by Lenore Jarvis, Children’s National
with Shilpa Patel, Children’s National

The Case
The challenge of this case involves the appropriate lab work-up, diagnostic imaging and treatment of a 14 year old prev healthy male presenting with severe LUQ pain, fever, tachycardia and splenomegaly.

Here’s How You Answered Our Questions

Providers wanted a CXR to rule out PNA and effusion.  All providers also felt that abdominal imaging was warranted to look for intra-abdominal pathology.  Most stated that they would start with an abdominal ultrasound.  Several stated that if ultrasound were not available that they would obtain an Abd CT with PO & IV contrast due to concerns for fever, tachycardia, splenomegaly and persisting pain despite morphine.  Most providers stated that if the Bed Czar requested a Surgical consult that they would obtain one.  However, several providers commented that they obtained the consult because it was asked for and not necessarily because they thought one was needed.  It was reiterated that we should better determine what is going on with the patient prior to admission.  As Emergency physicians, we should steer clear of the diagnosis “abdominal pain NOS,” especially if severe abdominal pain is persistent.

Denouement
AXR showed a non-specific bowel gas pattern. The lung bases were normal on AXR, so a CXR was not obtained. Unfortunately, ultrasound was not available until morning. The decision was made to do serial abdominal exams in the ED rather than obtain an abdominal CT urgently. Over the course of several hours, the patient improved. His fever defervesced s/p motrin and his HR normalized. After the 2nd dose of morphine, the patient did not require further morphine doses and his pain improved. He was able to sleep comfortably; however, when he was awoken for exam, he had 4/10 LUQ TTP (without rebound or guarding). EBV, CMV and HIV labs were drawn in the ED. The working diagnosis was a viral etiology, likely EBV or CMV.

The Hospitalist was called to discuss continued observation in the ED until the morning for ultrasound vs admission with ultrasound from the floor in the morning. The Hospitalist decided that it was ok to admit the patient with ultrasound in the morning. The Bed Czar did not actually request a surgical consult (that point was changed for educational purposes).

The abdominal ultrasound was normal, and the spleen was within normal limits (despite noted mild splenomegaly on exam). He was hospitalized for 1.5 days for pain control and IVFs. His abdominal pain was thought to be related to infectious mononucleosis. It was felt that the positive strep test (which had been treated with Bicillin) was more likely to be colonization than the cause of his current presentation. EBV, CMV, and HIV studies were pending at discharge. At discharge, he was tolerating PO off IVF with pain managed with ibuprofen. He was given anticipatory guidance to avoid contact sports for 3 weeks or until advised differently by the PMD.

Labs after discharge: HIV neg, CMV neg
EBV viral capsid IgG positive, Viral capsid IgM negative, nuclear Ag IgG positive, early (D) IgG negative

Teaching Points
This week we had great comments from Dewesh, Dave, Jennifer, Joelle and Shilpa on work-up and diagnostic considerations.

As a reminder, EBV viral capsid IgG positive, Viral capsid IgM negative, nuclear Ag IgG positive, early (D) IgG negative= Convalescent Phase