An elderly male with fever and abdominal pain

The patient has been dully informed and consent has been taken to disclose his particulars and illness in front of this

gathering.

Particulars of the patient

• Name: X• Age: 75 years• Sex: Male• Religion: Islam• Marital status: Married• Occupation: Retired Govt. officer• Address: Mirpur DOHS, Dhaka• Date of examination: 12.05.15

Presenting complaints

1. Fever for 25 days2. Abdominal pain for 25 days

History of present illness

• FeverHigh gradeIntermittent (Quotidian)Highest recorded temperature was 106°FChills and rigorSubsided with profuse sweating

• Abdominal painUpper and right side of the abdomenNo radiationColicky Occasional vomitingRelieved by taking diclofenac suppository

• Systemic enquiryAnorexia Weight loss of about six kgPruritus for last six days more intense at night

No headacheJoint painCough Breathlessness Jaundice Burning micturationAltered consciousnessNo hematemesis or melenaNo altered bowel habit

• Non diabetic• Normotensive • IHD - Single vessel disease. PCI & stenting -

2008

• Treated with ciprofloxacin, levofloxacin, cefixime and ceftriaxone without any improvement.

• Fever responded to meropenem and the drug was continued for 14 days.

Past medical history

• He was investigated with a USG of abdomen one year back for colicky upper abdominal pain diagnosed sonologically as choledocholithiasis

• ERCP was performed subsequently but no stones were found and intrahepatic and extrahepatic biliary channels were normal. Papillotomy was performed at that setting.

• No past illness of jaundice, tuberculosis or other significant illness

Personal history

• Non smoker• Non alcoholic

Social history

• Middle class family

Travel history

• No significant travel history

Physical examination

• General examinationToxic Febrile (103°F)Pulse – 96/min, regularBP – 110/70 mm Hg

No jaundiceNo anemiaNo clubbingNo significant lymphadenopathyNo bony tendernessNo purpuraNo edema

• Examination of abdomenRight hypochondriac and epigastric tendernessNo hepato-splenomegalyNo other massesNo para aortic lymphadenopathyDigital rectal examination was normal

• Examination of other system:Normal

Salient features

• Mr. X, 75 years, non diabetic and normotensive patient presented with High grade and intermittent fever associated with

chills and rigor for 25 days. He had also history of severe colicky epigastric

and right hypochondriac pain which was sometimes associated with vomiting for the same duration..

On query, he also give history of marked anorexia, weight loss during the period of his illness

For the last six days he complained of pruritus that became more intense at night.

He had no history of cough, chest pain, joint pain, hematemesis or melena, alteration of bowel or bladder habit.

• On general examinationHe is febrile with normal vitals. He had no anemia,

jaundice, clubbing, lymphadenopathy.

• Examination of abdomen revealedTenderness over the epigastrium and right

hypochondriac region. He had no hepato-splennomegaly and para aortic lymphadenopathy.

• Examination of other systems revealed no abnormalities

Investigations

• CBCWBC – 20,300/cmm

DCo Neutrophil – 92%o Lymphocyte – 4%o Monocyte – 3%o Eosinophil – 1%

Platelet – 232,000/cmmHb – 10.50 gm/dlESR – 45 mm in the 1st hour

• Urine R/M/EProtein: +Reducing substance: NilPus cell: 2-3/HPFRBC: Nil

• Urine C/S: No growth• Blood culture: No growth

• Random blood glucose: 5.2 mmol/l• Chest x-ray – Normal• ECG – Old anterior MI• Echo

Inferior wall, inferior septum & inferolateral wall hypokinesia at basal level. Anterior wall, anterior septum & antero-lateral wall hypokinesia at mid and apical level

EF – 44%

• Serum creatinine – 1.1 mg/dl• Serum bilirubin – 1.2 mg/dl• ALT – 57 U/L• Alkaline phosphatase – 550 U/L ( Ref 40-129

U/L)• Serum amylase – 95 U/L

• Plain x-ray abdomen – Normal• USG ( on 6 days of fever)

Mild fatty change in liver with increased periportal echogenecity

Slight dilated intrahepatic biliary tree but extra hepatic ducts are normal

A small left renal cyst is seen in the upper pole

• MRCP was planned but could not be performed due to coronary artery stenting.

• Spiral CT scan of upper abdomen (on 22nd day of fever)Liver is enlarged in size, hypodense areas are

observed in both lobes of liver more on left lobesGall bladder is not discernable.Post contrast images revealed target like

enhancement of hepatic lesionsIntrahepatic biliary channels reveal air within the

lumenSimple cortical cysts are seen in both kidneys

Impression: Findings are in favour ofoHepatomegaly with metastasiso Fibrosed/? Operated gall bladderoBilateral simple renal cysts

• USG of HBS and USG guided FNAC from the lesionMultiple SOL in the both lobes of liver suggestive

of secondaries.

• FNAC Smears of aspirate show scattered and occasional

clusters of cells with hyperchromatic mildly pleomorphic nucleus and moderate amount of cytoplasm mixed with inflammatory cells and red blood cells. Features are suggestive of malignant lesion, metastatic.

• CEA – 6.14 ng/ml (Ref <5, smoker’s <10)• CA 19-9 – 14.4 U/ml (Ref < 33)• Alpha feto protein – 1.56 ng/ml (Ref up to 15)• Endoscopy of upper GIT – Normal• Colonoscopy – normal colon & rectum

The End

• Follow up USG of HBS (six weeks after the patient became afebrile)Multiple SOL in the liver, more on the left lobe –

suggestive of metastasis

• Follow up CT scan of HBS (3 months after first CT scan)Multiple pneumobilia in biliary channels causing

mild dilatationsBilateral renal cortical cyst