levels suggestive of ileus or enteritis. 

Abdominal US revealed hepatomegaly with nonspecific diffuse increased echogenicity.  Spleen is within normal limits for size, however with nonspecific diffuse heterogeneous echogenicity. Gallbladder sludging without evidence of acute cholecystitis. Intra-abdominal noncomplicated small free fluid.

CBC reveals anemia with a hemoglobin of 7.8, normal platelet and WBC count and unremarkable differential, CMP reveals normal AST (14) and ALT (10) but elevated Tbili to 1.5, hypoalbuminemia to 2.0, normal Cr and kidney function. Uric acid low at 1.9; LDH slightly elevated (294, upper limit of normal 213). Coags are abnormal with INR 1.39, PTT 39.

You take a moment to review CRISP and you see the result from her prior CT at the OSH which revealed “ascites with omental nodularity and serosal implants at the dome of the liver, with associated mesenteric adenopathy and prominent retroperitoneal lymph nodes and cardiophrenic lymph nodes, which encases small bowel without obstruction; constellation of findings suggestive of infectious etiology (TB), less likely are malignant etiologies”. A Quantiferon Gold test and chest XR done at that time both had negative results.

You discuss travel history with the patient and she states she was born in the US. Travelled to the Philippines and to Canada. She does not spend any time in homeless shelters or near anyone who was incarcerated. You decide to repeat the patient’s abdominal CT scan and discuss with the radiologist who recommends IV and PO contrast. It shows intra-abdominal findings of hepatic steatosis, mild ascites, and probable right lower lobar segmental and subsegmental pulmonary emboli, multiple sub-6mm pulmonary nodules, with overall picture nonspecific but suggesting chronic infectious vs. neoplastic processes.

You obtain CT-PE which reveals a right lower lobar pulmonary embolism with extension into multiple segmental and subsegmental pulmonary arteries, and cavitary right upper lung lobe lesion, numerous bilateral pulmonary nodules, thoracic adenopathy, and subcapsular hepatic lesions. The radiologist tells you that these findings are highly concerning for disseminated tuberculosis or fungal infection, with malignancy on the differential as well.