Pictorial quiz: A 2-year-old boy with abdominal pain

A 2-year-old boy presented with abdominal pain and non-coffee-ground emesis for 1 day. He was afebrile and without decreased activity. Examination showed lower abdominal tenderness, but psoas and obturator signs were negative. Laboratory test showed mildly elevated C-reactive protein (1.321 mg/dL) without leukocytosis. An abdominal X-ray revealed a high-attenuation-calcified lesion near the right sacroiliac joint which was highly suspected as an appendicolith. Subsequent abdominal computed tomography proved an appendicitis with appendicolith inside. He underwent laparoscopic appendectomy and was discharged uneventfully 4 days later. Acute appendicitis is a commonly misdiagnosed pediatric emergency because of the atypical presentations. Appendicoliths are presented in more than half of pediatric appendicitis and are highly associated with perforation. Surgery is recommended instead of antibiotics therapy alone to manage appendicolith-related appendicitis. A careful interpretation of the plain abdominal films and keeping a high suspicion are vital to early diagnosis of this disease.

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APPENDECTOMY IN CHILDREN WITH ACUTE RHEUMATIC FEVER

PEDIATRICS ◽

10.1542/peds.43.4.573 ◽

1969 ◽

Vol 43 (4) ◽

pp. 573-577

Author(s):

Jer-Shoung Lin ◽

Ramon Rodriguez-Torres

Keyword(s):

Differential Diagnosis ◽

Abdominal Pain ◽

Acute Appendicitis ◽

Rheumatic Fever ◽

Acute Rheumatic Fever ◽

Laboratory Data ◽

Initial Symptom ◽

C Reactive Protein ◽

Reactive Protein ◽

The Right

Clinical and laboratory data on five patients with appendectomy, later proved to have acute rheumatic fever, are presented in detail. The findings indicate that abdominal pain simulating acute appendicitis can be presented as the only initial symptom in acute rheumatic fever. Awareness and knowledge of the presence of clues-high fever, rapid sedimentation rate, prolonged P-R interval, and 4 plus C-reactive protein-usually help to make the differential diagnosis. However, if doubt remains, the right approach is to go ahead with surgery since these patients tolerate anesthesia and laparotomy very well.

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Recurrent Empyema Thoracic Secondary to Pulmonary Nocardiosis in Immunocompetent Patients

Case Reports in Pulmonology ◽

10.1155/2020/8840920 ◽

2020 ◽

Vol 2020 ◽

pp. 1-5

Author(s):

Samshol Sukahri ◽

Lily Diana Zainudin ◽

Mohd Firdaus Hadi ◽

Mohd Al-Baqlish Mohd Firdaus ◽

Muhammad Imran Abdul Hafidz

Keyword(s):

Vital Signs ◽

C Reactive Protein ◽

Nocardia Species ◽

X Ray ◽

Reactive Protein ◽

Pulmonary Nocardiosis ◽

Erythrocyte Sedimentation ◽

Chest X Ray ◽

The Right ◽

Tomography Scan

Pulmonary nocardiosis is a rare disorder that mainly affects immune-compromised patients. We report a 37-year-old male who presented with persistent fever associated with productive cough. During this course of therapy, he had recurrent admissions for empyema thoracic. Clinically, his vital signs were normal. Blood investigations show leukocytosis with a significantly raised erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Sputum acid-fast bacilli (AFB) was scanty 1+ and sputum mycobacterium culture was negative. Chest X-ray (CXR) showed consolidative changes with mild to moderate pleural effusion on the right side. Skin biopsy was taken and showed Paecilomyces species. A computed tomography scan (CT thorax) was performed and revealed a multiloculated collection within the right hemithorax with a split pleura sign. Decortications were performed and tissue culture and sensitivity (C+S) growth of Nocardia species. And it is sensitive to sulfamethoxazole-trimethoprim and completed treatment for 4 months. This case highlights that pulmonary nocardiosis should be kept in mind in also immune-competent patients, especially in suspected cases of tuberculosis not responding to antitubercular therapy.

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Undifferentiated Abdominal Pain in Children Presenting to the Pediatric Emergency Department

Clinical Pediatrics ◽

10.1177/0009922819867459 ◽

2019 ◽

Vol 58 (11-12) ◽

pp. 1212-1223

Author(s):

Brendan R. Harris ◽

Sri S. Chinta ◽

Ryan Colvin ◽

David Schnadower ◽

Phillip I. Tarr ◽

...

Keyword(s):

Computed Tomography ◽

Emergency Department ◽

Abdominal Pain ◽

Laboratory Tests ◽

Pediatric Emergency ◽

Pediatric Emergency Department ◽

C Reactive Protein ◽

Reactive Protein ◽

Laboratory Results ◽

Ed Visits

Although common, little is known about the characteristics and management of undifferentiated abdominal pain (UAP) in the pediatric emergency department (ED). This study was a 12-month retrospective study for “abdominal pain” ED visits. Patients without an identifiable diagnosis were categorized as “UAP,” while others with identified disease processes were categorized as “structural gastrointestinal diagnosis (SGID).” We included 2383 (72%) visits with 869 (36.5%) UAP visits and 1514 (63.5%) SGID visits. SGID patients had more laboratory tests (811 [53.6%] vs 422 [48.6%], P = .0186), and often had multiple tests performed (565 [69.7%] vs 264 [62.6%], P = .0116). Computed tomography and ultrasound scans were more common in SGID (computed tomography: 108 [7.1%] vs 27 [3.1%], P = .0004; ultrasound: 377 [24.9%] vs 172 [19.9%], P = .0044), and laboratory results (white blood cell count, hemoglobin, albumin, C-reactive protein) were abnormal at significantly higher rates. Analyses revealed the duration of pain as primary covariate in variance of pain etiology. Clinical features, such as duration of pain, may be augmented by laboratory tests to facilitate recognition of UAP in the ED.

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Immunohistochemical detection of procalcitonin in fibrolamellar hepatocellular carcinoma

Clinical Journal of Gastroenterology ◽

10.1007/s12328-021-01354-1 ◽

2021 ◽

Author(s):

Kotaro Matsumoto ◽

Kentaro Kikuchi ◽

Ayako Hara ◽

Hiromichi Tsunashima ◽

Koichi Tsuneyama ◽

...

Keyword(s):

Hepatocellular Carcinoma ◽

Histopathological Examination ◽

Epigastric Pain ◽

Positive Staining ◽

C Reactive Protein ◽

Fibrolamellar Hepatocellular Carcinoma ◽

Tumor Biopsy ◽

Reactive Protein ◽

Right Lobe ◽

The Right

AbstractA 25-year-old woman with fever and epigastric pain was referred to our hospital. Blood examination showed significant liver dysfunction, markedly high C-reactive protein (CRP 19.1 mg/dL) and procalcitonin (48.3 ng/mL) levels. Dynamic computed tomography showed a tumor approximately 120 mm in size in the right lobe of the liver, but with no abscess formation. The patient was hospitalized and started on antibiotics; her CRP level improved, but the procalcitonin level did not decrease. Histopathological examination of the liver tumor biopsy revealed fibrolamellar hepatocellular carcinoma (FLC). Positive staining of the FLC with an anti-procalcitonin antibody suggested the production of procalcitonin.

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Nasopharyngeal Carriage of Invasive Pneumococcal Serotypes During Childhood Community-Acquired Alveolar Pneumonia Is Associated With Specific Clinical Presentation

The Journal of Infectious Diseases ◽

10.1093/infdis/jiz513 ◽

2019 ◽

Author(s):

Yaniv Faingelernt ◽

Ron Dagan ◽

Noga Givon-Lavi ◽

Shalom Ben-Shimol ◽

Jacob Bar-Ziv ◽

...

Keyword(s):

Clinical Presentation ◽

Pediatric Emergency ◽

Nasopharyngeal Carriage ◽

Pneumococcal Serotypes ◽

C Reactive Protein ◽

Blood Cell Count ◽

Invasive Potential ◽

Viral Detection ◽

Reactive Protein ◽

Lower Oxygen

Abstract Background Streptococcus pneumoniae (Pnc) serotypes differ in invasive potential. We examined whether community-acquired alveolar pneumonia (CAAP) in children carrying commonly recognized pneumonia invasive pneumococcal serotypes ([PnIST] 1, 5, 7F, 14, and 19A) differs from CAAP in children carrying less invasive serotypes (non-PnIST) or no Pnc (Pnc-neg). Methods Children <5 years, visiting the only regional Pediatric Emergency Room, with radiologically proven CAAP were enrolled. Nasopharyngeal cultures were processed for pneumococcal isolation and serotyping. Clinical and demographic characteristics were recorded. The study was conducted before pneumococcal conjugate vaccine implementation in Israel. Results A total of 1423 CAAP episodes were recorded: PnIST, 300 (21.1%); non-PnIST, 591 (41.5%); and Pnc-neg, 532 (37.4%). After adjustment for age, ethnicity, seasonality, and previous antibiotics, the following variables were positively associated with PnIST carriage compared with both groups: temperature ≥39°C, peripheral white blood cell count ≥20 000/mm3, C-reactive protein ≥70.0 mg/L, and serum sodium <135 mEq/L. Lower oxygen saturation, viral detection, and comorbidities were negatively associated with Pn-IST carriage (odds ratios, <1.0). Differences between non-PnIST carriers and Pnc-neg groups were smaller or nonsignificant. Conclusions Young children with CAAP carrying common PnIST had a lower proportion of comorbidities, hypoxemia, and viral detection and had more intense systemic inflammatory response than those carrying non-PnIST or not carrying Pnc.

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Induced by infection? A case of acute myocardial infarction with hypothermia

Journal of International Medical Research ◽

10.1177/0300060519860674 ◽

2019 ◽

Vol 47 (8) ◽

pp. 3963-3967

Author(s):

Liang Li ◽

Shudong Xia ◽

Chao Feng

Keyword(s):

Myocardial Infarction ◽

Abdominal Pain ◽

Body Temperature ◽

Vital Signs ◽

Reactive Protein ◽

St Segment ◽

Intravenous Antibiotics ◽

St Elevation ◽

Electrocardiographic Findings ◽

The Right

A 52-year-old man was admitted to our hospital because of abdominal pain, nausea, and vomiting. On arrival, his body temperature was <35°C. Although his other vital signs and electrocardiographic findings were normal, his white blood cell count and C-reactive protein concentration were elevated. He was diagnosed with severe infectious disease and treated with intravenous antibiotics and rewarming therapy. Two hours later, his body temperature had increased to 38.4°C, but his abdominal pain persisted. A repeat electrocardiographic examination showed an elevated ST-segment in leads II, III, and aVF. He was then diagnosed with ST-elevation myocardial infarction. Coronary angiography showed occlusion of the right coronary artery, and he underwent implantation of two stents. His symptoms were relieved soon thereafter, and his body temperature returned to normal without antibiotics.

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Sclerosing osteomyelitis of Garré: A confusing clinical diagnosis

Journal of Orthopaedic Surgery ◽

10.1177/2309499019874704 ◽

2019 ◽

Vol 27 (3) ◽

pp. 230949901987470

Author(s):

Seungcheol Song ◽

Hwa Jae Jeong ◽

Hun-Kyu Shin ◽

Eegene Kim ◽

Se-Jin Park ◽

...

Keyword(s):

Proximal Femur ◽

Chronic Osteomyelitis ◽

Magnetic Resonance Images ◽

Thigh Pain ◽

C Reactive Protein ◽

Reactive Protein ◽

Lower Back ◽

Erythrocyte Sedimentation ◽

The Right

We describe a rare case of sclerosing osteomyelitis of Garré in a 63-year-old woman with uncontrolled right thigh pain. She had suffered from lower back pain and radiating pain on the right lower leg for a year and 4 months and so had spine surgery 8 months ago. But the right thigh pain persisted, and the levels of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) remained abnormal. Right femur radiographs showed cortical thickening on the proximal femur. Magnetic resonance images showed T2 hypersignal intensity lesions in the proximal femur. Under suspicion of osteoid osteoma or sclerosing osteomyelitis, surgery was performed with biopsy, bone curettage, and drilling. The culture was negative, and the biopsy showed chronic osteomyelitis. Despite surgery, the levels of CRP and ESR still remained abnormal. After using venous antibiotics, the pain subsided and CRP and ESR levels turned to normal. Followed by 6 weeks of oral antibiotics, pain was relieved after 1-year follow-up.

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Disseminated Nocardia infection with a lesion occupying the intracranial space complicated with coma: a case report

BMC Infectious Diseases ◽

10.1186/s12879-020-05569-4 ◽

2020 ◽

Vol 20 (1) ◽

Cited By ~ 1

Author(s):

Mei-Hong Yu ◽

Xiao-Xin Wu ◽

Chun-Lei Chen ◽

Song-Jia Tang ◽

Jian-Di Jin ◽

...

Keyword(s):

Case Report ◽

Immunosuppressive Treatment ◽

Lung Infection ◽

C Reactive Protein ◽

Altered Consciousness ◽

Blood Cell Count ◽

Case Presentation ◽

Reactive Protein ◽

Nocardia Cyriacigeorgica ◽

The Right

Abstract Background Disseminated Nocardia infection is a disease that is easily overlooked in patients with lesions occupying the intracranial space complicated with coma. Early diagnosis and treatment are crucial. Case presentation A 65-year-old man was admitted to the First Affiliated Hospital of Zhejiang University in October 2018 with weakness in the right limbs for 3 days and altered consciousness for 1 day. Five months earlier, he had been diagnosed with membranous kidney disease and had received cyclophosphamide and prednisone. At admission, the white blood cell count was 1.37 × 1010/L (with 86.4% neutrophils), and C-reactive protein was 115.60 mg/L. Imaging examinations revealed a lesion occupying the intracranial space, lung infection, and multiple abscesses in the rhomboid muscle. The abscesses were drained. Pus culture confirmed Nocardia cyriacigeorgica infection. With antibiotics and vacuum-sealed drainage of the back wound, the patient improved and was discharged from the hospital. Conclusions This case report shows that infection should be considered during the differential diagnosis of lesions in the intracranial space, especially in patients receiving immunosuppressive treatment. In patients with disseminated N. cyriacigeorgica infection, combination antibiotic therapy and surgical drainage of localised abscesses can be effective.

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Escherichia coli Panophthalmitis after Pecking by a Great Egret (Ardea alba)

Case Reports in Ophthalmology ◽

10.1159/000509340 ◽

2020 ◽

Vol 11 (2) ◽

pp. 466-472

Author(s):

Takashi Ono ◽

Kentaro Abe ◽

Yosai Mori ◽

Ryohei Nejima ◽

Takuya Iwasaki ◽

...

Keyword(s):

Elevated Serum ◽

Ocular Infection ◽

Ocular Injury ◽

C Reactive Protein ◽

Upper Eyelid ◽

Protein Levels ◽

Reactive Protein ◽

Cell Counts ◽

Open Globe ◽

The Right

We report a case of open globe injury caused by Ardea albapecking that resulted in Escherichia colipanophthalmitis. A woman in her 70s complaining of ocular pain was referred to our hospital because her right eye had been pecked by an A. alba2 days earlier. Visual acuity in her right eye was reduced to light sensation. The right conjunctiva became hyperemic and edematous with swelling of the right upper eyelid. The upper side of the right cornea was densely cloudy with focal defect. Ultrasonography showed a thick sclera and choroid-like structure. Pathological investigation of a scraped sample from the infected site revealed gram-negative rods; E. coli was isolated. She had fever with elevated serum C-reactive protein levels and leukocytosis confirmed by laboratory examination. Topical levofloxacin and cefmenoxime and intravenous fosfomycin and aspoxicillin were initiated, but the right cornea melted near the perforated site with leakage of the eyeball contents on the next day. We decided to perform eye evisceration because of difficulty in controlling corneal melting and panophthalmitis. Her general state recovered the day after surgery. Orbital cellulitis improved gradually with normal C-reactive protein levels and white blood cell counts. As ocular injury caused by birds could become severe and cause ocular infection and visual dysfunction, it is important to exercise caution in the vicinity of wild birds, especially when they are aggressive.

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Stroke as the Sole Manifestation of Takayasu Arteritis in a 15-Year-Old Boy with Latent Tuberculosis

Case Reports in Neurological Medicine ◽

10.1155/2016/8736248 ◽

2016 ◽

Vol 2016 ◽

pp. 1-4 ◽

Cited By ~ 1

Author(s):

Espen Benjaminsen ◽

Anne Reigstad ◽

Vanja Cengija ◽

Vibke Lilleby ◽

Maria Carlsson

Keyword(s):

Carotid Artery ◽

Takayasu Arteritis ◽

Common Carotid Artery ◽

Right Hemisphere ◽

Latent Tuberculosis ◽

C Reactive Protein ◽

Laboratory Findings ◽

Case Presentation ◽

Reactive Protein ◽

The Right

Introduction. Takayasu arteritis is a rare disease affecting the aorta and its main branches, causing arterial claudication and end-organ ischemia, including stroke. The etiology is unknown but is believed to be autoimmune. An association between Takayasu arteritis and tuberculosis has been suggested, but the possible relation is unclear.Case Presentation. A 15-year-old Somali boy was diagnosed with latent tuberculosis. He had a lesion in the right lung, and both the tuberculin skin test by the Mantoux method and Quantiferon GOLD test turned out positive. After he suffered a cerebral infarct in the right hemisphere, childhood Takayasu arteritis was diagnosed. The diagnosis was based on diagnostic imaging showing a high-grade stenosis of the origin of the right common carotid artery, an occluded common carotid artery on the left side, a circumferential thickening of the vessel walls in the right and left common carotid artery, and laboratory findings with elevated C-reactive protein.Conclusion. Takayasu arteritis is an uncommon cause of stroke. It should however be kept in mind as a cause of cerebrovascular disease, especially in the young.

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