Background: Right lower quadrant (RLQ) pain is a common reason for visits to the emergency department. Acute appendicitis is often suspected but multiple other differential diagnoses must be taken into consideration including inflammatory bowel disease (IBD). A computed tomography (CT) scan of the abdomen is used routinely in adults presenting to the emergency department with RLQ pain. Ulcerative colitis (UC) may affect the appendix in cases of pancolitis, however, skip lesions in the appendix have been reported rarely. Nonoperative management of appendicitis has gained increasing acceptance. Case Presentation: A 49-year-old male with UC, who was non-compliant with therapy, presented to the emergency department with acute RLQ pain and diarrhea. Computed tomography scan showed a thickened and dilated appendix, peri-appendiceal stranding, and mild thickening of the cecum. We suspected the patient had a flare of UC involving the appendix and opted for non-operative management with intravenous antibiotics. His pain improved and colonoscopy revealed active pancolitis involving the cecum. Biopsies confirmed the diagnosis of a flare of UC. He was discharged with a course of antibiotics and followed as an outpatient and started on medication for UC. He remained well during follow-up without evidence of recurrent appendicitis. Discussion: Increasing evidence is available to support non-operative management of patients with acute appendicitis. We propose that patients with IBD who present with acute RLQ pain and CT findings of acute appendicitis should be managed non-operatively and a colonoscopy should be done to exclude active IBD. Appendectomy in a patient with active colitis may have an increased risk of morbidity such as stump leak or cecal perforation and may delay initiation of appropriate therapy.
Background: Vancomycin-resistant Enterococcus faecium (VRE) is a low virulent pathogen. It can cause a variety of infections most commonly in immunosuppressed patients and those with previous exposure to broadspectrum antibiotics. Case Presentation: A morbidly obese male with multiple comorbidities presented with acute cholecystitis. Because of the high operative risk it was decided to treat the condition with antibiotics and ultrasound-guided percutaneous cholecystostomy tube placement. Cultures of bile revealed VRE and initial therapy consisted of daptomycin. Cultures on day seven after initiation of daptomycin showed continuing growth of VRE and therapy was changed to linezolid and the patient was able to clear VRE from bile and cholecystitis resolved. The tube was removed after six months and interval cholecystectomy was planned after appropriate weight loss. Conclusions: We report the first case of VRE acute cholecystitis in North America. Only two additional cases have been reported thus far, both from Italy. One responded to daptomycin, which is in contrast to our experience. However, similar to the other reported case, our patient had a good response to linezolid, which may be the preferred agent to treat this condition.
Background: Persistent omphalomesenteric remnants are diagnosed most commonly in childhood. The condition is rare in adults with only a few cases of laparoscopic management reported thus far. Case Presentation: A 32-year-old male underwent open umbilical hernia repair without mesh at an outside hospital. He developed an abdominal wall phlegmone followed by a chronic umbilical infection. Computed tomography (CT) scan showed a tubular structure at the inner surface of the abdominal wall suggestive of a urachus cyst. During laparoscopy, the tubular structure was found to have no relation to the bladder but instead could be followed toward the small bowel originating 100 cm proximal to the terminal ileum. The chronic infected umbilical fistula was resected, and at the origin the duct was excised longitudinally and the enterotomy was closed transversely. The patient developed a superficial surgical site infection but ultimately did well. Discussion: Surgeons should be aware of this rare condition as a cause of chronic umbilical infection. The omphalomesenteric remnant is suitable for laparoscopic repair.
Background: Although Bordetella bronchiseptica is primarily an animal pathogen, cases of human disease caused by this pathogen have been published recently, most frequently pneumonia in immunocompromised patients. In human disease, transmission through animal vectors may play a key role. Although no standardized sensitivity testing is available for this pathogen in human disease, animal isolates are sensitive to most b-lactam antibiotics. Case Report: A 62-year-old Caucasian male with Child-Pugh class A cirrhosis caused by chronic hepatitis C infection underwent uneventful left lateral segmentectomy for a 3 cm cholangiocarcinoma. Within 48 h, he developed altered mental status, temperature of 39.4°C, leukocytosis (white blood cell count: 13,000/mm 3), and dyspnea followed by hypotension requiring vasopressor support and intubation. Computed tomography (CT) scan demonstrated left lower lobe pneumonia. Empiric antibiotic therapy including vancomycin (1 g every 12 h) and piperacillin-tazobactam (3.5 g every 6 h) was initiated and his signs of sepsis resolved within two days. Bordetella bronchiseptica was cultured from sputum. Upon questioning, the patient reported close contact with several pet cats on the days prior to admission. Antibiotics were continued for a total of seven days and he was discharged in good condition doing well at his six-month follow-up. Conclusions: Immunocompromised patients may develop infection with Bordetella bronchiseptica especially if they are in close contact with animals known to be a reservoir of this pathogen. If diagnosed early and treated appropriately, the outcome is favorable.
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