The presence of an intraabdominal mass suggested malignancy rather than an increasingly common sexually transmitted infection. A 20-year-old man presented with fever and severe epigastric pain. Three weeks earlier, he sought treatment for a sore throat at an urgent care center. At that time, rapid strep testing was negative, and his symptoms subsequently resolved. One week prior to his current hospital presentation, he had intermittent fevers as high as 40°C (104°F) with rigors, night sweats, and an unintentional 5-lb (2.27-kg) weight loss. Three days prior to presentation, he developed constant, severe epigastric pain. Laboratory testing at the urgent care center revealed an elevated white blood cell count of 28 × 103 cells/mm3. He was directed to our Emergency Department.
The patient’s recent medical history included a small area of nonpainful erythema at the urethral meatus that was not accompanied by dysuria. He also stated that he had undergone a “full sexually transmitted diseases panel” at the urgent care center, and the results had been negative. He was otherwise healthy, did not drink alcohol in excess, smoked 1-3 cigarettes and marijuana daily, denied use of injectable drugs, and reported using condoms with 3 male sexual partners within the past 6 months. He had no significant travel, animal, or occupational exposures.
Assessment
The patient was a thin, Caucasian man who appeared uncomfortable. His vital signs were as follows: temperature, 37.9°C (100.2°F); heart rate, 128 beats per minute; blood pressure, 119/49 mm Hg; and respirations, 16 breaths per minute. Oxygen saturation was 98% on room air. A cardiopulmonary examination was normal except for regular tachycardia. An abdominal examination disclosed normoactive bowel sounds, mild distension without a fluid wave, and significant epigastric tenderness without peritoneal signs or hepatosplenomegaly. He had small, scattered, nontender bilateral inguinal lymphadenopathy but no genital lesions.
Serum chemistries showed mild hyponatremia (130 mmol/L). A liver function panel indicated hypoalbuminemia (3.2 g/dL). Renal function was normal, as were levels of lipase, and lactate dehydrogenase. The complete blood count documented a white blood cell count of 18.9 × 103 cells/mm3, with 85% neutrophils and no bandemia, a hematocrit of 38.6%, and a platelet count of 192,000 cells/mm3. A test for group A Streptococcus species and a mononucleosis spot test for heterophile antibodies were negative.
Computed tomography of the abdomen and pelvis demonstrated a periportal soft tissue mass measuring 2.5 × 7 × 8.5 cm that encased the portal vein and common hepatic artery and multiple aortocaval and periaortic lymph nodes. These findings were highly concerning for malignancy or atypical infection. The patient was admitted to expedite the evaluation of a possible intraabdominal malignancy, with lymphoma high on the initial differential diagnosis. A disseminated viral infection was also strongly considered.
The patient underwent excisional biopsy of an inguinal lymph node. Pathology results identified follicular and paracortical hyperplasia, reactive lymphohistiocytosis, and focal microabscesses, but no evidence of lymphoma. Gram, acid-fast, and silver stains were negative. Immunostaining for adenovirus, cytomegalovirus, and herpes simplex virus and an analysis for Epstein-Barr virus were negative. Polymerase chain reaction assays were ordered to examine serum for Epstein-Barr virus, cytomegalovirus, human immunodeficiency virus (HIV), and human herpesvirus 6. All were negative. A rapid plasma reagin test was not performed at this time. Serum flow cytometry was negative for leukemia and lymphoma.
Intermittent fevers as high as 39.6°C (103.3°F) continued for 3 days. With supportive care, the patient’s abdominal pain resolved by hospital day 6 with concomitant normalization of his leukocytosis. At the same time, his alkaline phosphatase level steadily rose from 90 U/L on admission to 319 U/L (normal, < 128 U/L) on hospital day 6. His aspartate aminotransferase and alanine aminotransferase levels rose to 94 U/L and 98 U/L, respectively, while his bilirubin level remained normal at 0.7 mg/dL. With an acute hematologic malignancy and acute HIV infection excluded, he was discharged on hospital day 7 with close outpatient follow-up.
At the 1-week follow-up visit, the patient had an improved, though persistent, elevation in his alkaline phosphatase level, and new thrombocytosis (739,000 platelets/mm3) was detected. He also had a new, diffuse erythematous rash. A rapid plasma reagin test was obtained and was reactive at a titer of 1:32.
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-Avital Y. O’Glasser, MD, Catherine Meeker Kent, MD
This article originally appeared in the April 2016 issue of The American Journal of Medicine.
