I could really use some helpful suggestions and thoughts about the following case of intra-abdominal abscesses. All patients are special and deserving of this best, this one though happens to be my older brother.
Laboratory and diagnostic studies
In brief, my brother is a 41 year old male, no medical history at all, family man, attorney and accountant (save the jokes for later), who had a history of 2 1/2 weeks (begin before New Years) of temperature spikes associated with night sweats, lethargy, etc. No associated shortness of breath, no other respiratory symptoms, no chest pain, mild crampy abdominal pain”, no changes in bowel or bladder habits, etc. His initial visit to his PMD revealed a mild leukocytosis (16.0) with a slight left shift, slight elevation of his bilirubin (2.3: old records revealed a bili that may have been slightly elevated, normal direct however), no transaminitis, normal alk phos, normal H/H, UA negative, cultures negative, etc. His symptoms were initially attributed to a viral illness, but after a week, he had stool cultures sent (negative), repeat labs (wbc still elevated but less so), bili down; he was empirically placed on Ciprofloxacin.
Another week passed, symptoms and temps still didn’t abate, and an FUO work-up commenced. Chest Xray was negative, but a transthoracic echo suggested the possibility of endocarditis, as they saw myxomatous MV and TV. Two days after this, a TEE was performed however no vegetations were seen and no other sequelae/stigmata of endocarditis were noted.
Treatment of abscesses
At this time, I came in to see my brother, and along with his docs, became concerned about his belly. He quickly had an abdominal CT which revealed multiple abscesses with air fluid levels and was taken to the OR for an emergency lap. He had the abscesses drained, and the surgeons (a stellar colorectal group in central New Jersey) also detected a cecal perforation. The resected his cecum, performed a diverting ileostomy (because of his low albumin and multiple abscesses), and placed him on antibiotics. Cultures grew out Strep F and E. Coli, sensitive to Cipro and Unasyn (Ampicillin/Sulbactam). Vanco which had been started a few days earlier was d/ced.
My brother seemed to progress, although still had some low grade temps, but 2-3 days ago, he just became weaker, his wbc rose to 20.0 with a diff, and a repeat CT was performed which revealed another abscess.
He was taken to surgery last night, and the surgeon found another perforation in his jejeunum, which was repaired, and the abscess was drained, and a feed Jej was placed. FYI, the initial pathology did not reveal anything unusual: no Crohn’s, no other IBD no malignancy, no diverticula, etc. This morning, my brother had a temp spike to 103 degrees Farenheit (39.4 degrees C), associated with a sinus tachycardia, and a systolic BP of 100 mm Hg. Throughout this and thereafter, his mentation has remained perfectly lucid, he has had a decent Urine Output (even in the face of a recent lap one day ago), his lungs were clear, etc. I don’t know any other lab results, etc; will find out soon, yet another two hour drive to NJ.
Of further two note, my brother would make Mother Theresa seem like a deviant, he travels throughout the states on business but nothing exotic, no allergies, no cigarettes, no Etoh, no drugs, etc.
I hope no one is insulted by me using the collective knowledge and the resources of this list to inquire about a sick, relative. I would ask for people’s thoughts and suggestions, experience, differential diagnosis, etc. I do have a few specific questions. Of note, the surgeon emphatically stated to me that he believes that this may have been due to a foreign body but still no one is willing to close the book on anything. I therefore have a few questions.
1. Does anyone have any experience about similar cases. I have had patients had to go back for relaps and reaccumulations of abscesses, however, they have been in the face of trauma, both blunt and penetrating, pancreating, or in the face of a really obvious nasty pathologic process.
2. Is there anything that the pathologist should look for from the initial sample. IMHO, while it is certainly possible and perhaps likely that any peritoneal and retroperitoneal process (i.e. a perforation that wasnt detected until later perhaps, given a lovely chance for all colonic nasty beasties to grow and fluorish), may develop from a perforation, I still scratch my prematurely balding head and ask the question that why should a 41 y.o. healthy male develop a second abscess, i.e. what is being missed and what perhaps should we consider. The ID consultant even suggested the possibility of Familial Mediterranean Fever (I loved that one when it was tendered), given the fact that we are of Jewish decent (Ashkenazic not Sephardic, FMF I think is seen in Sephardic Jews and other Mediterranean cultures) albeit the fact that he is about 20 years (at least) beyond the time of usual presentation and did not fit the picture.
3. Anything microbiological that should also considered, in terms of etiology and empiric coverage?
Mind you, I still am hearing a horse, but maybe a zebra should be considered. I think my brother has received excellent care, but I want to exhaust all possibilities.