Acute abdominal pain as the initial manifestation of meningococcemia in adult patient / Dolor abdominal agudo como manifestación inicial de meningococemia en un paciente adulto

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[Treatment of abdominal tuberculosis : Background, diagnostics and treatment of a global problem]. / Therapie der abdominellen Tuberkulose : Hintergrund, Diagnostik und Therapie einer globalen Problematik.

BACKGROUND: Tuberculosis (TB) is among the 10 leading causes of global deaths and is a special threat to immunocompromised patients with human immunodeficiency virus (HIV). Due to migration from endemic areas cases in central Europe can also increase. OBJECTIVE: This article gives an overview of background information, detection methods, treatment and the role of surgery in abdominal manifestation of a systemic infection. MATERIAL AND METHODS: A PubMed search was carried out using the following keywords: abdominal TB, incidence, symptoms, diagnostics, treatment and surgery. RESULTS: The detection of TB in cases of abdominal manifestation can be carried out via percutaneous biopsy; however, laparoscopy is recommended due to the better detection rate, low complication rate and its ability to differentiate other diseases, such as peritoneal carcinomatosis and lymphomas. Antituberculous drugs are the primary treatment. An acute abdomen can occur in up to approximately 30% of cases. Complications such as strictures and perforations require surgical treatment. CONCLUSION: Although the prevalence of TB is decreasing, the infection causes more than 1 million deaths per year. The correct diagnosis can be impeded by a misleading clinical presentation. A multidisciplinary approach enables rapid and efficient diagnostics and treatment.

Group A streptococcal pharyngitis associated with primary peritonitis.

Primary peritonitis, a bacterial infection within the peritoneal cavity that arises in the absence of an intraperitoneal source, is a rare entity in paediatrics. We describe the case of a previously healthy 11-year-old girl who presented with an acute abdomen and was found to have primary peritonitis due to Streptococcus pyogenes She had an episode of pharyngitis with pharyngeal cultures positive for S. pyogenes in the month prior to presentation. We performed a review of the literature to better elucidate the risk factors, pathophysiology and presentation of peritonitis due to S. pyogenes and to draw attention to the potential association between group A streptococcal pharyngitis and peritonitis.

[Acute abdominal pain caused by neuroborreliosis]. / Acute buikpijn bij neuroborreliose.

BACKGROUND: Lyme disease is a multisystem disease which can present itself in several ways. When the nervous system is involved, it is called Lyme neuroborreliosis. Both central and peripheral nervous systems can be affected. CASE DESCRIPTION: A 39-year-old man visited the emergency department multiple times with severe abdominal-pain attacks with motoric unrest. Extensive diagnostic work-up was done, which was initially inconclusive. Lyme neuroborreliosis was suspected when he developed a facial-nerve palsy during admission; the abdominal pain was thought to be caused by thoracic radiculoneuropathy. Serologic testing for antibodies against Borrelia burgdorferi was positive, confirming the diagnosis. The patient was treated with intravenous ceftriaxone. CONCLUSION: This case shows abdominal pain being caused by radiculoneuropathy at thoracic level, an uncommon presentation of Lyme neuroborreliosis. Often, this diagnosis is only made when neurological paralysis occurs. Information regarding skin lesions or a recent tick bite can lead to earlier recognition of the diagnosis.

A Case Report and Literature Review of Scrub Typhus With Acute Abdomen and Septic Shock in a Child-The Role of Leukocytoclastic Vasculitis and Granulysin.

Scrub typhus is becoming a clinically important cause of acute undifferentiated febrile illness in Taiwan. The incubation period is between 6 and 21 days after exposure. It is transmitted by chiggers (larva of trombiculid mite) in long grasses and in dirt-floor homes, with infection characterized by a flu-like illness of fever, headache, and myalgia lasting approximately 1 week. It has various systemic manifestations, including GI symptoms. In some, the illness progresses to multiorgan dysfunction syndrome and death. We report on a 13-year-old boy who lived in Taipei City and who had initially tentative diagnosis of acute pyrexia of unknown origin with high fever up to 40.3°C for 1 week, but later had thrombocytopenia and diffuse abdominal pain with peritoneal sign suspected acute appendicitis. During the clinical course, septic shock and disseminated intravascular coagulopathy (DIC) were noted. There were skin rash in his trunk and extremities and an eschar with black crust surrounded by a scaling erythematous rim on his right buttock. In addition, we got the information of his travel history in Green Island and Orchid Island for 10 days.With the correct antibiotics, vancomycin, meropenem, and doxycycline, the patient was getting better and corresponding with high level of granulysin and tumor necrosis factor-alpha. The diagnosis of scrub typhus was confirmed by the biopsy of eschar and high quantitative real-time polymerase chain reaction values of Orientia tsutsugamushi (16sRNA and 56 kDa) tested by Centers for Disease Control and Prevention, Taiwan. Histopathological findings of the eschar revealed the leukocytoclastic vasculitis, crust and thrombus formation with many gram-negative microorganisms, O. tsutsugamushi demonstrated by 47 kDa monoclonal antibody immunohistochemical stain and electromicroscopy. OUTCOMES: After the careful selection of appropriate antibiotics including meropenem, vancomycin, and doxycycline, he recovered and was subsequently discharged 7 days after admission. LESSON SUBSECTIONS: This case highlights that scrub typhus infection can mimic acute abdomen and septic shock with DIC. This rare presentation of acute abdomen and septic shock with thrombocytopenia and DIC caused by scrub typhus should remind physicians to be alert to the possibility of acute abdomen and febrile illness resulting from scrub typhus.

Surgical management of colonic basidiobolomycosis among adolescent and adult patients: presentation and outcome.

AIM: The aim of this study was to review retrospectively the clinical presentations, indications for surgery and surgical outcomes of adolescent and adult patients who were diagnosed with colonic basidiobolomycosis in the last 10 years. METHOD: The study was carried out in Aseer Central Hospital, Abha, Saudi Arabia by reviewing the medical files of all patients in the last 10 years who were diagnosed with colonic basidiobolomycosis and required surgical intervention. RESULTS: There were 22 patients. Common findings in all patients were weight loss, abdominal pain and an abdominal mass. The right colon was affected in 21 patients. The initial diagnosis was correct in seven patients while nine were thought to be malignant. All patients underwent colonic resection followed by at least 1 year of antifungal medical treatment. Intra-operatively, all patients had moderate or dense adhesions, an abdominal mass and lymphadenopathy. Most surgeons had the impression intra-operatively that the diagnosis was inflammatory rather than malignant. Postoperatively, three patients died within 6 months of the operation due to progression of the disease. Four patients developed severe wound infections, three of whom had abdominal dehiscence and required re-closure. CONCLUSION: Colonic basidiobolomycosis is a life-threatening fungal infection that should be considered a surgical condition. A high index of suspicion including basidiobolomycosis in the differential diagnosis for the acute abdomen with a colonic mass is required for a proper diagnosis. Early aggressive surgical management followed by a prolonged course of itraconazole postoperatively could improve the outcome of the condition.

Multiple jejunal perforation secondary to intestinal tuberculosis infection: a case report.

Abdominal tuberculosis (TB) may affect any part of the gastrointestinal tract resulting in significant morbidity and mortality. There is an increase in the incidence of abdominal TB favored by the emergence of multi-drug resistant Mycobacterium tuberculosis and immunosuppression especially from HIV co-infection. Our case is that of a 31 year old HIV-positive woman, adherent to antiretroviral therapy, who presented with a 2 month history of progressive abdominal distention, drenching night sweat and fatigue, but without fever. She was admitted on a presumptive diagnosis of peritoneal TB, and suddenly developed signs and symptoms of an acute abdomen. Laboratory investigations showed a CD4+ count of 155 cells/µL, white blood cell count of 15,700 cells/mm3 and haemoglobin of 8.0g/dl. An emergency laparotomy revealed small bowel caseous necrosis with multiple jejunal perforations. Ziehl-Nelsen staining of operative specimen was positive for acid fast bacilli. Given her immunodeficiency status, clinical signs and symptoms, CD4 cell count > 50 cells/µL, and intestinal sample showing caseous necrosis and perforations, a final diagnosis of intestinal TB was made. In conclusion, abdominal tuberculosis may mimic a number of intra-abdominal pathologies; thus should always be considered as a differential diagnosis in patients presenting with acute abdomen in TB-endemic areas especially in an HIV-positive individual.

Intra-abdominal Candida spp infection in acute abdomen in a quality assurance (QA)-certified academic setting.

AIMS: To evaluate the contribution of light microscopy to detecting Candida spp infection in patients with complicated intra-abdominal infections (IAIs) admitted for acute abdomen to a quality assurance (QA)-certified surgical emergency ward. METHODS: We conducted a retrospective study (2008-2012) of 809 abdominal intraoperative or biopsy tissue specimens obtained from patients admitted with acute abdomen and microbiological samples positive for Candida spp. Demographic data, mortality, comorbidities, specimen type, microscopy results, special histological staining performed, antimicrobial therapy were collected and analysed. Any comments at the multidisciplinary team meeting was recorded in minutes of and approved. RESULTS: Sixty-six patients with complicated IAIs due to Candida spp were identified (39 male, 27 female, mean±SD age 75±20 years). Candida albicans was isolated in 35 cases and Candida non-albicans spp in 31 cases. Candida spp were isolated from blood in 50% of all selected microbiological specimens. Patients were stratified according to Candida spp (albicans vs non-albicans), underlying cancer disease and no previous antimicrobial administration, and a positive correlation with C. albicans isolation was found (p=0.009 and p=0.048, respectively). Out of 41 cases with microscopic evaluation, we identified yeast forms, pseudohyphae or both, indicative of Candida spp, in 23. Identification of Candida spp in histological specimens was higher in C. albicans cases than in C. non-albicans cases (73% vs 37.5%). Microscopy allowed prompt treatment of all patients. CONCLUSIONS: Light microscopy still has great diagnostic significance, being a solid QA step. It provides rapid information and clues in patients who may harbour impaired defence mechanisms, concurrent chronic conditions and/or cancer.

Infected Congenital Epicardial Cyst Presenting as Acute Abdomen.

A previously healthy 3-year-old boy presented to the emergency department with abdominal pain, fever, and emesis. Laboratory and radiologic evaluation for causes of acute abdomen were negative; however, review of the abdominal x-ray demonstrated cardiomegaly with the subsequent diagnosis of pericardial cyst by echocardiogram and computed tomography. The patient underwent surgical decompression and attempted removal of the cystic structure revealing that the cyst originated from the epicardium. His abdominal pain and fever resolved postoperatively and he completed a 3-week course of ceftriaxone for treatment of Propionibacterium acnes infected congenital epicardial cyst. Emergency department physicians must maintain a broad differential in patients with symptoms of acute abdomen to prevent complications from serious cardiac or pulmonary diseases that present with symptoms of referred abdominal pain.

Neisseria meningitidis presenting as acute abdomen and recurrent reactive pericarditis

ABSTRACT Meningococcal meningitis is a well established potential fatal infection characterized by fever, headache, petechial rash, and vomiting in the majority of cases. However, protean manifestations including abdominal pain, sore throat, diarrhea and cough, even though rare, should not be overlooked. Similarly, although disseminated infection could potentially involve various organ-targets, secondary immune related complications including joints or pericardium should be dealt with caution, since they remain unresponsive to appropriate antibiotic regimens. We hereby report the rare case of an otherwise healthy adult female, presenting with acute abdominal pain masking Neisseria meningitidis serotype B meningitis, later complicated with recurrent reactive pericarditis despite appropriate antibiotic treatment. There follows a review of current literature.

Neisseria meningitidis presenting as acute abdomen and recurrent reactive pericarditis.

Meningococcal meningitis is a well established potential fatal infection characterized by fever, headache, petechial rash, and vomiting in the majority of cases. However, protean manifestations including abdominal pain, sore throat, diarrhea and cough, even though rare, should not be overlooked. Similarly, although disseminated infection could potentially involve various organ-targets, secondary immune related complications including joints or pericardium should be dealt with caution, since they remain unresponsive to appropriate antibiotic regimens. We hereby report the rare case of an otherwise healthy adult female, presenting with acute abdominal pain masking Neisseria meningitidis serotype B meningitis, later complicated with recurrent reactive pericarditis despite appropriate antibiotic treatment. There follows a review of current literature.

Is abdominal tuberculosis a surgical problem?

INTRODUCTION: Abdominal tuberculosis (TB) has always been a diagnostic challenge, even for the astute surgeon. In developing countries, extrapulmonary TB often presents as an acute abdomen in surgical emergencies such as perforations and obstructions of the gut. Abdominal TB in different forms has been found more often as an aetiology for the chronic abdomen. This paper aims to evaluate TB as a surgical problem. METHODS: A comprehensive review of the literature on abdominal TB was undertaken. PubMed searches for articles listing abdominal TB/different types/diagnosis/treatment (1980-2012) were performed. RESULTS: TB is still a global health problem and the abdomen is one of the most common sites of extrapulmonary TB. Presentation may vary from an acute abdomen to a number of different chronic presentations, which can mimic other abdominal diseases. While some may benefit from antitubercular therapy, others may develop surgical problems such as strictures or obstruction, which may necessitate surgical intervention. CONCLUSIONS: Abdominal TB should always be considered one of the differential diagnoses of acute or chronic abdomen in endemic areas.

Acute abdomen due to group A streptococcus bacteremia caused by an isolate with a mutation in the csrS gene.

Streptococcus pyogenes (group A streptococcus) is an aerobic gram-positive coccus that causes infections ranging from non-invasive pharyngitis to severely invasive necrotizing fasciitis. Mutations in csrS/csrR and rgg, negative regulator genes of group A streptococcus, are crucial factors in the pathogenesis of streptococcal toxic shock syndrome, which is a severe, invasive infection characterized by sudden onset of shock and multiorgan failure, resulting in a high mortality rate. Here we present a case of group A streptococcal bacteremia in a 28-year-old Japanese woman with no relevant previous medical history. The patient developed progressive abdominal symptoms that may have been due to spontaneous bacterial peritonitis, followed by a state of shock, which did not fulfill the proposed criteria for streptococcal toxic shock. The isolate was found to harbor a mutation in the negative regulator csrS gene, whereas the csrR and rgg genes were intact. It was noteworthy that this strain carrying a csrS mutation had caused group A streptococcal bacteremia characterized by acute abdomen as the presenting symptom in a young individual who had been previously healthy. This case indicates that group A streptococcus with csrS mutations has potential virulence factors that are associated with the onset of group A streptococcal bacteremia that does not meet the diagnostic criteria for streptococcal toxic shock syndrome.

Tuberculosis peritonitis with features of acute abdomen in HIV infection.

This case report introduces a 26-year-old male IV drug abuser with fever, abdominal pain and distension referred to the emergency ward. According to these findings, abdominal tenderness and involuntary guarding, an explorative laparotomy was performed. Multiple biopsies of omentum, peritoneum and liver were taken. Pathologic assessment of multiple biopsies confirmed intra-abdominal TB infection.

Diagnosing abdominal tuberculosis in the acute abdomen.

BACKGROUND: Despite recent improvements in medical treatments, the incidence of abdominal tuberculosis (ATB) in the United Kingdom has increased over the past two decades. This case series examined the difficulties encountered in correctly diagnosing this infection. PATIENTS AND METHODS: A retrospective study was undertaken, reviewing the records of 36 patients diagnosed with ATB from 2000 to 2012 at a district general hospital in outer East London. RESULTS: The commonest presenting feature was abdominal pain in 67% of patients, and the most common sites of infection were the iliocaecal junction and peritoneum, seen in 36.1% and 33.3% respectively. Six patients were initially investigated for Crohn's disease and one for ileitis. The highest disease prevalence was seen in patients born in India and Pakistan, which was 27.8% and 19.4% of patients respectively. Colonoscopy was performed in nine patients, and three of these reported normal findings. The other six reported visible non-specific inflammatory changes. Three patients had abdominal X-rays reported and one patient had an abdominal ultrasound, all of which were normal. An abdominal computerised topography (CT) scan was performed in 26 patients and a chest CT was undertaken in 19 patients. Varying degrees of inflammatory changes were seen in all of the patients who had CT scans. Microbiological culture was positive for Mycobacterium tuberculosis or acid-fast bacilli in 71% of patients. CONCLUSIONS: Abdominal tuberculosis can be very difficult to diagnose as symptoms are non-specific and can mimic other types of granulomatous inflammatory bowel diseases. Radiology appears largely unhelpful due to the non-specificity of any positive imaging findings, and there is a lack of diagnostic procedural and microbiological tests with high specificity and sensitivity. In view of the increasing incidence of tuberculosis in London, there should be a high index of suspicion for ATB in individuals from high-incidence countries who present with non-specific abdominal symptoms.

[Ileocaecal actinomycosis - a case report]. / Ileocékalna aktinomykóza - kazuistika.

Abdominal actinomycosis as an aetiological cause of acute abdomen in immunocompetent patients is considered to be very rare. The authors present a case of a young patient with acute appendicitis in the terrain of specific colitis imitating caecal tumour. Especially nowadays, in the era of globalization, it would be an unnecessary mistake not to think of this aetiological unit when the pain and tenderness in the right hypogastrium with signs of peritonism are expressed.