Mark Crislip, MD


September 28, 2010

Clinical Presentation: A Teenager With Fever and Abdominal Pain

A 17-year-old Hispanic teenager who has had fevers for 3 weeks presents to the emergency department. Her fevers started abruptly and have been associated with rigors, sweating, and diffuse abdominal pain that is more severe in the right upper quadrant.

She has not any other complaints, but as a result of progressive weakness and hypotension, she is admitted to the hospital.


The patient's history revealed the following:

  • Review of systems: negative;

  • Medical history: negative;

  • Habits: no alcohol, no drugs, and she is not sexually active;

  • Travel: none -- she has lived her entire life in suburban Portland;

  • Pets: a cat;

  • Ill contacts: none;

  • Dental work: 5 weeks ago;

  • Diet: typical for US teen; and

  • Immunizations: up-to-date.

Physical Examination

The patient's physical examination revealed the following:

  • General: ill-appearing, lethargic female;

  • Vital signs: temperature 104°F, pulse 75 beats per minute, respiratory rate 16 breaths per minute;

  • HEENT: normal, no emboli or adenopathy;

  • Heart: grade 1/6 murmur (possibly long-standing);

  • Abdomen: large spleen and tender liver, mild rebound in the right upper quadrant;

  • Genitourinary: normal; and

  • Extremities: negative for emboli.

Laboratory Values and Imaging Results

  • White blood cell count, 4100/mm3, 5% bands; hemoglobin, 10.1 g/dL; erythrocyte sedimentation rate, >100 mm/hour;

  • Urinalysis: negative;

  • Transaminases: 2-3 times normal;

  • Viral: hepatitis ABC negative; cytomegalovirus negative; Monospot test negative; antinuclear antibodies negative;

  • Chest x-ray: negative; and

  • Computed tomography abdomen and pelvis: hepatosplenomegaly with a slightly thickened and edematous gallbladder.

Over the next 3 days, the patient's right upper quadrant pain worsens and her transaminase levels increase to 4 times the normal values. The decision is made to remove her gallbladder. While she is in the operating room, the blood cultures grow small gram-negative rods on day 3.


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