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 days
2. Abdominal pain for 25 days
History of present illness
Fever
High grade
Intermittent (Quotidian)
Highest recorded temperature was
106F
Chills and rigor
Subsided with profuse sweating
Abdominal pain
Upper and right side of the abdomen
No radiation
Colicky
Occasional vomiting
Relieved by taking diclofenac
suppository
Systemic enquiry
Anorexia
Weight loss of about six kg
Pruritus for last six days more intense at
night
No headache
Joint pain
Cough
Breathlessness
Jaundice
Burning micturation
Altered consciousness
No hematemesis or melena
No 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 examination
Toxic
Febrile (103F)
Pulse 96/min, regular
BP 110/70 mm Hg
No
No
No
No
No
No
No
jaundice
anemia
clubbing
significant lymphadenopathy
bony tenderness
purpura
edema
Examination of abdomen
Right hypochondriac and epigastric
tenderness
No hepato-splenomegaly
No other masses
No para aortic lymphadenopathy
Digital 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 examination
He is febrile with normal vitals. He had no
anemia, jaundice, clubbing, lymphadenopathy.
Examination of abdomen revealed
Tenderness over the epigastrium and right
hypochondriac region. He had no hepatosplennomegaly and para aortic
lymphadenopathy.
Examination of other systems revealed no
abnormalities
Investigations
CBC
WBC 20,300/cmm
DC
o
o
o
o
Neutrophil 92%
Lymphocyte 4%
Monocyte 3%
Eosinophil 1%
Platelet 232,000/cmm
Hb 10.50 gm/dl
ESR 45 mm in the 1st hour
Urine R/M/E
Protein: +
Reducing substance: Nil
Pus cell: 2-3/HPF
RBC: 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 22 nd
day of fever)
Liver is enlarged in size, hypodense areas are
observed in both lobes of liver more on left
lobes
Gall bladder is not discernable.
Post contrast images revealed target like
enhancement of hepatic lesions
Intrahepatic biliary channels reveal air within
the lumen
Simple cortical cysts are seen in both kidneys
Impression: Findings are in favour of
o Hepatomegaly with metastasis
o Fibrosed/? Operated gall bladder
o Bilateral simple renal cysts
USG of HBS and USG guided FNAC
from the lesion
Multiple 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, smokers
<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 dilatations
Bilateral renal cortical cyst
